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Accounting for geographical inequalities in the assessment of equity in health care: a benefi t incidence analysisLaura Anselmi, Quinhas F Fernandes, Kara Hanson, Mylene Lagarde
AbstractBackground Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefi t incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefi t distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such diff erences. We investigate how results would diff er if geographical inequalities were taken into account.
Methods We carry out four versions of BIA for outpatient public health-care expenditure in Manica Province, Mozambique and compare the results. First, following standard practice, we rank individuals by socioeconomic status (measured by their household consumption) and we use average expenditure across districts to estimate the individual benefi t. Second, we use a disaggregated measure of expenditure across districts to calculate the benefi t. Third, we rank individuals by a measure of need for health care based on socioeconomic status and average district health status (measured by child mortality). Fourth, we combine the second and third approaches. We use data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records.
Findings We fi nd that the gap in benefi t from public expenditure between highest and lowest quintiles widens substantially if diff erences in health status and expenditure across districts are taken into account, increasing from a ratio of 1·2 to 2·0.
Interpretation Results suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refi nement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems’ strengthening, and ultimately provide insights for a more equitable and effi cient allocation of resources.
Funding ML and KH are part of RESYST, a health systems research programme consortium funded by UKaid from the Department for International Development. The views expressed do not necessarily refl ect the department’s offi cial policies.
Contributors LA conceptualised the study, analysed the data, and wrote the fi rst draft. QFF contributed to the conceptualisation of the study and to data analysis
and validation. KH and ML supervised each phase and provided technical support when needed.
Confl icts of interest QFF is head of the Monitoring and Evaluation Department, Directorate of Planning and Cooperation, Ministry of Health of Mozambique. LA has
provided technical assistance to the Department of Planning and Health Economics, Directorate of Planning and Cooperation, Ministry of Health of
Mozambique. All other authors declare that they have no confl icts of interest.
Acknowledgments The authors wish to thank the Ministry of Health, the Ministry of Planning and Development, the Ministry of Finance, and the National Institute of
Statistics of Mozambique for providing all the data used in this analysis.
Published OnlineJune 17, 2013
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK (L Anselmi MPhil, Prof K Hanson PhD, M Lagarde PhD); Department of Global Health, Seattle, WA, USA (Q F Fernandes MD); and Directorate of Planning and Cooperation, Ministry of Health of Mozambique, Maputo, Mozambique (Q F Fernandes)
Correspondence to:Laura Anselmi, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, [email protected]
