World Bank

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World Banks Thematic Group on Health, Nutrition
and Population and PovertyREACHING THE POOR
CONFERENCE, February, 2004    ASSESSING
CHANGES IN TARGETING IN HEALTH AND NUTRITION
POLICIESTHE CASE OF ARGENTINA (Part
A)Leonardo Gasparini Mónica Panadeiros Funda
ción de Investigaciones Económicas
LatinoamericanasBuenos Aires, Argentina
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I. Introduction
REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

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

Real GDP, 1990100
Source authors calculations based on Ministerio
de Economía.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• 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.

Gini coefficient Household per capita
income Greater Buenos Aires, 1990-2002
Poverty headcount ratio Greater Buenos Aires,
1990-2002
Source CEDLAS (2003)
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• 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.

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

• II. Maternal 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.

Health care beds (1995)
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• 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.

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

• 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

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

• III. 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.

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

• 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.

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

• 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.

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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A
Population and children by quintilesDistribution
of equivalized household income
Source authors calculations based on the EDS
and ECV.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• 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.

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

• IV. Findings
• Antenatal 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.

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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A
Antenatal care By quintiles of the equivalent
household income distribution
Source authors calculations based on the EDS
and ECV.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• Attended 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.

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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A
Attended delivery By quintiles of the equivalent
household income distribution
Source authors calculations based on the EDS
and ECV.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• Visits 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.

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

• 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.

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

• Hospitalizations
• 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.

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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A
Hospitalizations By quintiles of the equivalent
household income distribution
Source authors calculations based on the EDS
and ECV.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• Medicines
• 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.

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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A
Medicines By quintiles of the equivalent
household income distribution
Source authors calculations based on the EDS
and ECV.
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REACHING THE POOR CONFERENCE (February 18-20,
2004) Gasparini-Panadeiros, Part A

• Summarizing 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.