Kakwani Index Research Articles

Explaining socioeconomic inequality in food consumption patterns among households with women of childbearing age in South Africa.

The changing food environment shifts peoples' eating behaviour toward unhealthy food, including ultra-processed food (UPF), leading to detrimental health outcomes like obesity. This study examines changes in socioeconomic inequalities in food consumption spending between 2005/06 and 2010/11 in South African households with women of childbearing age (15 to 49) (WCBA). Data come from the 2005/06 and 2010/11 Income and Expenditure Surveys. The distribution of spending according to the NOVA food classification system groupings (unprocessed or minimally processed foods, processed culinary ingredients, processed and UPF products) was analysed using standard methodologies. Changes in spending inequalities between 2005/06 and 2010/11 were assessed using the concentration index (C), while the factors explaining the changes in spending inequalities were identified using the Oaxaca decomposition approach. The Kakwani index (K) was used to assess progressivity. Results show that average real spending on all food categories, including UPF, increased between 2005/06 and 2010/11. Socioeconomic inequality in UPF consumption spending decreased (C = 0.498 in 2005/06 and C = 0.432 in 2010/11), and spending on processed foods (C = 0.248 in 2005/06 and C = 0.209 in 2010/11). Socioeconomic status, race, and urban residence contributed to overall socioeconomic inequality and changes in UPF consumption inequality between 2005/06 and 2010/11. Spending on all food categories was regressive in 2005/06 (K = -0.173 for UPF and -0.425 for processed foods) and 2010/11 (K = -0.192 for UPF and -0.418 for processed foods) because such spending comprises a larger share of poorer household's income than their wealthier counterparts. The government should address these contributors to inequality to mitigate the risks associated with UPF consumption, especially among less affluent households.

An analysis of financial protection and financing incidence of out-of-pocket health expenditures in Kazakhstan from 2018 to 2021

Universal health coverage relies on providing essential medical services and shielding individuals from financial risks. Our study assesses the progressivity of out-of-pocket (OOP) payments, identifies factors contributing to healthcare expenditure inequality, and examines catastrophic health expenditures (CHE) prevalence in Kazakhstan from 2018 to 2021. Using retrospective analysis of National Statistics Bureau data, we employed STATA 13 version for calculations CHE incidence, progressivity, Lorenz and concentration curves. In 2020–2021, OOP expenditures in Kazakhstan decreased, reflecting a nearly twofold reduction in the CHE incidence to 1.32% and 1.24%, respectively. However, during these years, we observe a transition towards a positive trend in the Kakwani index to 0.003 and 0.005, respectively, which may be explained by household size and education level factors. Increased state financing and quarantine measures contributed to reduced OOP payments. Despite a low healthcare expenditure share in gross domestic product, Kazakhstan exhibits a relatively high private healthcare spending proportion. The low CHE incidence and proportional expenditure system suggest private payments do not significantly impact financial resilience, prompting considerations about the role of government funding and social health insurance in the financing structure.

Assessing equity and efficiency of health financing towards universal health coverage between regions in Tanzania

Equity and efficiency in health financing are intermediate universal health coverage (UHC) objectives. While there is growing attention to monitoring these goals at the national level, subnational assessment is also needed to uncover potential divergences across subnational units. We assessed whether health funds were allocated or contributed equitably and spent efficiently across 26 regions in Tanzania in 2017/18 for four sources of funding. Government and donor health basket fund (HBF) expenditure data were obtained from government authorities. Household contributions to health insurance and out-of-pocket payments were obtained from the national household budget survey. We used the Kakwani index (KI) to measure regional funding equity, whereby regional GDP per capita measured regional economic status. Efficiency analysis included four financing inputs and two UHC outputs (maternal health service coverage and financial protection indices). Data envelopment analysis estimated efficiency scores. There was substantial variation in per capita regional funding, especially in insurance contributions (TZS 473–13,520), and service coverage performance (49–86.3%). There was less variation in per capita HBF spending (TZS 1294–2394) and financial protection (93.5–99.4%). Government spending (KI: -0.047, p = 0.348) was proportional to regional economic status; but HBF spending (KI: -0.195, p < 0.001) was significantly progressive (equitably distributed), being targeted to regions with high economic need (poor). The burden of contributing to social health insurance (NHIF) was proportional (KI: 0.058, p = 0.613), while the burden of paying for community-based insurance (CHF, KI: -0.152, p=0.012) and out-of-pocket payments (KI: -0.187, p=0.005) was higher among the poor (regressive). The average efficiency score across regions was 90%, indicating that 90% of financial resources were used optimally, while 10% were wasted or underutilised. Tanzania should continue mobilising domestic resources for health towards UHC, and reduce reliance on inequitable out-of-pocket payments and community-based health insurance. Policymakers must enhance resource allocation formulas, public financial management, and sub-national resource tracking to improve equity and efficiency in resource use.

E‐commerce and Consumption Inequality in China

AbstractConsumption inequality may impede economic development and hinder the achievement of common prosperity. Using three waves of the China Family Panel Studies from 2014 to 2018, this paper investigated the impact of e‐commerce on consumption inequality, as measured by the Kakwani index. The results indicate that e‐commerce can reduce household consumption inequality. A mechanism analysis shows that e‐commerce can narrow household income inequality, increase the purchasing power of low‐income households, and promote the consumption of households with limited access to offline markets, thereby reducing the consumption gap. A heterogeneity analysis suggests that the positive role of e‐commerce in reducing consumption inequality can be more significant among vulnerable households, such as households with elderly members and less‐educated households. E‐commerce can have varying impacts on consumption inequality across different subcategories of household expenditure, with the greatest impact seen in entertainment and education expenditure. These findings provide new evidence for the role of e‐commerce in reducing consumption inequality in the digital economy, and the implications of this are discussed.

The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data

Indonesia has committed to deliver universal health coverage by 2024. Reforming the country's health-financing system is key to achieving this commitment. We aimed to evaluate how the benefits and burden of health financing are distributed across income groups and the extent to which Indonesia has achieved equity in the funding and delivery of health care after financing reforms. We conducted benefit incidence analyses (BIA) and financing incidence analyses (FIA) using cross-sectional nationally representative data from several datasets. Two waves (Feb 1 to April 30, 2018, and Aug 1 to Oct 31, 2019) of the Equity and Health Care Financing in Indonesia (ENHANCE) study household survey involving 7500 households from ten of the 34 provinces in Indonesia were used to obtain health and socioeconomic status data for the BIA. Two waves (2018 and 2019) of the National Socioeconomic Survey (SUSENAS), the most recent wave (2014) of the Indonesian Family Life Survey, and the 2017 and 2018 National Health Accounts were used to obtain data for the FIA. In the BIA, we calculated a concentration index to assess the distribution of health-care benefits (-1·0 [pro-poor] to 1·0 [pro-rich]), considering potential differences in health-care need. In the FIA, we evaluated the equity of health-financing contributions by socioeconomic quintiles by calculating the Kakwani index to assess the relative progressivity of each financing source. Both the BIA and FIA compared results from early 2018 (baseline) with results from late 2019. There were 31 864 participants in the ENHANCE survey in 2018 compared with 31 215 in 2019. Women constituted 50·5% and men constituted 49·5% of the total participants for each year. SUSENAS had 1 131 825 participants in 2018 compared with 1 204 466 in 2019. Women constituted 49·9% of the participants for each year, whereas men constituted 51·1%. The distribution of health-care benefits in the public sector was marginally pro-poor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0·008, 95% CI -0·075 to 0·059) and 2019 (-0·060, -0·139 to 0·019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0·134, 0·065 to 0·203, p=0·0010) and 2019 (0·190, -0·192 to 0·572, p=0·0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0·034, 95% CI 0·030 to 0·038) to mildly regressive in 2019 (-0·030, -0·034 to -0·025). Although Indonesia has made substantial progress in expanding health-care coverage, a lot remains to be done to improve equity in financing and spending. Improving comprehensiveness of benefits will reduce out-of-pocket spending and allocating more funding to primary care would improve access to health-care services for people with low income. UK Health Systems Research Initiative, UK Department of International Development, UK Economic and Social Research Council, UK Medical Research Council, and Wellcome Trust.

A note on the orness classification of the rank-dependent welfare functions and rank-dependent poverty measures

This note focuses on ordering two families of rank-dependent poverty measures in terms of their distribution-sensitivity. It has been proved that a real value, between 1/2 and 1, called orness, which is assigned to every rank-dependent poverty measure, can be interpreted as a distribution-sensitivity indicator. Therefore, the rank-dependent poverty measures can be classified in terms of their distribution-sensitivity using the orness value assigned to them. This ranking has already been carried out for numerous poverty measures. However, two families of poverty measures, the Kakwani and the S-Gini families, which are defined for every real parameter larger than one, have only been ranked for natural values of their parameters. This note broadens the classification of these families for every real parameter larger than one, that is, for every member of these two families. It also provides a ranking between the two families for the same parameter. It concludes that for higher values of the parameter, the families will be more sensitive to the bottom part of the distribution. Furthermore, for the same value of the parameter, the Kakwani index will be more sensitive to poor incomes than the S-Gini index. In addition, we will see that the proposed ranking for the two families in terms of the orness value will be analogous to other distribution-sensitivity criteria existing in the literature.

How Accurate is the Kakwani Index in Predicting Whether a Tax or a Transfer is Equalizing?

The Kakwani index of progressivity is commonly used to establish whetherthe effect of a specific tax or transfer is equalizing. In the presence ofreranking or Lambert’s conundrum, however, a progressive tax could beunequalizing. While it is mathematically possible for counter-intuitiveresults to occur, how common are they in actual fiscal systems? Using anovel dataset that includes fiscal-incidence results for 39 countries, we findthat the likelihood of the Kakwani index to be progressive (regressive),while the tax or transfer is unequalizing (equalizing), is minimal, except inthe case of indirect taxes: in roughly 25 per cent of our sample, regressiveindirect taxes are equalizing (sign-inconsistent cases). Additionally, thelikelihood that the Kakwani index ranks the magnitude of the impact of atax or transfer wrongly also exists but it too is small. Finally, usingregression analysis, we find that increasing the size or progressivity of aprogressive tax or transfer is equalizing and statistically robust forsign-consistent cases. For sign-inconsistent cases, the coefficient for theKakwani index is not statistically significant. In sum, although theKakwani index could yield interpretations that are inaccurate in actualfiscal systems, the risk seems small, except for indirect taxes.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey

BackgroundThe vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda.MethodsParticipants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles.ResultsThere was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups.ConclusionsEfforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Progressivity of out-of-pocket costs for Medicare-subsidised services and medicines in Australia.

ObjectivesIn line with affordability and equity principles, Medicare—Australia’s universal public health insurance system—has measures to limit out-of-pocket costs (OOPC), especially among lower income households. We examined the distribution of OOPC for Medicare-subsidised out-of-hospital services and prescription medicines, for Census households, according to their ability to pay. MethodsWe used 2016 Australian Census data linked to Medicare claims to obtain OOPC for out-of-hospital services and medicines in each household in 2017-18. We derived household disposable income by combining income information from the Census linked to income tax and social security data. All data were available from the Multi-Agency Data Integration Project, enabled through a partnership of various government agencies. We quantified OOPC as a proportion of equivalised household disposable income and calculated Kakwani indices (K) to measure progressivity. We also used linked National Health Survey data to analyse costs separately by chronic conditions. ResultsWe analysed 85% (n=6,830,365) of all Census private households. Overall, OOPC as a percentage of equivalised household disposable income decreased from 1.16% (out-of-hospital services) and 1.35% (prescription medicines) in the poorest decile to 0.63% and 0.34% in the richest decile, respectively. The regressive trend was less pronounced for out-of-hospital services (K = -0.06), with percentage OOPC relatively stable between the 2nd and 9th income deciles; while percentage OOPC decreased steeply with increasing income for medicines (K = -0.24). (Chronic conditions results will be presented—embargoed at time of submission) ConclusionOOPC for out-of-hospital Medicare services were mildly regressive while those for prescription medicines were distinctly regressive. Actions to reduce inequity in OOPC for medicines, such as reducing the co-payments for low income households should be considered.

Evaluating Health Inequality in Five Caribbean Basin Countries Using EQ-5D-5L.

BackgroundEQ-5D-5L is a standardized health outcomes instrument that can be added to national surveys to measure inequality in health outcomes. The aim of this study was to produce baseline values of health inequality using EQ-5D-5L for five countries in the Caribbean Basin region based on national surveys in 2012–2014.MethodsThe EQ-5D-5L questionnaire was included in adult population surveys of Barbados, Belize, Colombia, Jamaica and Trinidad and Tobago. EQ-5D-5L measures were calculated for demographic groups using stratifiers from the World Health Organization’s PROGRESS-Plus framework, and generalized linear models were used to test for association between EQ-5D-5L and the PROGRESS-Plus variables. Ordered logit models were used to obtain odds ratios for the effect of the PROGRESS-Plus variables on reporting problems on the EQ-5D-5L dimensions. The Kakwani index was calculated for each country.ResultsData were obtained for representative samples in each country, giving a combined total of 11,284 respondents. Different patterns of inequality were observed among the five countries. The biggest drivers of inequality were age and gender, and the biggest EQ-5D factors were self-care in Belize and pain/discomfort in the other four countries.ConclusionThis study demonstrated that the EQ-5D-5L instrument can easily be added to national surveys. Inequality measures from this study can be used as baseline values for comparisons with future similar surveys in these five countries to infer changes in health inequality as measured by EQ-5D outcomes. These can be used to track the performance of policy initiatives aimed at specific demographic groups.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-022-00754-9.

Tax progressivity and social welfare with a continuum of inequality views

We develop a framework for analysing the loss of social welfare due to taxation, where tax progressivity and regressivity, measured by the Kakwani index, are given interpretation in terms of welfare gain and loss, respectively. Our framework generalises the framework of Kakwani and Son (J Econ Inequal 19:185–212, 2021), by taking account of the intermediate inequality views, a continuum of combinations of the relative view (equal relative change of all incomes does not change inequality) and the absolute view (equal absolute change of all incomes does not change inequality). The welfare loss of taxation is decomposed into three components, one being a generalised Kakwani index, which accommodates the intermediate inequality views. We show that for a progressive (regressive) tax, moving closer to the relative view reduces (increases) the importance of progressivity (regressivity) for the welfare impact of the tax. The perception of the importance of progressivity and regressivity is thus affected by the inequality view taken. The empirical application considers the welfare loss of taxation in Croatia.

Application of reduced social welfare functions for estimating household insurance expenditures in Poland

Due to the role of insurance in economy, the factors determining the demand for insurance (e.g. income) have been the subject of many studies. On the other hand, income inequalities significantly affect many purchasing decisions and the perception of income among individuals. The aim of this study is to verify the relationship between social welfare and insurance expenditure. This verification was carried out on the basis of data on various socio-economic groups in Poland by using reduced social welfare functions such as: the Sen Index, Kakwani Index, Dagum indexes and the ‘naïve’ welfare function (income). As part of the research, a linear regression was applied between the dependent variable (average monthly expenses on insurance per 1 person in households by socio-economic groups) and the explanatory variable (reduced welfare functions) for a given social group. Reduced social welfare functions was determined on the basis of the average monthly disposable income per capita in households and the Gini coefficient for this group. Social welfare in the form of reduced welfare functions turned out to be a statistically better predictor of insurance expenditure than the income itself for social groups with relatively small income disparities (low Gini coefficient). For the group of farmers in Poland, where the income disproportions were statistically the largest, income turned out to be a better predictor.

Is the “social face” of AKP's pharmaceutical price reforms mostly instrumental? A progressivity analysis of household pharmaceutical expenditures in Turkey

ObjectivesRedistributive health policies aim to orchestrate welfare distribution in response to the needs of the underprivileged sections of society. Turkey has undertaken a massive pharmaceutical price reform since 2009 to show a more appealing, positive side to its citizens. This investigation examines the welfare implications of pharmaceutical price reductions on Turkish households. MethodsData from the Turkish Statistical Institute, pertaining to the national household budget survey for 2003, 2009, 2015, and 2019, were collected and analyzed. Difference-in-difference estimators combined with propensity score matching were applied to repeated cross-sectional microdata to evaluate the impact of strict pharmaceutical price policy on households’ out-of-pocket (OOP) pharmaceutical expenditures. ResultsThe Kakwani index and the Lorenz and concentration curves revealed a coherently regressive pattern and highlighted that vulnerable groups shoulder the burden of pharmaceutical expenditures (KW2003 = −0.49; KW2009 = −0.61; KW2015 = −0.62; KW2019 = −0.52). Because of the positive and significant interaction parameter obtained from caliper matching (0.06090, P < 0.05), the increase in OOP pharmaceutical expenditure is high in households with catastrophic OOP health expenditure. ConclusionsThe effective use of fiscal capacity, the continual monitoring of the household poverty effect of pharmaceutical price reductions, and the groundwork for a developmental pharmaceutical sector industrial policy agenda are imperative to disseminating the benefits of universal health coverage and constructing rationally conceived inclusive policies.

Distributive Pattern of Health Services Utilization Under Public Health Reform and Promotion in Turkey

Objectives: Inclusive health policies and health promotion to ensure strong primary healthcare systems are main tenets of health reforms in developing countries, such as Turkey. Nevertheless, there has been a lack of interest regarding the assessment of equity in health services utilization under public health reform and promotion of primary care. This study aims to analyze equity by measuring deviations from proportionality in the relationship between the utilization of health services and income using indices and curve approaches. MethodsA cross-sectional national Turkey Health Survey used the years 2008, 2010, 2012, and 2014. Gini and Kakwani indices and concentration curves were estimated, and the degree of regressivity was analyzed to understand the sources of equity in health services utilization. ResultsHealth services utilization for inpatient and outpatient services and family medicine and general practitioner services were regressive between the years 2008 and 2014. The most regressive pattern was observed in the year 2014 regarding medicine usage (Kakwani index = –0.1808904). ConclusionsDifferences in the utilization of health services have increased, hurting the poorest during the health reform in Turkey. Policies focused on health promotion to strengthen the primary health system and continuous monitoring of health services utilization by vulnerable groups are essential for ensuring a fairer health service usage in developing countries.

Vertical Equity in Healthcare Financing: A Progressivity Analysis for the Italian Regions.

Background: The aim of this paper is to measure for the first time in Italy the progressivity of healthcare financing systems at the regional level by using the Kakwani index (KI), the most widely used summary measure of progressivity in the healthcare financing literature. Methods: KIs were reported by region and by health financing sources for the year 2015. Results: There were significant vertical inequities in healthcare financing at both national and regional level. OOP (out-of-pocket) payments and value added tax were slightly regressive; income taxation on firms and households was progressive. Conclusions: After the introduction of fiscal federalism during the 90s, the healthcare financing system became regressive. A regional divide emerged: Overall regressivity is higher in the south and lower in the north, partly compensated by the interregional equalization mechanism, based on the redistribution of VAT from northern to southern regions. In times of policy interventions aiming at recovering the economy during the COVID-19 pandemic, it is important to monitor equity in healthcare financing.

Equity of health care financing in South Korea: 1990\u20132016

BackgroundThe National Health Insurance in Korea has been in operation for more than 30 years since having achieved universal health coverage in 1989 and has gone through several policy reforms. Despite its achievements, the Korean health insurance has some shortfalls, one of which concerns the fairness of paying for health care.MethodUsing the population representative Household Income and Expenditure Survey data in Korea, this study examined the yearly changes in the vertical equity of paying for health care between 1990 and 2016 by the source of financing using the Kakwani index, considering health insurance and other related policy reforms in Korea during this period.ResultsThe study results suggest that direct tax was the most progressive mode of health care financing in all years, whereas indirect tax was proportional. The out-of-pocket payments were weakly regressive in all years. The Kakwani index for health insurance contributions was regressive but now is proportional to the ability to pay, whereas the Kakwani index for private health insurance premiums turned from progressive to weakly regressive. The Kakwani index for overall health care financing showed a weak regressivity during the study period.DiscussionThe overall health care financing in Korea has transformed from a slight regressivity to proportional over time between 1990 and 2016. It is expected that these changes were closely related to the improved equity of health insurance contributions from 1998 to 2008, which was the result of a merger of the health insurance societies and an amendment in the health insurance contribution structure. These results suggest that standardizing insurance managing organizations and financing rules potentially has positive implications for the equity of healthcare financing in a country where the major method of health care financing is social health insurance.

Improving equity in the distribution and financing of health services in Mauritius, a small island state with deeply rooted welfare state standards

BackgroundEnsuring benefits of free healthcare services are accessible to those in need is essential to achieve universal health coverage (UHC). Mauritius has sustained a welfare state over four decades with...

An empirical analysis of the impact of income inequality and social capital on physical and mental health - take China\u2019s micro-database analysis as an example

BackgroundIncome inequality is one of the important reflections of the unbalanced development of the world economy and can have adverse effects on physical and mental health.MethodsThis article used the 2018 China Family Panel Studies Database as an empirical analysis data source. The Kakwani index (KI) was used to measure income inequality, and social capital was broken into cognitive social capital and structural social capital. Our assessment was conducted by using STATA16 software for ordered logistic regression, verifying income inequality, social capital on correlation between physical and mental health firstly; then by gradual regression methods to verify intermediary effect, and demonstrate the social capital as an intermediary variable affecting physical and mental health as income inequality.ResultThe income inequality has a significant negative effect on physical and mental health (β = − 0.964, − 0.381; OR = 0.382, 0.758; P < 0.01), Social capital has a significant effect on physical and mental health (Cognitive SC(MH): β = 0.146 and 0.104, OR = 1.157 and 1.110, P < 0.01; Cognitive SC(PH): β = 0.046 and 0.069, OR = 1.047 and 1.071, P < 0.01; Structural SC(MH): β = − 0.005, 0.025 and 0.015, OR = 0.995, 1.025 and 1.015, P > 0.1, P < 0.01 and P < 0.01; Structural SC(PH): β = − 0.026, 0.009 and − 0.013, OR = 0.975, 1.009 and 0.987, P < 0.01, P > 0.1 and P < 0.01). Our analysis also showed that social capital (cognitive social capital and structural social capital) has an intermediary effect on physical and mental health due to income inequality.ConclusionThis study shows that income inequality can not only directly affect physical and mental health, but also through social capital intermediary utility indirectly affect physical and mental health, social capital has positive effects on physical and mental health. At the same time, income inequality and social capital’s effects on physical and mental health exist regional differences, urban-rural differences, and gender differences. Therefore, in the development of special policies to support and take care of vulnerable groups, special attention needs to be paid to poor rural areas and female groups.

Equity in healthcare financing following the introduction of the unified residents' health insurance scheme in China.

This study sought to explore whether there are significant disparities in the financing of healthcare between urban and rural populations following the introduction in 2016 of the Urban and Rural Resident Basic Medical Insurance (URRBMI) scheme in China. We used household survey data from Heilongjiang province to estimate separate concentration curves in the financing burden and the resultant Kakwani indices (KIs) for urban and rural populations. This enabled the assessment of the progressivity (or otherwise) of this burden. The results show that in urban areas indirect taxes were proportional (KI = 0.0009, P = 0.8449), while indirect taxes in rural areas were progressive (KI = 0.0284, P = 0.0002). In both urban and rural areas, direct taxes were found to be progressive (urban: KI = 0.4628, P < 0.0001; rural: KI = 0.4087, P = 0.0064), while URRBMI was regressive (urban: KI = - 0.6236, P < 0.0001; rural: KI = - 0.4325, P < 0.0001). Out-of-pocket payments were proportional in urban areas (KI = - 0.0064, P = 0.7490); in contrast, they were regressive in rural areas (KI = - 0.1078, P = 0.0012). Overall, the burden of healthcare finance in urban China was found to be neither regressive nor progressive (KI = - 0.0142, P = 0. 1397), whereas in rural China it was found to be regressive (KI = - 0.1208, P < 0.0001). This result is driven by high reliance on regressive forms of funding, namely, fixed contributions to URRBMI, out-of-pocket costs and private health insurance. It is concluded that achieving equity in health financing in China will require strong measures to reduce the regressivity of financing, particularly for rural populations. This can be achieved through a shift towards means-adjusted URRBMI contributions, a greater reliance on tax-based financing and reducing the reliance on out-of-pocket payments and private health insurance.

Redistributive effects of health care out-of-pocket payments in Cameroon

BackgroundThe bulk of health care financing in Cameroon is derived from out-of-pocket payments. Given that poverty is pervasive, with a third of the population living below the poverty line, health care financing from out-of-pocket payments is likely to have redistributive and equity effects. In addition, out-of-pocket payments on health care can limit the ability of households to afford non-healthcare goods and services.MethodThe study estimates the Kakwani index for analyzing tax progressivity and applies the model developed by Aronson, Johnson, and Lambert (1994) to measure the redistributive effects of health care financing using data from the 2014 Cameroon Household Survey. The estimated indexes measure the extent of the progressivity of health care payments and the reranking that results from the payments.ResultsThe results indicate that out-of-pocket payments for health care in Cameroon in 2014 represented a significant share of household prepayment income. The results also show some evidence of inequity as few people change ranks after payment despite the slight progressivity of health care out-of-pocket payments.ConclusionThe existence of some disparities among income groups implies that the burdens of ill-health and out-of-pocket payments are unequal. The detected disparities within income groups can be reduced by targeting low-income groups through increases in government expenditures on health care and pro-poor prioritization of the expenditures.