Adam Wagstaff

• BA, DPhil
• Project Manager at World Bank

This paper provides an overview of research on out-of-pocket health expenditures by reviewing the various summary measures and the results of multi-country studies using these measures. The paper presents estimates for 146 countries from all World Bank income groups for all summary measures, along with correlations between the summary measures and...

In this prospective study, conducted in China where providers have traditionally been paid fee-for-service, and where drug spending is high and irrational drug prescribing common, township health centers in two counties were assigned to two groups: in one fee-for-service was replaced by a capitated global budget (CGB); in the other by a mix of CGB...

A cluster randomized experiment was undertaken testing two sets of interventions encouraging enrollment in the Individually Paying Program (IPP), the voluntary component of the Philippines' social health insurance program. In early 2011, 1037 unenrolled IPP-eligible families in 179 randomly selected intervention municipalities were given an informa...

Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens’ rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already “reached” universal health c...

The recent paper by Garcia-Gomez et al. (2014) in this journal is part of a rapidly growing industry aiming to quantify, and hence give some policy teeth to, the concept of inequality of opportunity. The idea behind the concept is simple yet powerful. Not all inequality is bad. The bad bit of inequality (‘inequality of opportunity’) is the part tha...

Value judgments lurk beneath the surface in any study of health inequalities; analystsought to understand them, make them explicit, and present results transparently to policymakersso that they, rather than analysts, decide which set of value judgments should beinvoked. The authors emphasize that the value judgment between attainment and shortfall...

The authors welcome the comments of Pedro Rosa Dias and Erik Schokkaert on our Editorial as a means of stimulating further debate on the usefulness of estimates of inequality of opportunity, especially for policy purposes. Our responses to their comments are in three categories. First, they broadly agree with many of our criticisms of the Paes de B...

A fi nes de la década de 1980, muchos países de América Latina comenzaron reformas en el sector social para aliviar la pobreza, reducir las desigualdades socioeconómicas, mejorar los resultados de salud, y proporcionar protección ante el riesgo fi nanciero. Particularmente, a partir de la década de 1990, las reformas encaminadas a fortalecer los si...

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focuse...

Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health s...

We examine differential progress on health Millennium Development Goals (MDGs) between the poor and the better off within countries. Our findings are based on an original analysis of 235 DHS and MICS surveys spanning 64 developing countries over the 1990–2011 period. We track five health status indicators and seven intervention indicators from all...

The academic literature on equality of opportunity has burgeoned. The concepts and measures have begun to be used by policy institutions, including in specific sectors such as health and education. It is argued that one advantage of focusing on equality of opportunity is that policy makers are more responsive to that discourse than to equality of o...

Objectives To compare the effects of the Rajiv Aarogyasri Health Insurance Scheme of Andhra Pradesh (AP) with health financing innovations including the Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra (MH) over time on access to and out-of-pocket expenditure (OOPE) on hospital inpatient care. Study design A difference-in-differences (DID) stu...

Using primary data from Laos, we compare a broad range of different types of shocks in terms of their incidence, distribution between the poor and the better off, idiosyncrasy, costs, coping responses, and self-reported impacts on well-being. Health shocks are more common than most other shocks, more concentrated among the poor, more idiosyncratic,...

Up to now catastrophic and impoverishing payments have been seen as two alternative approaches to measuring financial protection in health. Building on the previous literature, the authors propose a unified methodology in which impoverishing and catastrophic payments are mutually exclusive outcomes. They achieve this by expressing out-of-pocket pay...

This paper looks at differential progress on the health Millennium Development Goals between the poor and better-off within countries. The findings are based on original analysis of 235 Demographic and Health Surveys and Multiple Indicator Cluster Surveys, spanning 64 developing countries over the period 1990-2011. Five health status indicators and...

This paper uses a common household survey instrument and a common set of imputation assumptions to estimate the pro-poorness of government health expenditure across 69 countries at all levels of income. On average, government health expenditure emerges as significantly pro-rich, but there is heterogeneity across countries: in the majority, governme...

In China, health care providers have traditionally been paid fee-for-service and overprescribing and high out-of-pocket spending are common. In this study, township health centers in two counties were assigned almost randomly to two groups: in one, fee-for-service was replaced by a global capitated budget; in the other, by a mix of global capitated...

Subsidized voluntary enrollment in government-run health insurance schemes is often proposed as a way of increasing coverage among informal sector workers and their families. This paper reports the results of a cluster randomized control trial in which 3,000 households in 20 communes in Vietnam were randomly assigned at baseline to a control group...

With the movement toward universal health coverage gaining momentum, the global health research community has made significant efforts to advance knowledge about the impact of various schemes to expand population coverage. The impacts on efficiency, quality, and gaps in service utilization of reforms to provider payment methods are less well studie...

This paper exploits the staggered rollout of Vietnam’s hospital autonomization policy to estimate its impacts on several key health sector outcomes including hospital efficiency, use of hospital care, and out-of-pocket spending. The authors use six years of panel data covering all Vietnam’s public hospitals, and three stacked cross-sections of hous...

This paper exploits the staggered rollout of Thailand’s universal health coverage scheme to estimate its impacts on whether individuals report themselves as being too ill to work. The statistical power comes from the fact that there is an average of 62,000 respondents in the labor force survey at each survey date and no less than 68 survey dates, m...

This paper explores the possibility that universal health coverage may inadvertently result in distorted labor market choices, with workers preferring informal employment over formal employment, leading to negative effects on investment and growth, as well as reduced protection against non-health risks and the income risks associated with ill healt...

Authors of benefit-incidence analyses (BIA) have to impute subsidies using assumptions about the relationship between unobserved subsidies 'captured' by the household and what can be observed at the household and aggregate levels. This paper shows that one of the two assumptions used in BIA studies to date will necessarily produce a more pro-rich (...

In this paper, we take a bibliometric tour of the last forty years of health economics using bibliographic "metadata" from EconLit supplemented by citation data from Google Scholar and our own topical classifications. We report the growth of health economics (we find 33,000 publications since 1969-12,000 more than in the economics of education) and...

The binary variable is one of the most common types of variables in the analysis of income-related health inequalities. I argue that while the binary variable has some unusual properties, it shares many of the properties of the ratio-scale variable and hence lends itself to both relative and absolute inequality analyses, albeit with some qualificat...

Inefficiency is commonplace, yet exercises aimed at improving provider performance efforts to date to measure inefficiency and use it in benchmarking exercises have not been altogether satisfactory. This paper proposes a new approach that blends the themes of Data Envelopment Analysis and the Stochastic Frontier Approach to measure overall efficien...

Bibliometric measures based on citations are widely used in assessing the scientific publication records of authors, institutions and journals. Yet currently favored measures lack a clear theoretical foundation and are known to have counter-intuitive properties. The paper proposes a new approach that is grounded on a theoretical “influence function...

ADePT is a software package that generates standardized tables and charts summarizing the results of distributional analyses of household survey data. Users input a Stata (or SPSS) data set, indicate which variables are which, and tell ADePT what tables and charts to produce; ADePT then outputs the results in a spreadsheet with one page for each re...

While there is broad agreement that the way that health care providers are paid affects their performance, the empirical literature on the impacts of provider payment reforms is surprisingly thin. During the 1990s and early 2000s, many European and Central Asian (ECA) countries shifted from paying hospitals through historical budgets to fee-for-ser...

Bibliometric measures based on citations are widely used in assessing the scientific publication records of authors, institutions and journals. Yet currently favored measures lack a clear conceptual foundation and are known to have counter-intuitive properties. The authors propose a new approach that is grounded on a theoretical"influence function,...

In Laos health shocks are more common than most other shocks and more concentrated among the poor. They tend to be more idiosyncratic than non-health shocks, and are more costly, partly because they lead to high medical expenses, but also because they lead to income losses that are sizeable compared with the income losses associated with non-health...

Vietnam's health care fund for the poor (HCFP) uses government revenues to finance health care for the poor, ethnic minorities living in selected mountainous provinces, and all households living in communes officially designated as highly disadvantaged. As of 2006, the program, which started in 2003, covered around 60% of those eligible. Those who...

The World Bank has produced a huge volume of books and papers on development -- 20,000 publications spanning decades, but growing appreciably since 1990. This paper finds evidence that many of these publications have influenced development thinking, as indicated by the citations found using Google Scholar and in bibliographic data bases. However, t...

Reranking in the move from one income distribution to another makes it impossible to infer from changes in Lorenz and generalised Lorenz curves how income growth among those toward the bottom of the initial income distribution compares to that among those toward the top, and whether there has been income growth among those who were initially poor....

This paper provides a survey of the recent empirical research on China's 'old' health system (i.e. prior to the spate of reforms beginning in 2003). It argues that this research has enhanced our understanding of the system prior to 2003, in some cases reinforcing conclusions (e.g. the demand-inducement associated with perverse incentives) while in...

This book began in 2003 during the initial formulations of China's 11th five-year plan, which covers the period 2006-10. During the entire period, the rural health Analytic and Advisory Activities (AAA) team analyzed the sector and debated reform options with government officials and scholars. It is helped the government in its extensive reform eff...

The implications of social health insurance (SHI) for labor markets have featured prominently in recent debates over the merits of SHI and general revenue financing. It has been argued that by raising the nonwage component of labor costs, SHI reduces firms' demand for labor, lowers employment levels and net wages, and encourages self-employment and...

Social health insurance (SHI) is enjoying something of a revival in parts of the developing world. Many countries that have in the past relied largely on tax finance (and out-of-pocket payments) have introduced SHI, or are thinking about doing so. And countries with SHI already in place are making vigorous efforts to extend coverage to the informal...

In a recent article in this journal, Erreygers [Erreygers, G., 2008. Correcting the concentration index. Journal of Health Economics] has proposed a new measure of income-related health inequality to overcome three shortcomings of the concentration index (CI). I think Erreygers is absolutely right to probe on these issues, and I welcome his general...

How can the impact of aid be estimated in the presence of fungibility? And how far does fungibility reduce its benefits? These questions are analyzed in a context where a donor wants to target its efforts on a specific sector and specific geographic areas. A traditional differences-in-differences method comparing the change in outcomes between the...

This paper exploits the transitions between tax-financed health care and social health insurance in the OECD countries over the period 1960-2006 to assess the effects of adopting social health insurance over tax finance on per capita health spending, amenable mortality, and labor market outcomes. The paper uses regression-based generalizations of d...

This article describes how health care has been and is currently financed, organized, and delivered in China, Hong Kong, and Taiwan. Each system's performance is assessed on the equity and efficiency axes in terms of how well it deals with important market failures. We conclude by drawing comparative lessons and showing how policymakers are trying...

In 2003, China launched a heavily subsidized voluntary health insurance program for rural residents. We combine differences-in-differences with matching methods to obtain impact estimates, using data collected from program administrators, health facilities and households. The scheme has increased outpatient and inpatient utilization, and has reduce...

The post-Communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs regression-based generaliz...

We analyze the effect of insurance on the probability of an individual incurring 'high' annual health expenses using data from three household surveys. All come from China, a country where providers are paid fee-for-service according to a schedule that encourages the overprovision of high-tech care and who are only lightly regulated. We define annu...

Health systems are not just about improving health: good ones also ensure that people are protected from the financial consequences of receiving medical care. Anecdotal evidence suggests health systems often perform badly in this respect, apparently with devastating consequences for households, especially poor ones and near-poor ones. Two principal...

We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that...

This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the devel...

Collective Volume Article

In many countries health services and/or health insurance are delivered but also partly financed by subnational entities that vary in their fiscal or financial capacity, e.g. local governments and social health insurance schemes. The central government typically mandates a specific (or at least minimum) level of benefit or expenditure per intended...

The first aim of this paper is to compare health shocks with other (labor market and agricultural) shocks in terms of their incidence (preliminary results suggest that crop failure is more common than health shocks), the factors determining their incidence, their impacts on income (do health shocks have a larger and longer-lasting impact on income...

China's old rural Cooperative Medical Scheme (CMS) all but collapsed following the economic reforms of the early 1980s. In an effort to reduce financial risk and make health care more affordable, the Government of China recently began piloting of a new voluntary health insurance scheme for rural areas, commonly referred to as the New Cooperative Me...

This paper combines differences-in-differences with propensity score matching to estimate the impacts of a health reform project in China that combined supply-side interventions aimed at improving the effectiveness and quality of care with demand-side measures aimed at expanding health insurance and providing financial support to the very poor. Dat...

The health systems of Japan and the Asian Tigers (Hong Kong, Korea, Singapore and Taiwan), and the recent reforms to them, provide many potentially valuable lessons to East Asia's developing countries. All five systems have managed to keep a check on health spending despite their different approaches to financing and delivery. These differences are...

Vietnam's Health Care Fund for the Poor (HCFP) uses government revenues to finance health care for the poor, ethnic minorities living in selected mountainous provinces designated as difficult, and all households living in communes officially designated as highly disadvantaged. The program, which started in 2003, did not as of 2004 include all these...

This paper finds that the incomes of urban households are more vulnerable to health shocks than rural households, that health shocks may precipitate increases in unearned income that partially offset reductions in earned income and large increases in medical spending even among insured households. It also finds that households spend less on food fo...

The post-communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs a regression-based general...

In the 1990s, the international community recognized the importance of health in development. In a period when overall official development assistance declined, development assistance to health rose in real terms. World Bank lending for health increased, with a doubling of the share of International Development Association disbursements going to he...

Health shocks have been shown to have important economic consequences in industrial countries. Less is known about how health shocks affect income, consumption, labor market outcomes, and medical expenditures in middle- and low-income countries. The authors explore these issues in China. In addition to providing new evidence on the general impact o...