World Bank’s Thematic Group on Health, Nutrition and Population and Poverty REACHING THE POOR...

World Bank’s Thematic Group on Health, Nutrition and Population and PovertyREACHING THE POOR CONFERENCE, February, 2004

ASSESSING CHANGES IN TARGETING

IN HEALTH AND NUTRITION POLICIES:THE CASE OF ARGENTINA

(Part A)

Leonardo Gasparini Mónica Panadeiros

Fundación de Investigaciones Económicas LatinoamericanasBuenos Aires, Argentina

I. IntroductionI. Introduction

• Argentina suffered a deep recession from 1998 to 2002: GDP fell 18.4% between those years.

REACHING THE POOR CONFERENCE (February 18-20, 2004)Gasparini-Panadeiros, Part A

80

100

120

140

160

180

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Real GDP, 1990=100

Source: authors´ calculations based on Ministerio de Economía.

• In concordance, inequality and poverty have substantially increased. The poverty headcount ratio was 20.1% in 1998; four years later that rate had increased to 54.3%.


0.40

0.45

0.50

0.55

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

0

10

20

30

40

50

60

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Gini coefficientHousehold per capita incomeGreater Buenos Aires, 1990-2002

Poverty headcount ratioGreater Buenos Aires, 1990-2002

Source: CEDLAS (2003)

• In this scenario, it is very relevant to target the (scarce) public resources to the needy.

• This study contributes to the understanding of the distributional incidence of social policies in Argentina. In particular, we focus the analysis on health and nutrition policies directed to pregnant women and children under 4. This presentation deals with maternal and child health services.


II. II. Maternal and child health programsMaternal and child health programs• The health system is organized around a strong

participation of the public sector: besides regulating health services, it owns and operates an extensive network of public hospitals and primary health care centers.


Public sector54%

Private sector43%

Social Security3%

Health care beds (1995)

• The public health system is universal: no requirements are needed to use most of the services in public health facilities.

• In these health facilities, people have access to all sorts of services free of charge, but to outpatient drugs.

• The access to the system is also free in enrollment: any citizen is allowed to attend the primary health center and/or hospital freely chosen each time.


• In this study, we concentrate the analysis on the following health services to pregnant women and children under 4:

- Antenatal care

- Attended delivery

- Visits to a physician

- Medicines

- Hospitalizations


III. MethodologyIII. Methodology

• One of the main questions the study is intended to contribute to the answer is: “Who are the beneficiaries of public health programs directed to pregnant women and children?”

• To tackle this question, we perform a traditional benefit-incidence analysis of public spending on these programs.

• A benefit-incidence analysis allows an assessment of the degree of targeting of average public spending.


• An usual assumption is that users of the subsidized service and their families are the beneficiaries of the public program.

• Benefits from a specific program are assigned to individuals according to their answers to a household survey on the use of that program.

• Information from two Living Standard Surveys with questions on the use of various health services (1997 and 2001) is used in this study.


• A crucial stage in a benefit-incidence analysis is sorting households by a welfare indicator.

• We mostly use household income adjusted for demographics, or equivalized household income, as the individual welfare indicator.

• Total population and children are grouped in quintiles of the distribution of equivalized households income. By construction, quintiles have 20% of total population. Instead, since the number of children per household is decreasing in income, the share of children is not uniform along income distribution.



Population and children by quintilesDistribution of equivalized household income

1997

Shares 1 2 3 4 5 Total

All 20.0 20.0 20.0 20.0 19.9 100.0

Children under 2 29.7 24.6 19.1 13.6 13.0 100.0

Children under 4 30.1 24.5 18.4 14.8 12.1 100.0

2001

Shares 1 2 3 4 5 Total

All 20.0 20.0 20.0 20.0 19.9 100.0

Children under 2 27.6 21.7 20.1 15.6 15.1 100.0

Children under 4 27.8 21.6 20.4 15.6 14.6 100.0

Source: authors´ calculations based on the EDS and ECV.

• To find the beneficiaries of each public program, we proceed in three stages by identifying (i) the potential users of the service (for example: mothers with children under 2 in the case of antenatal care), (ii) the effective use of the service, and (iii) the public/private choice.

• The fact that the number of children per household (potential users) is decreasing in income, will have a fundamental consequence on the distributional incidence of public programs directed to children. Even a universal program to all children will be pro-poor, given the negative correlation between the number of children and household income. This relationship became less strong between 1997 and 2001, implying a potential reduction in the targeting of social policies.



IV. FindingsIV. FindingsAntenatal careAntenatal care

• Antenatal care is widespread in Argentina, even for poor mothers. Subsidies are highly pro-poor. This pro-poor pattern is basically the consequence of a greater concentration of children under 2 in the bottom tail of the distribution, and a choice of public facilities significantly decreasing in income.

• The degree of targeting decreased between 1997 and 2001. This change seems to be mostly the consequence of a reduction in the share of children under 2 in the bottom quintile, and the increase in the use of public facilities in mid and high-income households.


Antenatal care By quintiles of the equivalent household income distribution


19971 2 3 4 5 Total

Children under 2 29.7 24.6 19.1 13.6 13.0 100.0

% visits 94.8 96.3 99.5 99.4 98.4 97.1

Visits in public facilities 81.6 56.0 46.0 25.7 7.6 51.6

Incidence 46.5 26.8 17.7 7.0 2.0 100.0

20011 2 3 4 5 Total

Children under 2 27.6 21.7 20.1 15.6 15.1 100.0

% visits 97.6 96.5 97.6 98.5 99.2 97.7

Visits in public facilities 85.6 68.1 52.4 27.7 9.0 54.9

Incidence 43.3 26.8 19.3 8.0 2.5 100.0


Attended deliveryAttended delivery

• Most deliveries in urban Argentina are assisted by a medically trained person.

• Deliveries in public hospitals are much more often for poor than for rich mothers.

• Given that fertility is higher in poor households and the use of public hospitals is more widespread, the subsidy to attended deliveries in public hospitals is clearly pro-poor.

• This service seems to have become less targeted over time.


Attended delivery By quintiles of the equivalent household income distribution


19971 2 3 4 5 Total

Children under 2 29.7 24.6 19.1 13.6 13.0 100.0

% attended delivery 98.3 99.4 99.9 100.0 100.0 99.3

Delivery in public hospital 79.5 59.4 49.1 27.3 10.9 53.4

Incidence 44.5 27.7 17.9 7.1 2.7 100.0

20011 2 3 4 5 Total

Children under 2 27.6 21.7 20.1 15.6 15.1 100.0

% attended delivery 98.3 99.4 99.9 100.0 100.0 99.3

Delivery in public hospital 83.4 67.5 49.5 33.0 11.3 55.0

Incidence 41.9 27.0 18.4 9.5 3.2 100.0


Visits to a doctorVisits to a doctor

• There are differences in the 1997 and 2001 questionnaires. The 1997 survey reports consultations with a physician only for those children reported sick. The 2001 survey instead asks directly for consultations with a physician. Because of that, there are large differences in the share of children seen by a doctor in 1997 and 2001. If in 2001 we restrict the analysis to those reported sick, the shares are similar.

• The share of children under 4 who visited a doctor in the month previous to the survey is more sensitive to household income in the 2001 survey than in the 1997 survey.

• This is a sign that taking a child to the doctor when not considering her sick is a more frequent behavior in wealthier households than in poorer ones.


• Results for both 1997 and 2001 clearly indicate a pro-poor profile of public subsidies. Around 70% of the beneficiaries of these subsidies are individuals in the two poorest quintiles of the population.

• The main reasons of this pro-poor pattern is the greater concentration of children under 4 in the bottom tail of the distribution, and a choice of public facilities decreasing in income.

• The degree of targeting decreased between 1997 and 2001.


Visits to doctor By quintiles of the equivalent household income distribution

Source: authors´ calculations based on the EDS and ECV.Note: (1) calculated as the product of the two previous rows, (2) actual answers. (3) Incidence is estimated as in (1).

19971 2 3 4 5 Total

Children under 4 30.1 24.5 18.4 14.8 12.1 100.0

Reported sick 33.6 36.6 34.5 37.3 37.1 35.5

Saw a doctor if reported sick 90.7 90.8 92.4 94.4 95.4 92.2

Saw a doctor 30.5 33.3 31.9 35.2 35.4 32.7

Publicly financed 83.0 61.5 45.0 22.3 11.1 51.7

Incidence 45.1 29.6 15.6 6.9 2.8 100.0

20011 2 3 4 5 Total

Children under 4 27.8 21.6 20.4 15.6 14.6 100.0

Reported sick 31.3 34.7 35.9 31.8 44.3 35.0

Saw a doctor if reported sick 81.3 79.0 84.7 85.0 90.7 83.8

Saw a doctor (1) 25.4 27.4 30.4 27.1 40.2 29.3

Saw a doctor (2) 46.7 51.2 54.9 57.3 65.9 53.8


Incidence (3) 43.2 27.5 19.1 6.7 3.4 100.0


HospitalizationsHospitalizations

• Subsidies to this service are highly pro-poor, but the degree of targeting has decreased over time.

• During 1997-2001 there has been a slow increase in the use of public facilities. That increase was rather widespread along the income distribution.


Hospitalizations By quintiles of the equivalent household income distribution


19971 2 3 4 5 Total

Children under 4 30.1 24.5 18.4 14.8 12.1 100.0

In-hospital last year 8.8 10.6 6.9 7.1 7.0 8.4


Incidence 42.5 35.0 15.1 5.9 1.5 100.0

20011 2 3 4 5 Total

Children under 4 27.8 21.6 20.4 15.6 14.6 100.0

In-hospital last year 9.6 6.8 10.9 9.1 4.5 8.4


Incidence 44.5 17.5 27.1 9.1 1.8 100.0


MedicinesMedicines

• Only some medicines are given for free or at subsidized prices at public health facilities.

• The results unambiguously suggests a pro-poor profile of public subsidies to medicines for children in public facilities. Around 50% of these drugs go to children from households in the bottom quintile of the income distribution.

• Again, there is a clear reduction in the degree of targeting of this public program between 1997 and 2001.


Medicines By quintiles of the equivalent household income distribution


19971 2 3 4 5 Total

Children under 4 30.1 24.5 18.4 14.8 12.1 100.0

Obtained prescribed medicines 96.7 94.9 97.7 96.4 97.3 96.5


Incidence 51.6 26.1 14.8 6.1 1.4 100.0

20011 2 3 4 5 Total

Children under 4 27.8 21.6 20.4 15.6 14.6 100.0

Obtained prescribed medicines 94.5 94.5 97.0 96.4 99.4 96.3


Incidence 49.4 21.7 16.3 8.7 3.9 100.0


Summarizing incidence resultsSummarizing incidence results

• All health programs considered are pro-poor. Incidence results do not significantly differ among these programs.

• The pro-poor pattern is basically the consequence of i) a greater number of children per household of low-income families relative to the rest; ii) a choice of public facilities significantly decreasing in income.

• The degree of targeting seems to have decreased for all health services considered since 1997.

• Demographic changes (fall in the relative fertility rates of poor people) would explain a sizeable part of the decrease in the degree of targeting.

• The other explanatory factor would be an increase in the use of public facilities by better-off households, likely triggered by the economic crises that Argentina has suffered since 1998.

World Bank’s Thematic Group on Health, Nutrition and Population and Poverty REACHING THE POOR...

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