INTRODUCTION Universal Health Coverage (UHC) is a widely accepted objective among entities providing development assistance for health (DAH) and DAH recipient governments. One key metric to assess progress with UHC is financial risk protection, but empirical evidence on the extent to which DAH is associated to financial risk protection (and hence UHC) is scarce. METHODS Our sample is comprised of 65 countries whose DAH per capita is above the population -weighted average DAH per capita across all countries. The sample comprises of 1.7 million household observations, for the period 2000-2016. We run country and year fixed effects regressions, and pseudo-panel models, to assess the association between DAH and three measures of financial risk protection: catastrophic health expenditure (i.e., out-of-pocket health expenditures larger than 10% of total household expenditures [‘CHE10%’]), out-of-pocket health expenditure as a share of total expenditure (‘OOP%’), and impoverishment due to health expenditures, at the 1.90US$ per day poverty line (‘IMP190’). RESULTS on average, DAH investment does not appear to be significantly associated with financial risk protection outcomes. However, we find suggestive evidence that a 1 US$ increase in DAH per capita is negatively associated (i.e., an improvement) with at least one financial risk protection outcome for the poorest household quintile within countries (in fixed effects models, IMP190: -0.05 percentage points, p<0.1; in pseudo-panel models, CHE10%: -0.12 percentage points, p<0.01). DAH is also negatively associated (i.e., an improvement) with most financial risk protection outcomes when it is largely channelled via government systems (i.e., when it is “on-budget”) (CHE10%: -0.68 percentage points, p<0.05). Several robustness checks confirm these results. DISCUSSION DAH investments require careful planning to improve financial risk protection. For example, positive DAH effects for the poorest quintiles of the population might be driven by DAH targeting poorer populations and doing so effectively. Our results also suggest that channelling more resources via governments might be a promising avenue to enhance the impact of DAH on financial risk protection.

Research has begun to clarify links between discrimination and health, but important gaps remain. A more complete understanding may arise from data on both frequency of discrimination as well as the various forms of discrimination. Using unique Panel Study of Income Dynamics (PSID) Transition to Adulthood Supplement (TAS) data on a representative sample of young adults from the 2017 and 2019 waves, we consider frequency and forms of discrimination separately and in tandem. Using generalized estimating equations panel models, we find that the association between discrimination and health is more pronounced when the frequency of, and the number of reasons for, discriminatory experiences are considered together. For example, relative to experiencing no discrimination, perceiving frequent discrimination and for three or more reasons results in nearly three times higher odds of poor/fair self-rated health and 1.25 points lower on the languishing/flourishing scale. The impact of perceived discrimination on health is likely underestimated if frequency and rationale are not considered as a holistic experience.

Although access to health services by poor populations has improved in most low- and middle-income countries, wealth remains associated with better quality of care that in turn leads to better health outcomes. Understanding the patterns of such inequities can inform the design of policies to improve services received by poor populations. We employ regression and inequality decomposition analyses using household survey data from 58 low- and middle-income countries between 2010 and 2021 to characterize inequity in quality of antenatal care, to test at which levels inequity exists, and to assess at which levels inequities are most pronounced. We find that in most countries and in both rural and urban areas, wealthier women are more likely to receive high-quality antenatal care than their poorer peers who reside in the same locality (village or neighborhood), even when attending similar types of health facilities (public vs. private, and primary care facilities vs. hospitals). However, although inequity exists at such a local level, most of the wealth gradient in quality of antenatal care is explained by variation in quality of care between wealthier and poorer localities.

Universal Health Coverage is one of the key targets of the Sustainable Development Goals and it implies that everyone can access the healthcare they need without suffering financial hardship. In this paper, we use a large set of household surveys to examine if older populations are facing different degrees of financial hardship compared to younger populations. We find that while differences in average age structures between countries are not systematically associated with higher financial risk related to out-of-pocket health expenditures, there are large differences in financial hardship between younger and older households within countries. Households with more elderly members are more likely to face catastrophic and impoverishing out-of-pocket health payments compared to younger households, and this age gradient is stronger for the poorest segments of the population. Making progress toward Universal Health Coverage will require extension and improved targeting of benefit packages and financial protection to meet the health needs of older adults, and especially the poorest and most vulnerable segments of elderly populations.

Prior to the Sustainable Development Goals (SDG) era, considerable progress was made toward the Millennium Development Goals (MDGs) health indicators. Despite these achievements, many countries failed to meet the MDG target levels, between-country inequalities in health outcomes did not improve, and many countries making progress in average indicator levels did so while at the same time seeing increasing within-country inequalities. We build on the existing literature documenting levels and trends in health inequalities by expanding the number of data-points under focus, and we contribute to this literature by analyzing the extent to which inequalities in child health outcomes are related to socioeconomic inequalities, and to aggregate income growth. The objective of this paper is to examine long-run trends in average population levels and within-country inequalities for two child health outcomes—the under-five mortality rate (U5MR) and stunting—in 102 countries across 6 regions. We find that only about a third of countries in our sample managed to both reduce U5MR levels and inequalities, and only a quarter did so for stunting. The fact that inequality in service coverage seems to follow a more favorable trend than inequality in health outcomes suggests that policies aiming to reduce health inequities should not only foster more equitable service coverage but also focus on the social determinants of health. Moreover, there is no strong correlation between changes in health inequalities and income growth, suggesting that income generating development policies alone will typically not suffice to improve health outcomes and reduce health inequalities.

COVID-19 has shocked all countries' economic and health systems. The combined direct health impact and the current macro-fiscal picture present real and present risks to health financing that facilitate progress toward universal health coverage (UHC). This paper lays out the health financing mechanisms through which the UHC objectives of service coverage and financial protection may be impacted. Macroeconomic, fiscal capacity, and poverty indicators and trends are analyzed in conjunction with health financing indicators to present spending scenarios. The analysis shows that falling or reduced economic growth, combined with rising poverty, is likely to lead to a fall in service use and coverage, while any observed reductions in out-of-pocket spending have to be analyzed carefully to make sure they reflect improved financial protection and not just decreased utilization of services. Potential decreases in out-of-pocket spending will likely be drive by households' financial constraints that lead to less service use. In this way, it is critical to measure and monitor both the service coverage and financial protection indicators of UHC to have a complete picture of downstream effects. The analysis of historical data, including available evidence since the start of the COVID-19 pandemic, lay the foundation for health financing-related policy options that can effectively safeguard UHC progress particularly for the poor and most vulnerable. These targeted policy options are based on documented evidence of effective country responses to previous crises as well as the overall evidence base around health financing for UHC.

No AccessHealth, Nutrition and Population Discussion Papers1 Mar 2021From Double Shock to Double RecoveryImplications and Options for Health Financing in the Time of COVID-19Authors/Editors: Christoph Kurowski, David B Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, Alec Irwin, Jewelwayne Salcedo Cain, Eko Setyo Pambudi, Iryna PostolovskaChristoph Kurowski, David B Evans, Ajay Tandon, Patrick Hoang-Vu Eozenou, Martin Schmidt, Alec Irwin, Jewelwayne Salcedo Cain, Eko Setyo Pambudi, Iryna Postolovskahttps://doi.org/10.1596/35298SectionsSupplemental MaterialAboutView ChaptersPDF (2.5 MB) ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinked In Abstract: Volume 2 updates the analyses presented in the original discussion paper, Volume 1, "From Double Shock to Double Recovery – Implications and Options for Health Financing in the Time of COVID-19," published in March 2021. The original paper used macroeconomic projections released by the International Monetary Fund in October 2020 to project the possible time path of health spending per capita in 178 countries and territories from 2020 to 2025, under different scenarios. The scenarios built on observations of how health spending had responded during and immediately after previous economic crises, while taking into account that the economic crisis provoked by COVID-19 is different in its nature and scale. The most recent IMF country macroeconomic data, released in April 2021, forecast country macroeconomic performance through 2026. In comparison to earlier estimates, these projections suggest a less severe global economic downturn in 2020 and a stronger recovery in 2021. The objective of the present update is threefold. First, the paper briefly reports the IMF's revised macroeconomic projections. Second, it spells out the implications of these projections for countries' health spending. Finally, it compares different spending scenarios with estimates of countries' incremental spending needs if they are to halt the COVID-19 pandemic and return to a path of progress toward universal health coverage (UHC). Previous bookNext book FiguresreferencesRecommendeddetailsCited byChallenges for Health Systems: COVID-19 and Beyond6 May 2022 View Published: March 2021 Copyright & Permissions Related TopicsHealth Nutrition and Population KeywordsCORONAVIRUSCOVID-19EQUITY PDF DownloadLoading ...

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 macroeconomic and health system indicators. Large differences emerge across countries in per capita out-of-pocket expenditures in 2011 international dollars, driven in large part by differences in per capita income and the share of GDP spent on health. The two measures of dispersion or risk-the coefficient of variation and Q90/Q50-are only weakly correlated across countries and not explained by our macroeconomic and health system indicators. Considerable variation emerges in the out-of-pocket health expenditure budget share, which is highly correlated with the incidence of "catastrophic expenditures". Out-of-pocket expenditures tend to be regressive and catastrophic expenditures tend to be concentrated among the poor when expenditures are assessed relative to income, while expenditures tend to be progressive and catastrophic expenditures tend to be concentrated among the richwhen expenditures are assessed relative to consumption. At the extreme poverty line of $1.90-a-day, most impoverishment due to out-of-pocket expenditures occurs among low-income countries.

Benefit-cost analysis and other forms of economic evaluation are powerful tools, encouraging the systematic collection and assessment of the evidence needed to support sound policy decisions. In low-and middle-income countries, where resources are very scarce and needs are very great, such decisions are particularly difficult and economic evaluation can be especially useful. If not well conducted and clearly reported, however, these studies can lead to erroneous conclusions. Differences in analytic methods and assumptions can also obscure important differences in policy impacts.Recognizing these challenges, a team of experts developed reference case guidelines to increase the comparability of benefit-cost analyses, improve their quality, and expand their use. The development process involved extensive participation from stakeholders as well as experts, including both practitioners and consumers, incorporating a variety of perspectives. The resulting guidelines provide an overview of the analytic framework, including its conceptual underpinnings and its implementation. They also provide specific recommendations in seven areas: (a) comparing values across countries and over time; (2) valuing mortality risk reductions; (3) valuing nonfatal health risk reductions; (4) valuing changes in time use; (5) assessing the distribution of impacts; (6) accounting for uncertainty and nonquantifiable impacts; and (7) summarizing and presenting the results. The goal is to support the conduct of high-quality analyses that promote understanding of difficult trade-offs and support evidence-based decisions.

Biofortification, Crop Adoption, and Health Information: Impact Pathways in Mozambique and Uganda

Among the many shifts of emphasis that have been evident in global health over the past 25 years or so, two stand out: a concern over the poor lagging behind the better off in progress towards global goals; and a concern to look beyond whether people get the services they need to the affordability of the out-of-pocket expenditures associated with these services. These concerns over health equity and financial protection were absent from the Millennium Development Goals (MDGs), but are integral to the Sustainable Development Goals (SDGs).

This paper outlines changes that have been made in the 2019 version of the Health Equity and Financial Protection Indicators database. On the financial protection side, the changes include an increase in the number of indicators from five to 14; revisions to several previous data points, reflecting the analysis of new surveys (or adaptations thereof); and refinements to the estimation of out-of-pocket expenditures. On the health equity side, the 2019 database includes 198 more data points than the 9,733 in the 2018 database, reflecting the addition of 535 new datapoints, and the dropping of 337 previously included data points now considered to be substandard.

Using the recent migratory phenomenon in Chile this paper evaluates the impact of exposure to foreign students on causal municipality effect. I do so by estimating municipality’s causal effect on children’s test scores rank at 4th grade (10 years old) in two windows: before and after the large wave of immigrants. Following Chetty and Hendren’s (2018) methodology I estimate each municipality’ effect using a fixed effect regression model identified by students who move across municipalities at different ages. I found that on average there is a negative effect of foreign students arrival on municipality effect. My estimation suggest that an increase of 1 standard deviation of immigrant students, lowered students test scores by 1.8 percentiles rank per each year spend. This effect can not be explained by peers effect at the school level, and it is likely driven by segregation induced by natives flight.

Background: The goal of universal health coverage (UHC) requires inter alia that families who get needed health care do not suffer undue financial hardship as a result. This can be measured by the percentage of people in households whose out-of-pocket health expenditures are large relative to their income or consumption. We aimed to estimate the global incidence of catastrophic health spending, trends between 2000 and 2010, and associations between catastrophic health spending and macroeconomic and health system variables at the country level. Methods: We did a retrospective observational study of health spending using data obtained from household surveys. Of 1566 potentially suitable household surveys, 553 passed quality checks, covering 133 countries between 1984 and 2015. We defined health spending as catastrophic when it exceeded 10% or 25% of household consumption. We estimated global incidence by aggregating up from every country, using a survey for the year in question when available, and interpolation and model-based estimates otherwise. We used multiple regression to explore the relation between a country's incidence of catastrophic spending and gross domestic product (GDP) per person, the Gini coefficient for income inequality, and the share of total health expenditure spent by social security funds, other government agencies, private insurance schemes, and non-profit institutions. Findings: The global incidence of catastrophic spending at the 10% threshold was estimated as 9·7% in 2000, 11·4% in 2005, and 11·7% in 2010. Globally, 808 million people in 2010 incurred catastrophic health spending. Across 94 countries with two or more survey datapoints, the population-weighted median annual rate of change of catastrophic payment incidence was positive whatever catastrophic payment incidence measure was used. Incidence of catastrophic payments was correlated positively with GDP per person and the share of GDP spent on health, and incidence correlated negatively with the share of total health spending channelled through social security funds and other government agencies. Interpretation: The proportion of the population that is supposed to be covered by health insurance schemes or by national or subnational health services is a poor indicator of financial protection. Increasing the share of GDP spent on health is not sufficient to reduce catastrophic payment incidence; rather, what is required is increasing the share of total health expenditure that is prepaid, particularly through taxes and mandatory contributions. Funding: Rockefeller Foundation, Ministry of Health of Japan, UK Department for International Development (DFID).

Biofortification is a promising strategy to combat micronutrient malnutrition by promoting the adoption of staple food crops bred to be dense sources of specific micronutrients. Research on biofortified orange-fleshed sweet potato (OFSP) has shown that the crop improves the vitamin A status of children who consume as little as 100 grams per day, and intensive promotion strategies improve dietary intakes of vitamin A in field experiments. However, little is known about OFSP adoption behavior, or about the role that nutrition information plays in promoting adoption and changing diet. We report evidence from similar randomized field experiments conducted in Mozambique and Uganda to promote OFSP. We further use causal mediation analysis to study impact pathways for adoption and dietary intakes. Despite different agronomic conditions and sweet potato cropping patterns across the two countries, the project had similar impacts, leading to adoption by 61% to 68% of farmers exposed to the project, and doubling vitamin A intakes in children. In both countries, two intervention models that differed in training intensity and cost had comparable impacts relative to the control group. The project increased the knowledge of key nutrition messages; however, added knowledge of nutrition messages appears to have minimally affected adoption, conditional on assumptions required for causal mediation analysis. Increased vitamin A intakes were largely explained by adoption and not by nutrition knowledge gained, though in Uganda a large share of impacts on vitamin A intakes cannot be explained by mediating variables. Similar impacts could likely have been achieved by reducing the scope of nutrition trainings.

Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the