Public Expenditures in Health

Main Principles Establish Market Failures Identify beneficiaries of expenditures Balance potential benefits with ability to deliver services

Health - Market Failures Public goods (pest control, sanitation, health education) Externalities (infectious disease control) Information advantage of doctors Insurance

Health - equity concerns Inequities in health status Inequities in benefits of services

The poor are sicker than other people: Under two mortality by “wealth”- Brazil, 1996

Prevalence of disease by “wealth”: India 1992-3

Female 45Q15 by cause of death by income group, China 1987

Health - Problems of Implementation Management challenge Personnel placement Quality of services Conscientious providers Maintenance of facilities Political Influence

Percentage of health centers without doctors by province: Indonesia I didn’t bother to put the names. I wanted to show correlation with income or urbanization but it didn’t work. But it is still true that there is something about the attractiveness of the area. Irian Jaya, central Kalimantan (Borneo) - high income from logging or minerals but lousy places to live - grey are mostly poor. Light blue are Java/Bali/Sumatra nice places to live.

Absence rates from public health care centers: Bangladesh 2002

Health: Complementarity/ conflict between goals Public goods - strong complementarity Primary health care - modest efficiency effects (varies), potentially high equity effects, difficult management Hospitals - high efficiency, high potential but low actual equity effects, easier management(?)

In Brazil, the poor have worse sanitation facilities… Percent of households with no sanitation facilities

…they have less access to safe water…

…and this costs the lives of their children

What’s this look like in Egypt What’s this look like in Egypt? Percentage of households with no sanitation facilities

And for Jordan?: Sanitation facilities by household wealth 100% Other 50% Covered Dry Toilet/septic 0% Toilet/sewage 1 2 3 4 5 6 7 8 9 10

Jordan: Sanitation facilities by governorate 100% 80% Other 60% Covered Dry Toilet/septic 40% Toilet/sewage 20% 0% Balqa Irbid Zarqa Mafraq Jerash Ajloun Karak Tafileh Ma'an Madaba Aqaba Amman

Health: Complementarity/ conflict between goals Public goods - strong complementarity Primary health care - modest efficiency effects (varies), potentially high equity effects, difficult management Hospitals - high efficiency, high potential but low actual equity effects, easier management(?)

Determinants of infant mortality

Philippines: Effect of public medical care Poor area Not-so-poor area

Substitution between public and private providers

Substitution between public and private providers in Jordan A 10% increase in primary health care facilities per capita (by governorate): - increases their use by 4.4% - decreases use of private facilities by 3.2% - decreases use of public hospitals by 2.6% Net effect?

Distribution of health care subsidies, Indonesia

Jordan: Not enough information Place of first health consultation by household wealth 100% UNRWA Gvt health ct 50% Pvt clinic 0% Gvt hospital 1 2 3 4 5 6 7 8 9 10 Pvt hospital

Health: Complementarity/ conflict between goals Public goods - strong complementarity Primary health care - modest efficiency effects (varies), potentially high equity effects, difficult management Hospitals - high efficiency, high potential but low actual equity effects, easier management(?)

Value of insurance as a % of expected cost

Priorities in health policy