DEFINING AND MEASURING FAIRNESS IN FINANCIAL CONTRIBUTION TO THE HEALTH SYSTEM 1

DEFINING AND MEASURING FAIRNESS IN FINANCIAL CONTRIBUTION TO THE HEALTH SYSTEM 1 Chrstopher JL Murray Felca Knaul Phlp Musgrove Ke Xu Ke Kawabata GPE Dscusson Paper Seres : No.24 EIP/GPE/FAR World Health Organzaton 1 We would lke to acknowledge the support receved from the Natonal Insttute of Agng through an Inter-Agency Agreement wth WHO that was used to undertake a part of ths work. We would also lke to thank Davd Evans, Julo Frenk, Emmanuela Gakdou, Patrca Hernández and Jean Perre Pouller for comments, suggestons and nputs; Ana Mylena Agular, Juan Pablo Ortz and Paola Zuñga for outstandng research assstance; the team of researchers at WHO workng on the WHO-NHA calculatons; and Gabrella Covno and Nankhonde Kasonde for support n edtng and producton.

I. Introducton One of the challenges common to all socal systems s to acheve farness n the dstrbuton of the fnancng burden, and protecton from the rsk of fnancal loss. For health systems, ths goal s of partcular mportance and especally dffcult to acheve due to the catastrophc and unpredctable nature of some expendtures. Socetes have long demonstrated a specal concern about how health systems are fnanced.(behrman 1995;Londoño & Frenk 1997;World Health Organzaton 2000)Much of the publc dscourse n countres undertakng health sector reform s focused on the desgn of health system fnancng and ts farness.(londoño & Frenk 1997;Wagstaff A & Van Doorslaer E 1998) The purpose of ths paper s to present a defnton, a measure and an ndex of farness n fnancal contrbuton to the health system. Our noton of farness s not a concern about the extent to whch contrbutons to the cost of the health system across households redstrbute ncome. Startng from a socety s efforts to redstrbute ncome, there are, nevertheless, mportant consderatons of farness that we try to defne and quantfy. Three ssues are crtcal to ths concept of farness: avodng catastrophc payments by households, horzontal equty and (to some extent) progressvty of contrbuton. Further, our approach separates fnancng from utlsaton, so that farness n fnancal contrbuton s determned ndependently of the health status of the ndvdual or household or the use of health servces. Our defnton, measure and ndex of farness n fnancal contrbuton are desgned and developed to be applcable across and wthn countres wth varyng types of health systems and at dfferent stages of development and of the health transton. The ndex can be used as a tool to analyse changes over tme wthn countres such as the results of health reform, economc crses, or polces such as decentralsaton. Some emprcal applcatons consderng dfferences across countres and relatng these to the organsaton of health systems are dscussed n companon publcatons.(world Health Organzaton 2000;Xu et al. 2000) The paper s dvded nto eght sectons. The second secton descrbes the overall WHO Framework for Measurng Health System Performance, for whch the measure of far fnance was desgned. The thrd secton provdes some background nformaton on health system fnancng arrangements. The fourth secton s a bref revew of the lterature on equty n health fnance. Secton fve dscusses the conceptual and theoretcal aspects of our measure of farness of health fnancng. Secton sx explores the propertes of the measure and ndex usng smulaton analyss. The seventh secton gves detaled nformaton on the constructon of the measure. The fnal secton provdes a summary, conclusons and a dscusson of future applcatons. II. WHO Framework for Assessng Health System Performance The measure of farness of fnancng presented here s part of a framework beng appled by the World Health Organsaton to assst countres to assess the overall performance of ther health systems. The framework sets out three ntrnsc goals: mprovng health, enhancng the responsveness of the system to the legtmate expectatons of the populaton; and assurng farness n fnancal contrbuton. For the frst two goals, we are concerned both wth rasng ther level and mprovng ther dstrbuton.. Health and responsveness are addressed n more detal n other papers. (Murray CJL & Frenk J 1999;World Health Organzaton 2000)

For fnancng, we consder only the dstrbuton, not the level, as there s no consensus on what the level of health spendng should be. The ntrnsc goals of the WHO framework do not nclude ether ncreasng or decreasng the amount spent on health. Whle the level of health spendng s clearly an mportant determnant of the outcomes of a health system on all three ntrnsc goals, t s not an ntrnsc goal n and of tself. Socetes must choose the approprate level of fnancng for the health system. Gven a level of spendng, however, every socety wll want the greatest amount of the socally desred mx of health, responsveness and farness n fnancal contrbuton possble; ths s the concept of performance or effcency. The choce of the level of total fnancng s a very mportant polcy choce but unlke health, responsveness, and farness n fnancal contrbuton, more consumpton of healthcare s not unequvocally better. Farness n fnancal contrbuton s an ntrnsc goal of a health system because t s a desred outcome n and of tself. Farness n fnancal contrbuton may also mprove access to health care and health outcomes, but ths nstrumental role of far fnancng s a separate ssue. Consder two systems, both havng exactly the same level of health, the same dstrbuton of health, the same responsveness and the same dstrbuton of responsveness. But n one, many households pay catastrophc shares of ther effectve non-subsstence ncome for health and n the other no household makes catastrophc payments. Most would agree that the system that protects households from catastrophc payment s more far and to be preferred. The goal of farness n fnancal contrbuton s nested wthn a framework of overall health system performance n whch t s not the only ntrnsc goal. A system n whch all households contrbute 0% of ther ncome to health s farly fnanced, but would do very poorly n the goals of producng health and responsveness. Smlarly, a system fnanced entrely through out-of-pocket payments where the poor pay very lttle because healthcare s unaffordable may score relatvely well on fnancal farness but wll do poorly on the level and dstrbuton of health and responsveness. The ncluson of farness n fnancng as an ntrnsc goal s mrrored by general preferences regardng the goals of health systems. In a survey where respondents were asked to weght the relatve mportance of all fve aspects of health system performance, farness n fnancal contrbuton s consdered by respondents to be as mportant as achevng hgher levels of health and greater equalty n the dstrbuton of health. Each of these goals receved a weght of 20-25%.(Gakdou, Frenk, & Murray 2000) III. Dversty of Health Fnancng Systems The household s the basc unt of analyss for ths and many other studes of fnancng. Whle funds for health servces may flow from households, employers and governments, t s households or ndvduals who ultmately own the productve resources n a socety. (Fuchs V.R. 1988;Iglehart J.K. 1999)Funds for health servces are extracted from households through such means as payroll deductons, ncome taxes, value-added taxes ncorporated nto the purchase prce of goods and servces, out of pocket payments for health care, and prvate nsurance premums. As Fuchs (Fuchs V.R. 1988) wrtes: The most basc pont, often obscured n publc dscussons, s that the publc must pay for care under any system of fnance. the ultmate cost falls on famles and ndvduals even when the payment mechansm makes t appear that the blls are beng sent elsewhere.

There are four man types of fnancng for health: government-rased (through general and specfc taxes); socal nsurance contrbutons (often leved through payroll and other taxes, as well as other contrbutons); prvate nsurance contrbutons; and outof-pocket payments. The frst three types of fnance are pre-pad, nvolve a substantal degree of rsk poolng and can protect both rch and poor from catastrophc and mpovershng health expendtures. Contrbutons are often a functon of ncome. It s mportant to emphasze that government-fnanced and socal nsurance schemes can, but do not necessarly, protect all ctzens. Partcular groups are often excluded such as the poor, recent mmgrants or nformal workers. Wthn the categores of government-rased and socal nsurance, there s also substantal varaton across countres. Most countres rely on a mx of value-added, ncome, excse and other taxes. The structure of each tax system reflects the preferences of each country for soldarty and progressvty, as well as the economc structure and wealth of the economy. Some countres rely heavly on general taxaton as compared to a socal nsurance or socal securty scheme. Further, countres vary n the proporton of the populaton covered by socal securty through payroll taxes, dependng on the sze of the formal labour market. Socal securty may be fnanced from general or payroll taxes, and there may be redstrbuton away from, or toward, those ndvduals that are nsured. In most cases, socal nsurance s pad for by dedcated payroll taxes where a fxed proporton goes to fnance health care for workers and ther famles. Some countres supplement ths wth funds collected through general taxes, whle others use funds from payroll collectons to fnance publc health programs that also cover the nformal populaton. Prvate payments are of two types: prvate nsurance premums and out-of-pocket payments. Prvate nsurance can protect ndvduals from catastrophc expendtures, but coverage, access and rsk poolng are often lmted. Prvate nsurance s typcally a good avalable only to the rch n poor countres, the healthy and those that lve n urban areas. Out of pocket payments are typcally made at pont-of-servce and the ndvdual consumers choose, as a functon of ncome, how much they are wllng and able to purchase. Catastrophc, and potentally mpovershng, expendtures arse because households wll sell assets and borrow from future potental earnngs n order to purchase care. The fnancng of out of pocket payments s, n fact, often severely constraned by the ndvdual or household access to credt and borrowng. Necessary care s forgone and expendtures are zero f the cost of care exceeds the ablty to pay at the tme of servce. Further, out of pocket payments are the most fragmented across ndvdual consumers, wth no possblty of poolng rsks. Out of pocket fnancng of health s the most lkely reason that would characterze unfar dstrbutons of health fnancng, and to generate severe fnancal losses and rsk of mpovershment for some famles. Ths s partcularly evdent n countres where other fnancng optons are restrcted to the rch, and out of pocket payments are the only opton for the poor.

By Source of Revenue % RAISED THROUGH GOVERNMENT TAXES 100 80 60 40 A E D 20 0 PRIVATE SPENDING = 100% Adapted from: Van Doorslaer and Wagstaff, 1993. B F 0 20 40 60 80 100 % RAISED THROUGH SOCIAL HEALTH INSURANCE C The health fnance mx tends to vary substantally across countres. The degree to whch governments rely on each of the four sources of funds government rased, socal health nsurance, prvate nsurance and out-of-pocket spendng -- vares substantally. A varety of combnatons are llustrated n Fgure 1. In ths dagram, the closer the pont s to the lne A-C, the less the relance on prvate spendng. A country that reled entrely on prvate out-of-pocket spendng would be found n the bottom left-hand corner (pont B). Systems fnanced (almost) entrely from one source-- such as at ponts A, B and C n Fgure 1 are rare. Most wealther and some developng countres rely on some combnaton of sources (pont D), wth certan countres leanng less heavly on out-of-pocket payments (Pont D as compared to Pont F). Many countres are close to ponts E or F wth a heavy relance on prvate fundng, most of whch s out of pocket n poor countres, to supplement publc and socal nsurance-based fnance. In only a few countres s prvate nsurance (pont G) mportant.(van Doorslaer E & Wagstaff A 1999) IV. Equty n Health Fnance Before presentng our framework on farness n fnancal contrbuton a useful startng pont s to revew the rch lterature on equty n health fnance.(wagstaff A & Van Doorslaer E 1998) Ths has grown out of the publc fnance lterature that analyzes the extent to whch the tax system acheves one of socety s goals, that of redstrbuton of ncome and wealth. In transferrng ths concept to the health system, equty n health fnance has been formulated as the extent to whch all forms of health payments (taxes, socal nsurance payments, prvate nsurance and out-of-pocket payments) contrbute to the redstrbuton of ncome. (Deaton A & Muellbauer J 1980) 2 Ths vew of equty n health fnance has been justfed usng two types of arguments. Frst, t s clamed that the health system should be consdered as one of many mechansms to redstrbute ncome and should thus be evaluated n terms of how well 2 There s good evdence that polcy-makers n the OECD countres are concerned about the effects of health care fnancng arrangements on the dstrbuton of ncome as well as on who receves health care (cf. E.g., OECD,1992).

t acheves ths ntrnsc goal. The second argument s nstrumental: health systems that redstrbute ncome are lkely to gve more access to the poor and thus lead to better health outcomes. Ths latter vew leads naturally to a related set of analyses on the dstrbuton of the benefts of health servces. As Van Doorslaer, Wagstaff et al.(van Doorslaer E & Wagstaff A 1999) note, the most nclusve measure of equty n health fnance s the total effect of health fnancng contrbutons on the redstrbuton of ncome. One way to capture ths net effect s to compare the Gn coeffcent of household ncome pror to health system payments wth the Gn coeffcent of household ncome after health system contrbutons. The total re-dstrbutve effect can be conceptually and quanttatvely dvded nto the contrbutons of vertcal equty and horzontal equty. 3 Vertcal equty s the extent to whch the rch pay more for the health system than the poor. Horzontal equty s the extent to whch households wth the same ncome pay the same amount to the health system. The extent to whch health system contrbutons redstrbute ncome s domnated by the progressvty of the contrbutons, wth the progressvty of each mode of fnancng weghted by ts mportance relatve to other sources. 4 Several authors have appled the well-developed methods for evaluatng the progressvty of tax payments to payments for health care.(aronson JR, Johnson P, & Lambert PJ 1994;Kakwan K 1977;Kakwan K, Wagstaff A, & Van Doorslaer E 1997;Kakwan N. 1997;Rasell E, Bernsten J, & Tang K 1994;Wagstaff A & Van Doorslaer E 1992;Wagstaff A & Van Doorslaer E 1993;Wagstaff A & Van Doorslaer E 1999;Wagstaff A., Van Doorslaer E, & Pac P 1989;Aronson JR, Johnson P, & Lambert PJ 1994;Aronson JR, Johnson P, & Lambert PJ 1994;Aronson JR, Johnson P, & Lambert PJ 1994;Aronson JR, Johnson P, & Lambert PJ 1994;Aronson JR, Johnson P, & Lambert PJ 1994) Many of these studes have used the Kakwan ndex, whch consders the degree to whch a payment (for tax or health care) departs from proportonalty, where proportonalty s measured aganst the dstrbuton of pre-payment ncome n the populaton. The method nvolves plottng ranked pre-payment ncome aganst the cumulatve proporton of health care payments. The area between the two dstrbutons provdes a measure of the extent of regressvty or progressvty n health care payments relatve to that of ncome (Fgure 2). 5 When health system contrbutons are progressve the Kakwan ndex wll be postve and when health system contrbutons are regressve the Kakwan ndex wll be negatve. 3 Unequal treatment of households wth the same ncome by the tax system or the health system can be further dvded nto two components: the extent to whch the rankng of households by ncome changes after payments for the health system, and the extent to whch there s nequalty n payments to the health system when households are ranked wthn bands of smlar post-payment ncome. For most purposes ths dstncton may not be that nformatve. 4 A progressve system of payments means that rcher households pay a larger share of ther ncome than poorer households. In a regressve system, the rcher households pay a smaller share of ncome than poorer households. 5 The Kakwan ndex s formulated as the dfference between the Gn coeffcent for prepayment ncome, and the concentraton ndex for health care payments.

100 Fgure 2: Kakwan Index of Progressvty Health contrbuton concentraton curve Lorenz Curve of ncome* pre health contrbuton Cumulatve percent of ncome* and of health payments 0 0 Cumulatve percent of populaton Adapted from: Van Doorslaer and Wagstaff, 1993. *May be ncome, expendture, or some other measure of capacty to pay. The analyss of progressvty usng the Kakwan ndex has been appled to a number of OECD countres.(rasell E, Bernsten J, & Tang K 1994;Wagstaff A & Van Doorslaer E 1993;Wagstaff A & Van Doorslaer E 1999;Wagstaff A., Van Doorslaer E, & Pac P 1989;Wagstaff A., Van Doorslaer E, & Pac P 1989) These studes fnd that drect taxes are progressve n all developed countres, whle ndrect taxes are generally regressve. Socal nsurance s progressve n countres where coverage s unversal, and regressve n those that exclude the hgher ncome groups. Prvate nsurance s regressve n countres such as the Unted States and Swtzerland, because premums are not related to ncome but are constant or related to rsks. For those who purchase t, prvate nsurance s often the sole source of coverage. Even when the poor do not buy nsurance, the dstrbuton can be regressve among those who do buy, because of the large dfferences n ncome. A common fndng of these studes s that out-of-pocket payment s regressve. It s partcularly so n countres where pre-pad health care does not cover the low-ncome groups. The overall fndngs show that n countres where health fnancng s predomnantly prvate, ether va nsurance or out-of-pocket payments, the system s most regressve. Socal nsurance-based countres are mxed, dependng on whether the hgher ncome groups are permtted to opt out of the system. Tax-fnanced systems are proportonal or mldly progressve. Several authors have analysed changes over tme, the mpact of reforms or proposed changes n health fnancng wthn countres such as the Unted States, the Netherlands and Australa. These studes have measured the extent to whch changes n fnancng have generated or would generate more or less progressve health fnancng regmes.(holahan J & Zedlewsk S 2000;Larson DR, Hndson P, & Hauqutz A 1995;Wagstaff A & Van Doorslaer E 1998)

Informaton on vertcal equty n developng countres s scarce. Several studes have shown that n some countres, all famles, ncludng the poor, spend a hgh share of ther budget on out of pocket health spendng.(hotchkss DR et al. 1998) In Thaland and Mexco, the poor spend a hgher proporton of ther ncome on out-of-pocket health spendng than the rch. Further, the regressvty of out-of-pocket spendng s related to the degree to whch populatons are covered by pre-pad nsurance schemes. (Frenk J, Lozano R, & González Block MA. 1994;Pannarunotha & Mlls 1997)A study of Jamaca, Ghana, Côte d Ivore, Peru and Bolva usng Lvng Standard Measurement Surveys, concluded that health fnancng channelled through the publc sector dd lttle to amelorate nequaltes n spendng and access to health care.(baker JL & van der Gaag J 1993) Efforts are under-way to extend the work on the progressvty of health fnancng n OECD countres to the developng world, partcularly to Latn Amerca and the Carbbean. Some early results from these studes have shown a heavy relance on out-of-pocket payment that vares from 30 to 60% of health fnance. Further, out-of-pocket payments are regressve n a number of countres, and exacerbate the exstng nequaltes n the dstrbuton of ncome. (Gonzalez Per E & Parker S 1999;Lasprlla E, ObandoC, & Encalad E Lasprlla C 1999;Suarez RM 1999;Valladares R & Barllas E 1999)A recent study of health fnancng n Mexco usng Kakwan ndces found that overall the system s close to neutral, out of pocket spendng s regressve and other sources of fnance tend to be somewhat progressve.(gonzalez Per E & Parker S 1999) When health system payments dffer for households wth the same ncome, the mpact on ncome redstrbuton s less than f households of the same ncome pad the same amount. Ths s a central ssue n studes of horzontal equty wthn the context of the total re-dstrbutve effect. Emprcal studes of ths effect n OECD countres show t to be relatvely small. There are few studes of the effect of horzontal equty on ncome redstrbuton n developng countres. Although not part of the equty n health fnance lterature, another type of study that s relevant to farness of fnancal contrbuton attempts to quantfy the extent of catastrophc or mpovershng payments for healthcare.(frenk J, Lozano R, & González Block MA. 1994) Whle few such studes exst, mpovershment has been recognzed as a crtcal dmenson for polcy. In summary, work to date relevant to evaluatng the farness of fnancal contrbuton has proceeded n three man drectons. Frst, the domnant conceptual framework s to analyze equty of the health fnancng system by ts contrbuton to ncome redstrbuton. In practce, ths means a focus on progressvty. Ths work has clearly been mportant, useful and nfluental, but the concept of farness s much broader than ths concern for ncome redstrbuton. For example, most would agree that when households face catastrophc payments to purchase needed healthcare that ths s undesrable and unfar. Yet, catastrophc payments for rch households mght actually mprove the dstrbuton of ncome and catastrophc payments for a small number of poor households would have a neglgble effect on overall ncome dstrbuton. Second, most of the emprcal work has been on developed country systems. Thrd, the recent trend n the lterature s to lnk analyses of payments to the health system to the analyss of the dstrbuton of the benefts of the health system. In the WHO Framework for Health Systems Performance Assessment, the ultmate mpact of the dstrbuton of healthcare resources should be captured n the

measure of farness n fnancal contrbuton. V. Concepts and Theory In ths secton, we defne our concept of farness, operatonalze ths defnton and propose a summary measure or ndex to compare the farness of fnancal contrbuton n two dfferent populatons. A. Conceptual Framework Let us explore the concept of a far dstrbuton of contrbutons to the health system across households wth a completely dfferent pont of reference. Socetes do not purchase health systems n order to redstrbute ncome. Socetes may have a very mportant socal goal to redstrbute ncome through government tax polcy but ths can be acheved through many mechansms unrelated to the overall fnancng of the health system. A parsmonous lst of goals for the health system to acheve s not lkely to nclude ncome redstrbuton as one of the man goals. Rather, gven ncome redstrbuton efforts n socety, there are stll ways to fnance the health system that are more far than others. We begn ths dscusson of the conceptual bass for measurng farness of fnancal contrbuton wth the queston: what s a maxmally far dstrbuton of fnancal contrbuton to the health system? Ths normatve dscusson s a useful bass for makng sure that any measure captures the crtcal dmensons of farness and provdes some bass for establshng meanngful endponts for any scale. Ultmately, the measure of farness may be used only to descrbe the state of affars n dfferent populatons. Nevertheless, startng from some explct normatve dscusson wll help clarfy the meanng of the measurements. The followng dscusson wll lead us to a more nclusve formulaton of farness than has been the focus of much of the lterature n developed countres revewed above. To explore notons of farness n fnancal contrbuton, we can start by dentfyng what s unfar. Almost everyone would agree that catastrophc payments are undesrable and unfar. Imagne two systems, one n whch health, health nequalty, responsveness and responsveness nequalty are dentcal but n one system two percent of households make catastrophc payments and n the other zero percent. Most would prefer the zero percent. Unequal payments by equvalent households are also unfar. The concern that should be gven equal consderaton s a powerful nfluence on the formulaton of socal systems. For example, wdely dfferent shares of ncome gong to pay for health nsurance n dfferent German sckness funds was broadly seen as unfar, leadng to the rsk equalzaton reforms of the 1990s.(Wagstaff A & Van Doorslaer E 1998) Fnally, many thnk that farness should nclude some noton that the rch contrbute more for the health system than the poor on a per capta bass. Ths concern can be dstnct from a general consderaton of ncome redstrbuton. Ths specal concern for how the health system s fnanced may stem from the specal nature of health tself as an ngredent to opportunty and the pursut of the good lfe.

All three of these concerns, avodng catastrophc payments, equal payment by equvalent households and some element of progressvty, can be related to the core concept of farness. Farness n the phlosophcal lterature s often assocated wth the concept of mpartalty. One way to thnk about mpartalty s usng the devce of the orgnal poston. If you do not know who you are n socety, what would be a far way to organze the fnancng of the health system? We argue that from such an mpartal pont of vew, we want households or ndvduals to contrbute equal shares of ther capacty to pay for the health system. The debate about defnng farness n fnancal contrbuton then becomes a debate over the meanng of capacty to pay. Is a household s capacty to pay smply ts ncome? Households face unavodable costs to mantan subsstence, such as expendtures requred for food, mnmal clothng and shelter. Surely a household s capacty to pay should exclude expendture requred for these basc needs. Capacty to pay could then be defned as to equal a household s ncome mnus subsstence expendture. But a household s capacty to pay may not smply be a functon of current ncome. Households may have assets, and they may also have access to ther future earnngs through formal and nformal fnancal mechansms. Current ncome, assets and future earnngs may all contrbute to the effectve ncome of a household. We beleve that capacty to pay needs to be defned n terms of effectve ncome (see below for a more formal defnton) rather than current ncome. Effectve ncome may be hgher or lower than current ncome; t can be consdered as the ncome that households would behave as f they have when makng consumpton decsons. In that respect t s akn to permanent ncome (Fredman M 1957), but wth at least one mportant dfferences. Permanent ncome s a postve theory of consumer behavour whch wll reflect among other factors the dscount rate that ndvduals use n decson-makng. For a normatve concept to compare to health expendture, effectve ncome must be defned ndependent of varaton n ndvduals subjectve dscount rate. Ths s dscussed more fully below. Although we do not argue that emprcal ethcs s the soluton to all normatve choces 6, measurements of populaton preferences can be nformatve. WHO undertook a survey of 1007 respondents of ther preferences for health systems, ncludng preferences for the fnancng arrangements n the health system. The sample was a convenence sample of health professonals and those wth a specal nterest n health from over 100 countres, but was not a representatve sample. Ths survey was dstrbuted to the world-wde staff of WHO and then placed on the WHO web ste n order to elct responses from a broad range of nterested ndvduals. The results of the survey strongly ndcate preferences for a system n whch everyone contrbutes an equal share of capacty to pay nto a health system (Table 1A). For ease of explanaton, n the survey dsposable ncome was defned to be equal to capacty to pay. More than 70% of the WHO staff and more than 60% of nternet respondents voted for ths opton as ther preferred method for achevng a far system of health fnancng. 6 Well-known problems wth abhorrent preferences lmt the scope for usng emprcal ethcs (Hausman Danel M 2000). Perhaps even more problematc s that many of these choces requre consderable delberaton, the tme for whch s rarely avalable n surveys.

Table 1: Preferences for Farness of Health Fnancng based on the WHO Survey of Preferences on Health System Performance Assessment (percentages of respondents) Table 1A: Preferred fnancng mechansm for a health system WHO staff Internet respondents All respondents Everyone pays the same amount 0.21 1.8 1.0 Everyone pays for what they receve 5.4 6.8 6.1 Everyone pays an equal share of ther ncome 19.8 25.3 22.5 Everyone pays an equal share of ther 71.7 61.2 66.6 dsposable ncome The rchest 10% pay for everyone 2.9 4.9 3.9 Table 1B: Choce between one household payng 50% of dsposable ncome and two households each payng 25% of dsposable ncome WHO staff Internet respondents All respondents One household more far 3.0 4.6 3.8 Two households more far 72.6 74.8 73.7 Equally far 12.2 9.6 10.9 Don t know 12.2 11.0 11.6 Table 1C: Choce between one household payng 100% of dsposable ncome and two households each payng 50% of dsposable ncome WHO staff Internet respondents All respondents One household more far 3.5 3.9 3.7 Two households more far 73.8 75.1 74.4 Equally far 11.5 10.1 10.8 Don t know 11.3 11.0 11.1 Table 1D: Choce between one household payng 200% of dsposable ncome and two households each payng 100% of dsposable ncome WHO staff Internet respondents All respondents One household more far 3.7 3.7 3.7 Two households more far 68.3 73.2 70.7 Equally far 10.2 7.8 9.2 Don t know 17.8 15.3 16.6

To summarze, we make the normatve clam that: A health system s farly fnanced f the rato of total health system contrbuton of each household through all payment mechansms to that households capacty to pay (effectve non-subsstence ncome) s dentcal for all households, ndependent of the households health status or use of the health system. Ths s a plausble normatve clam that may appeal to many. Nevertheless, we recognze that there may be a long and lvely debate as to the deal concepton of farness of fnancng for the health system. Not everyone wll agree wth ths normatve clam, but the measure derved from lookng at the share of non-subsstence effectve ncome that goes for the health system across households can be stll be used for comparsons, just as the Gn coeffcent can be used wthout endorsng complete equalty of ncome across households as a socal goal. In practce, those who prefer want a health fnancng system that s even more progressve than that mpled by ths measure should not be concerned, as no country we have studed comes even close to equal shares of nonsubsstence permanent ncome. We expect and hope that ths approach to examnng the farness of health system fnancng through shares of household non-subsstence effectve ncome wll spark debate. But we beleve t captures the three key ssues: a specal concern of for those households facng catastrophc spendng for health, for unequal contrbutons for equvalent households and for the overall progressvty of the system. B. Operatonalzaton of HFC The defnton of farness developed above s an equal dstrbuton of shares of capacty to pay across households. Capacty to pay for a household has been defned as effectve ncome mnus subsstence expendture. We begn by formulatng the quantty of nterest at the household level as the health fnancng contrbuton (HFC): HE (1) HFC = ENSY where HFC s the health system fnancng contrbuton of the household, HE s the per capta expendture on health of household, and ENSY s the per capta effectve ncome mnus subsstence expendture of household. HFC s deally defned over a perod of one year for a household. One year has been chosen because for most households t s a natural unt of tme that encompasses many predctable fluctuatons n ncome and expendture. It s also the nterval over whch the World Health Organzaton ntends regularly to evaluate health systems. 7 In practce, HFC has been estmated usng shorter perod data, typcally referrng to one month, because survey data seldom refers to an entre year. 7 The perod of evaluaton of health expendture and permanent non-subsstence ncome s mportant. Dependng on the avalablty of varous formal and nformal mechansms to borrow and save, households may behave as f they average ther ncome over longer perods. In the extreme, the lfe cycle consumpton hypothess argues that households smooth consumpton over the stream of all future ncome. (Ando A & Modglan F 1963)In practce, n dfferent socetes the perod over whch permanent ncome s defned wll vary, beng generally longer at hgher ncomes.

The numerator (HE ) ncludes all fnancal contrbutons to the health system attrbutable to the household through taxes, socal securty contrbutons, prvate nsurance, and drect, out-of-pocket payments. These nclude fnancal outlays that the household tself s not necessarly aware of payng, such as the share of sales or valueadded taxes that governments then devote to health. For taxes that are not earmarked and for socal securty contrbutons, total household payments must be multpled by the share of these revenues that ultmately goes to fnance the health system. 8 To operatonalze the denomnator of HFC, we need to defne effectve ncome and subsstence expendture. Our noton of effectve ncome s meant to reflect household tendences to smooth consumpton over tme, takng account of expected varatons n ncome over the course of the year, ther assets (allowng for savng or non-savng) and ther future earnngs potental. There s a rch lterature n economcs offerng dfferent theores of how households make consumpton decsons. For example, n the lfe cycle ncome hypothess, households are assumed to smooth ther consumpton over the lfe cycle, such that expected consumpton s equal n all subsequent tme perods. One formulsaton of ths theory of consumpton behavour that s adapted to the crcumstances of health s: (2) C Y + A + 0 0 t= 1 0 = l t 1+ Pδ t= 1 l t t Y Pδ Where C 0 s the consumpton of a household at tme t = 0, gven complete access to mechansms to smooth consumpton and consume assets, Y t s the ncome at tme t > 0, P t s the probablty of beng alve n each future year, Ao s the net value of assets (savngs or debts) at tme t = 0, and δ s 1/(1+r), where r s the market nterest or dscount rate, equal for all households. The lfe cycle hypothess s a postve theory of consumer behavour. In ths context, the dscount rate must be the dscount rate of the ndvdual or household. However, for the purposes of defnng the capacty to pay of a household, we do not want to use the subjectve present value of future consumpton, but rather the fnancal present value. In other words, the dscount rate should be the market rate of nterest. The lfe cycle ncome hypothess s partcularly mportant for three sets of crcumstances: when households face predctable fluctuatons n ncome durng the course of the year, when ther ncome n future years s expected to change and when they have postve assets or negatve assets (debts). A household s lkely to consume n a year, more or less, than t earns, n all of these crcumstances. t t 8 Two potentally mportant sources of fnance for the health system n some countres, donor assstance and government non-tax revenue through the sale of assets such as ol, need further dscusson. Donor assstance s pad for by households n other countres through voluntary contrbutons or taxes; therefore, we do not nclude donor assstance n the defnton of household health expendture n the recpent country. Ol revenue or the sale of any other natonal asset s a more dffcult ssue. One argument holds that natonal assets are owned equally by all households. Thus government revenues from ther sale should be attrbuted n equal amounts to all households. Such fnancng would appear to be extremely regressve because the same dollar value of sales for a poor household would be a much larger share of ncome than for a rch household. Alternatvely, t can be argued that sale of assets should be treated n the same way as donor assstance and not attrbuted to households n the analyss of farness n fnancal contrbuton, so that t has no effect on the measure. A thrd possblty s to attrbute n proporton to the capacty to pay, so the effect s neutral.

For households to succeed n smoothng consumpton over long perods of tme, effectve formal or nformal mechansms must exst to allow borrowng on the bass of the present value of ther future earnngs or savng earnngs n a form of assets that can be subsequently sold as needed. If households possess assets, n most settngs these can be sold and converted nto effectve ncome although temporary problems may exst that mpede the sale of assets and create lqudty problems for households. A more mportant problem s that n many countres mechansms may not be avalable to allow households to ncrease consumpton by borrowng on the bass of future earnngs. Because of the mperfectons of formal and nformal mechansms to smooth consumpton, the ncome that a household s able to consume and would seek to consume accordngly gven ts current ncome, assets and access to future earnngs could dffer from that predcted by the lfe cycle hypothess. Where no mechansms exst to borrow or save, effectve ncome equals ncome at that tme; where mperfect mechansms exst, consumpton would be somewhere between current ncome and expresson 2.(Behrman 1995) One of the many ways to model the effects of the lmted access of mechansms to borrow s: (3) C0 Y = Mn o + A 1+ + t= 1 L 0 t= 1 L t t Y Pδ t t Pδ t, Y o + A F 0 0 + L t= 1 t Y P F δ t t t Where F t s a measure of the access a household has currently to future earnngs at tme t. The Mn expresson means that a household would lke to consume at the level suggested by the lfe cycle hypothess, but when ts access to borrowng s less than what s requred t s forced to consume less. When all F t are zero, but F 0 > 0, households cannot draw on future ncome, but are lmted n ther consumpton to current ncome and current assets.

At frst pass, the noton of consumpton smoothng may be confusng. Fgure 3 shows a smple llustratve example. Annual ncome for the household shown s expected to ncrease rregularly for the next 15 years and then steadly decrease. If the household has access to mechansms to smooth consumpton, then we would expect the household to consume the amounts shown by the pnk lne. In the absence of effectve mechansms to smooth consumpton, consumpton may be as shown n the dashed lne. 2000 Fgure 3: 1500 $ 1000 500 Y PY EY 0 0 10 20 30 Year Consderatons of farness n fnancal contrbuton are normatve and the denomnator n HFC needs to be defned n terms of some meanngful comparable standard across households. Reflectng the desre of households to smooth consumpton over tme and the lmtatons to consumpton smoothng n many envronments, we defne effectve ncome as the level of consumpton that a household would seek and s able to consume, based on a lfe cycle perspectve assumng that all households share a standard dscount rate. To avod all ambguty, we are argue that effectve ncome s as defned n equaton 3 wth the added constrant that all households use the market nterest rate as the dscount rate. Because we defne capacty to pay n terms of effectve ncome, t leads naturally to certan conclusons about what should be ncluded n the denomnator. For example, subsdes rase a household s net ncome and therefore ts effectve ncome. Lkewse, tax payments generally lower ncome and effectve ncome. 9 Because F t cannot be easly observed, estmatng effectve ncome presents a number of challenges that are addressed n the secton on mplementaton. 9 Medcal savngs accounts are an nterestng llustraton of how the measure depends on the nature of an asset. In Sngapore, Medsave s a mandatory savngs account of a certan percentage of ncome that can only be used to pay for health servces. When a household pays for healthcare from a medcal savngs account, the expendture s clearly to be ncluded n HE, the numerator of HFC. But how does the medcal savngs account affect effectve ncome? Because a medcal savngs account can only be used to pay for health care, t has a dfferent effect on effectve ncome than regular assets. When t s used, t ncreases effectve ncome by the same amount that s used n the numerator.

The second step n defnng capacty to pay s to defne expendture requred for subsstence. There s an extensve lterature on basc needs whch addresses ths queston.(sen A 1981;Sen A 1984;Sen A 1985;Streeten P et al. 1981)Clearly, subsstence expendture for the purposes of defnng HFC should not nclude expendture on health even f t s seen as essental. Subsstence mnmally ncludes expendture on food, basc shelter and mnmal clothng. Implementaton of the defnton of subsstence wll address the mportant problem of usng defntons that are comparable across populatons. Household composton wll have an mportant effect on total subsstence expendture. The capacty to pay and thus HFC wll, therefore, reflect dfferences across households n ther composton. In prncple, t wll be mportant to develop estmates of actual subsstence requrements for dfferent households that reflect the composton of households and ther crcumstances. Expendture requred for subsstence can vary wth local events. For example, durng a famne the fracton of ncome requred to purchase subsstence needs may ncrease dramatcally. The conceptualzaton of HFC as effectve non-subsstence ncome (ENSY) captures these effects. C. Summarzng the dstrbuton of HFC We have formally defned HFC so that for each country one could wth the approprate nformaton on health expendture, effectve ncome and subsstence expendture, estmate the household dstrbuton of HFC. Fgure 4 shows the dstrbuton for two countres (the Russan Federaton and the Unted Republc of Tanzana) based on the analyss of household survey data. Fgure 4: Russa: The Dstrbuton of Health Fnancng Contrbuton Tanzana: The Dstrbuton of Health Fnancng Contrbuton 1 1.8.8 Fracton.6.4 Fracton.6.4.2.2 0 0.2.4.6.8 1 Health fnancng contrbuton 0 0.2.4.6.8 1 Health fnancng contrbuton The dstrbuton of HFC n the Russan Federaton s much broader than for the Unted Republc of Tanzana; there are more households contrbutng catastrophc shares of ther capacty to pay to the health system than n the Unted Republc of Tanzana. Even n the lower ranges of capacty to pay, there s much more nequalty n the Russan Federaton than n the Unted Republc of Tanzana.

Cumulatve Dstrbuton of Households Health Fnancal Contrbuton Fracton of Households Russa 1 0.8 0.6 0.4 0.2 0 0 0.2 0.4 0.6 0.8 1 Contrbuton Fracton of Households 1 0.8 0.6 0.4 0.2 0 Tanzana 0 0.2 0.4 0.6 0.8 1 Contrbuton Dstrbutons of Households Accordng to Health Expendture as a Fracton of Effectve Non-Subsstence Income Russa Tanzana 13.5 3.6 18.5 0-10% 10-30% 30-50% 50-100% 64.4 36.0 1.5 0.6 61.9 0-10% 10-30% 30-50% 50-100% Fgure 4 also shows the nformaton contaned n the dstrbuton of HFC n two other ways: a pe chart emphaszng the percentage of households wth very hgh shares of ther capacty to pay spent on health and a lne chart representng the cumulatve dstrbuton across households of HFC. Such graphcal representatons of the dstrbuton of HFC are all nformatve n dfferent ways. But when we want to compare many such dstrbutons across countres, t s necessary to develop an ndex that can summarze the extent of nequalty n the dstrbuton of HFC. Ths s analogous to the problem of comparng dstrbutons of ncome where measures such as the Gn coeffcent are commonly used to represent dstrbutons as a sngle ndex.

Whle there s a vast lterature on ndexes of nequalty to summarze dstrbutons, the development of ths ndex should take nto account the specal concern we have about catastrophc spendng. Ths means that the rght hand tal of the dstrbuton should be heavly weghted. Preference measurement through the survey of health systems preferences dscussed above s also nformatve. When faced wth a choce between dstrbutng the burden of health fnance among two households as opposed to concentratng the burden n a sngle household, more than 70% of respondents favoured dstrbutng the burden across the households (Tables 1B, 1C, 1D). Ths preference for a shared burden s robust to varyng the magntude of the fnancng burden from 25 to 100 percent of household dsposable ncome. Ths s consstent wth a strong preference for protectng ndvdual households from catastrophc expendtures and for sharng the burden of health fnancng across households. One famly of nequalty measures that can be desgned to gve specal weght to the tal of the dstrbuton, compares the quantty of nterest, n ths case each ndvdual s fnancal contrbuton, to the mean of the populaton. The general form of such ndvdual-mean dfference (IMD) measures s: (4) IMD( α, β ) n = = 1 HFC µ nµ where HFC s the fnancal contrbuton of household, µ s the mean fnancal contrbuton of the populaton, and n s the number of households n the populaton. The choce of the parameter α determnes the sgnfcance attached to dfferences n the health fnancal contrbuton observed at the tals of the dstrbuton, compared to dfferences observed close to the mean of the dstrbuton. The parameter β determnes the extent to whch the measure s relatve to the mean as opposed to measurng absolute dfferences. If β =1, the measure s strctly relatve and when β =0 the measure s restrcted to absolute devatons from the mean. β can take any value between 0 or 1, reflectng some mx of concern for relatve and absolute ndvdualmean dfferences. Varance s a measure of ndvdual-mean dfference where α = 2 and β =0, and the coeffcent of varaton corresponds to α = 2 and β =1. We argue that to gve approprate emphass to households spendng catastrophc shares of ther capacty to pay, α should be greater than 2. We have selected a value of 3 for smplcty. So that the ndex s not affected by the level of spendng we have set β equal to zero. Ths means that the ndex has translaton ndependence, namely that a fxed quantty added to every household wll not affect the extent of nequalty. Fnally n constructng an ndex of Farness of Fnancal Contrbutons to Health (IFFC), we have rescaled the measure so that t has unt value when all households pay the same fracton of ther capacty to pay; n other words, 1.0 means complete equalty of HFC. A constant has been added to the ndex so that the mnmum value represents a maxmum dstrbuton of nequalty that s not exceeded n any emprcal example studed: β α

(5) IFFC = 1 4 n = 1 HFC 0.125n HFC 3 We have compared results for a number of countres usng some alternatve values of α. For example, there s lttle mpact of changng α from 2 to 3. We expect to contnue work n ths area n order to explore the propertes of other ndexes to summarze the dstrbuton of HFC. We also ntend to nvestgate ndvdual preferences further as a bass for gudng the selecton of the parameters and rescalng of the ndex. D. Other aspects of the dstrbuton of HFC As wth any measure, there are some ssues that are not captured n the dstrbuton of HFC or n the IFFC. It s mportant to note that the dstrbuton of HFC wll not show f a poor household chooses not to purchase healthcare because t s unaffordable. In ths sense, a far dstrbuton of HFC may mask a stuaton where poor households have opted out of the system and are not recevng needed health servces. Ths lack of fnancal access to needed servces wll reduce overall health of the populaton and ncrease health nequalty. It s also lkely to reduce responsveness and ncrease responsveness nequalty. Ths smply emphaszes the mportance of judgng the overall equty of a health system n terms of the dstrbuton of health, responsveness and fnancal contrbuton. The relaton between the dstrbuton of HFC and the extent of fnancal rsk protecton n a populaton s mportant. Measures of fnancal rsk protecton such as the coverage of nsurance are dffcult to nterpret because the benefts packages, copayments and premums for nsurance vary so much wthn and across populatons. The ex post dstrbuton of health expendture across households s a good estmator of the average ex ante dstrbuton of fnancal rsk n the populaton. In other words, n a very large sample, the dstrbuton of health expendture last year (the ex post dstrbuton) wll equal the average ex ante dstrbuton of fnancal rsk across households. Because health expendture s n the numerator of HFC, changes n the ex ante dstrbuton of fnancal rsk wll be reflected n changes n the dstrbuton of HFC. Nevertheless, t s mportant to recognze that the dstrbuton of HFC may not capture all the nequalty n the dstrbuton of ex ante fnancal rsk protecton. However, f average ex ante fnancal rsk s correlated wth effectve ncome or subsstence payments then the dstrbuton of HFC wll reflect these dfferences. We conclude that because the ex post dstrbuton of expendture can be measured through household surveys and the ex ante dstrbuton of fnancal rsk s extremely dffcult to measure, the dstrbuton of HFC s a convenent and feasble measure of farness n fnancal contrbuton and of ex ante fnancal rsk protecton. VI. Measurement Propertes of the IFFC In ths secton, we wll use a hypothetcal populaton to llustrate the propertes of the IFFC: the dstrbutons of ncome per capta, ex ante health expendture rsk, and food expendture per capta are based on real populatons. We use smulatons that are explaned n more detal below to show how the dstrbuton of HFC across households would change as prepayment mechansms are ntroduced n a populaton

and as the progressvty of the fees or prepayments s ncreased. These smulatons also allow us to explore the phenomenon of optng out and to contrast the measurement propertes of the IFFC and the wdely used measure of vertcal equty, the Kakwan ndex. To calculate the dstrbuton of HFC across households n a populaton, we need nformaton on ncome, subsstence expendture, and the rsk of health expendture. Health expendture rsk s a functon of the avalable technology and ts cost and the rsk of llness. We have developed the smulatons for a populaton of 2000 households, whch can be consdered equvalent to montorng farness of fnancal contrbuton n a larger populaton usng a random sample survey of 2000 households. The assumed dstrbutons of the key quanttes have been developed from averaged results from selected households surveys to make sure they are realstc. 10, 11 One mportant phenomenon that we want to present n these smulatons s that households may need to borrow n order to pay for healthcare, because health expendture exceeds the capacty of a household to pay. In the smulatons, we have assumed that households faced wth a health expendture that s three tmes greater than capacty to pay wll choose to not pay and not to receve care. Table 2 summarzes the base case when there s no prepayment to allow rsk poolng. In the base case, 5.7% of households are spendng more than 50% of ther capacty to pay for health. Four households n a thousand (0.4%) are choosng not to purchase care because t s unaffordable. The IFFC s 0.347 and the Kakwan ndex s 0.3, showng how out-of-pocket payment s hghly regressve. The fgure of 5.7% of households facng catastrophc payment s hgh, but lower than that found n a number of countres n real survey results.(xu et al. 2000) 10 Per capta ncome s smulated usng a log normal dstrbuton wth quartles at $US 562, 838 (medan) and 1251, correspondng to a mean of $US1000 and a standard devaton of $US650. The subsstence share s a decreasng share of total household expendture and the parameters are drawn from the household survey data mentoned above. The formula for subsstence expendture (percentage spent on food) s : (6) pctfd = exp( α + β * ln( ncome ) Where α== 2.24 and β== -0.5 Health expendture rsk s smulated usng a log normal dstrbuton wth quartles at $US 14, 25 (medan) and 67, correspondng to a mean of $US60 and a standard devaton of $US100. The mean corresponds to an average of 6% health expendture across countres. Agan, the dstrbuton s parametersed usng survey data for out of pocket expendture. Usng realsed expendture as a proxy for ex ante health expendture rsk has certan caveats. These two varables wll tend to concde, at least ex post, when there s rsk poolng. Stll, usng the realsed expendture from survey data does not provde nformaton on the rsk from health needs, but only the dstrbuton of those needs that actually resulted n expendture. The rsk assocated wth actual health need may be ether less or more that realsed expendture. In the absence of ndependent data on medcal needs, we draw a dstrbuton from the survey data 11 In ths smulaton, we assume that the dstrbuton of ex ante health expendture rsk s the same for all households. In fact, the dstrbuton may be shfted to the rght for poorer households because they have worse health status. Ths covarance between the ex ante dstrbuton of health expendture rsk and ncome per capta s not ncluded n ths llustraton.

To llustrate the propertes of the IFFC, we ntroduce nto ths populaton two polcy changes. Frst, we ntroduce rsk poolng through some form of unversal nsurance coverage. Fgure 5 llustrates a form of rsk poolng that begns by coverng the hghest cost healthcare rsks. Rsk poolng of 10% means that the hghest costs are pooled and charged n a unform premum to all households up to the pont that 10% of total expendture s covered. Ths assumpton corresponds to an nsurance that s deally suted to protect aganst catastrophc costs, far more than any country s actual fnancng arrangements, but s regressve because premums are not related to capacty to pay (the ndex of progressvty s zero).expandng rsk poolng means that the unversal nsurance covers lower and lower health care costs. Indvdual households stll face the full cost of non-pooled rsks. When rsk poolng reaches 100% there are no out-of-pocket payments and all health expendture s through prepayment. Fgure 5: Dstrbuton of health expendture rsk Rsk poolng 20% 0 300$ 1500$

Fgure 6: IFFC and Kakwan Index vs. rsk poolng (progressvty coeffcent=0) IFFC 1.00 0.90 0.20 0.10 0.80 0.00 0.70-0.10 0.60 0.50-0.20 0.40-0.30 0.30-0.40 0% 20% 40% 60% 80% 100% 120% Rsk poolng Kakwan IFFC Kakwan Fgure 6 shows the IFFC and the Kakwan ndex as a functon of rsk poolng. Increasng rsk poolng protects more and more households from catastrophc health expendtures and thus makes the dstrbuton of HFC more equal and the IFFC closer to one. Fgure 6 also ndcates that ncreasng rsk poolng has had lttle or no benefcal effect on the overall progressvty of payment accordng to the Kakwan measure. 12 In fact, the ntal expanson of rsk poolng makes the Kakwan ndex more negatve because access to prepayment means that fewer poor households wll opt out of recevng care, so that the total contrbuton of the poor to the fnancng of the health system ncreases. Clearly, a concern about farness that ncludes avodng catastrophc payment s captured n the IFFC but not n the Kakwan ndex. 12 We present the results for both the IFFC and the Kakwan ndex for each smulaton exercse. The Kakwan ndex has the followng formula: (7) Kakwan Index = Concentraton Index Gn Coeffcent where the 1 2 Concentrat on Index = 1+ + ( HE1 + HE2 + HE3 +... + HE n n mu n= Sample sze HE= Health expendture, HE 1 >HE 2 >..HE n mu= Mean 2 n ) and the Gn coeffcent s calculated wth respect to total household expendture or ncome.

The second polcy opton that we use to explore the propertes of the IFFC s the progressvty of payments. If we make the out-of-pocket payments (and the prepayments, as rsk poolng s ntroduced) a functon of ncome, we can test how the IFFC changes wth the ntroducton of more and more progressve contrbutons.. To capture progressvty, we defne a sngle parameter β such that : β (8) AHER = HER * Z * Y Where AHER s the adjusted health expendture rsk, HER s the health expendture rsk for a household, Y s ncome, and Z s a constant such that under any regme of progressvty total revenue collected s constant. When β equals zero, fees and prepayment are not a functon of ncome. When β equals one, then fees and prepayments are neutral wth respect to ncome that s they are defned n terms of shares of ncome. When β s greater than one, fees and prepayment are progressve. A plausble range of 0 to 1.4 for β=, based on country experence, has been used n the smulatons. Fgure 7 shows the IFFC and Kakwan ndex or a populaton wth no rsk poolng as a functon of β. Both the Kakwan ndex and the IFFC ncrease as progressvty s ncreased. Fgure 7: IFFC and Kakwan Index vs. progressvty (rsk poolng=0) IFFC 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00-0.10-0.20-0.30-0.40 0 0.2 0.4 0.6 0.8 1 1.2 1.4 Progressvty coeffcent Kakwan IFFC Kakwan

Table 2A and Fgure 8 llustrate the combned effect on IFFC of extendng rsk poolng and ntroducng progressvty nto the fee schedules. IFFC clearly captures both the extenson of fnancal rsk protecton and progressvty. In other words, the dstrbuton of HFC as summarzed by the IFFC captures at least two of the ntal consderatons that we set out for ts development. In contrast, the Kakwan ndex s largely nsenstve to the extenson of fnancal rsk protecton (Table 2C and Fgure 9), for a gven degree of progressvty. IFFC 1.000 0.900 0.800 0.700 0.600 0.500 0.400 Fgure 8: IFFC as a functon of rsk poolng and tt 0.300 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% rsk l Progressvty Coeffcne t 0 0.2 0.4 0.6 0.8 1 1.2 1.4 Fgure 9: Kakwan Index and rsk poolng, varyng the degree of progressvty 0.200 Kakwan Index 0.100 0.000-0.100-0.200-0.300 0 0.2 0.4 0.6 0.8 1 1.2 1.4-0.400 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Rsk poolng

Tables 2A, 2B, 2C and 2D: Smulaton of IFFC, Catastrophc Health Expendture, Kakwan Index and Health Expendture Rsk Exceedng the Borrowng Constrant, varyng the degree of progressvty and rsk poolng and applyng unversal populaton coverage Table 2A: IFFC Index of Farness of Fnancal Contrbuton (ff ) (IFFC) Progressvty Rsk Threshold 0 0.2 C 0.4 ff t 0.6 0.8 1 1.2 1.4 0% l 1500 0.347 0.474 0.562 0.643 0.680 0.720 0.767 0.800 10% 504 0.422 0.565 0.662 0.752 0.817 0.862 0.909 0.928 20% 304 0.505 0.648 0.763 0.849 0.904 0.935 0.963 0.976 30% 211 0.601 0.731 0.843 0.912 0.949 0.966 0.981 0.988 40% 155 0.708 0.810 0.894 0.941 0.966 0.977 0.988 0.993 50% 116 0.791 0.865 0.925 0.958 0.975 0.982 0.991 0.995 60% 87 0.829 0.891 0.940 0.965 0.979 0.984 0.992 0.996 70% 63 0.872 0.919 0.955 0.972 0.982 0.986 0.992 0.996 80% 44 0.905 0.941 0.966 0.977 0.984 0.987 0.992 0.996 90% 27 0.923 0.950 0.971 0.979 0.985 0.987 0.992 0.996 100% 0 0.939 0.961 0.977 0.986 0.991 0.995 0.997 0.999 Table 2B: Proporton of Households wth Catastrophc Health Expendture (HFC 0 5) Threshold Progressvty Rsk ($) 0 0.2 C 0.4 ff t 0.6 0.8 1 1.2 1.4 0% l 1500 5.65 4.75 4.35 3.50 2.45 2.15 1.80 1.60 10% 504 5.35 4.40 3.85 2.90 1.70 1.45 1.05 0.90 20% 304 4.75 3.95 2.85 1.95 0.80 0.30 0.10 0.00 30% 211 3.70 2.90 1.90 1.05 0.30 0.05 0.05 0.05 40% 155 3.00 2.25 1.15 0.60 0.05 0.05 0.05 0.05 50% 116 2.10 1.55 0.75 0.25 0.10 0.05 0.05 0.05 60% 87 1.70 1.05 0.60 0.20 0.10 0.05 0.05 0.05 70% 63 1.10 0.65 0.50 0.15 0.05 0.05 0.05 0.05 80% 44 1.00 0.30 0.30 0.10 0.05 0.05 0.05 0.05 90% 27 0.90 0.35 0.15 0.10 0.10 0.05 0.05 0.05 100% 0 0.60 0.25 0.15 0.05 0.05 0.05 0.05 0.05 Table 2C: 'Kakwan Index Threshold Progressvty Rsk ($) 0 0.2 C 0.4 ff t 0.6 0.8 1 1.2 1.4 0% l 1500-0.298-0.239-0.182-0.119-0.063-0.002 0.058 0.115 10% 504-0.319-0.254-0.195-0.129-0.065-0.002 0.059 0.117 20% 304-0.339-0.275-0.212-0.148-0.084-0.022 0.039 0.099 30% 211-0.332-0.266-0.199-0.133-0.068-0.005 0.057 0.117 40% 155-0.328-0.261-0.194-0.128-0.063 0.001 0.063 0.123 50% 116-0.324-0.258-0.191-0.125-0.060 0.003 0.065 0.125 60% 87-0.320-0.253-0.187-0.121-0.057 0.005 0.066 0.125 70% 63-0.321-0.255-0.189-0.124-0.060 0.002 0.061 0.118 80% 44-0.324-0.257-0.191-0.126-0.062 0.000 0.060 0.118 90% 27-0.327-0.260-0.194-0.128-0.064-0.001 0.060 0.119 100% 0-0.326-0.259-0.193-0.127-0.063 0.000 0.061 0.119 Table 2D: Proporton of Households that Cannot Afford Health Care (Health Expendture Rsk Exceeds the Borrowng Constrant of 3 Tmes Capacty to Pay) Threshold Progressvty Rsk ($) 0 0.2 C 0.4 ff t 0.6 0.8 1 1.2 1.4 0% l 1500 0.35 0.3 0.15 0.1 0 0 0 0 10% 504 0 0 0 0 0 0 0 0

Fgure 10: IFFC vs. Catastrophc health spendng 1.00 0.90 0.80 I F F C 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 0.00 1.00 2.00 3.00 4.00 5.00 6.00 Percent of households wth catastrophc health spendng (%) In developng HFC and the IFFC, avodance of catastrophc spendng by households was dentfed as an mportant component of farness n fnancal contrbuton. Table 2B and Fgure 10 llustrate that regardless of the level of rsk poolng or progressvty n the smulatons, IFFC s closely related to the fracton of households facng catastrophc spendng on health. Here we have defned catastrophc spendng as households that actually spend more than 50% of ther effectve ncome after payng for subsstence needs. Estmates of the number of households whch would forego health care because the cost would exceed three tmes ther capacty to pay are gven n Table 2D. Wth the assumpton about rsk poolng startng at the hghest costs, even a very low degree of poolng, or a modest degree of progressvty, s enough to elmnate the lkelhood of facng such hgh costs. The close mappng of the IFFC to the percentage of households wth catastrophc health spendng (correlaton of 0.987) means that the IFFC values capture ths component of farness. For the same set of smulatons, the correlaton between the Kakwan ndex and the percentage of households facng catastrophc spendng was much lower, only 0.558. The IFFC s also hghly senstve to the progressvty of fnance, as s the Kakwan measure. These fndngs that the IFFC s more closely related to both the degree of rsk poolng and the share of households facng catastrophc expendtures than the Kakwan ndex s also emerge from smulatons wth other assumptons about rsk poolng, such as random coverage of the populaton or coverage that starts wth the rchest households and s extended toward the poorest. All these smulatons are drawn from the same dstrbutons of capacty to pay and of household ex ante fnancal rsk, so they all have essentally the same mean HFC. If two populatons have the same mean, to whch all households are compared, then any ncrease n the varance or hgher moments of the dstrbuton wll ncrease the number of households facng catastrophc rsks and also lower the ndex of farness as households are spread farther from the mean and are more unequal among themselves.

When populatons wth dfferent means are compared, the assocaton between IFFC and the rsk of catastrophc expendture s naturally weakened, because f all households are tghtly clustered around a hgh mean value of HFC there wll be lttle nequalty but there can stll be a large number facng hgh expendture rsks. Smulatons n whch all values of HFC are doubled, contnue to show a strong correlaton as progressvty and rsk poolng are vared, but there s less correlaton when smulatons wth hgh and low means are compared. Nonetheless, the ndex of farness s related to catastrophc rsk even over a range of mean HFC from under four percent to over 20 percent, when 21 countres are compared.(xu et al. 2000) Hgh average contrbutons, as a share of capacty to pay, tend to be assocated emprcally wth hgh varance n the dstrbuton, so that both IFFC and catastrophc rsk are greater than for dstrbutons wth lower means and less varaton among households. Further analyses and polcy smulatons for partcular populatons wll be helpful n delneatng the measurement propertes of HFC and the summary across households, the IFFC. Ths dscusson has contrasted the IFFC wth the Kakwan ndex, because health system fnancng s often judged by the degree of progressvty alone and because progressvty s usually the domnant component of the total re-dstrbutve effect of health care fnancng.(van Doorslaer E & Wagstaff A 1999) The full re-dstrbutve effect can be wrtten as: (9) RE = V H R V gk = ( 1 g) where K s the Kakwan ndex, g s the mean share of health spendng n total household expendture, equvalent to HFC except for the adjustment for subsstence spendng, H s the effect of horzontal nequty and R s the effect of re-orderng households, compared to the dstrbuton pror to payng for health care (zero f no such re-rankng occurs). The re-dstrbutve effect can be computed for each source of fnance separately as well as for the total. In the smulatons reported here, only the total effect s consdered, but snce out-of-pocket payments have a large negatve redstrbutve effect (worsenng nequalty of HFC) whle rsk poolng has a postve effect (reducng nequalty), the overall effect depends on the degree of rsk poolng as well as on the progressvty of both modes of fnance. Table 3 and Fgure 11 show the results of the smulaton: the total ncome redstrbutve effect s strongly related to progressvty, but s largely nsenstve to the degree of rsk poolng, even when rsk poolng s assumed to cover the largest expendtures preferentally. The pattern n Fgure 11 resembles that for the Kakwan ndex alone, n Fgure 9, except that for degrees of progressvty greater than 0.2, the re-dstrbutve effect always mproves at rsk poolng s extended. In contrast, the Kakwan ndex always worsens as poolng ncreases from zero to 20 percent because more households become able to spend on health. As wth the Kakwan ndex, the total re-dstrbutve effect bears lttle relaton to the rsk of catastrophc spendng when rsk poolng starts wth the hghest expendtures, and no relaton at all f rsk poolng s random or favors the rch over the poor.

Table 3: Total redstrbuton effect as a functon of rsk poolng and progressvty Rsk Poolng Progressvty 0% 20% 40% 60% 80% 100% 0-0.0219-0.0233-0.0216-0.0206-0.0206-0.0207 0.2-0.0185-0.0192-0.0173-0.0164-0.0164-0.0165 0.4-0.0153-0.0152-0.0130-0.0122-0.0122-0.0122 0.6-0.0115-0.0110-0.0088-0.0080-0.0081-0.0081 0.8-0.0081-0.0069-0.0046-0.0039-0.0040-0.0040 1.0-0.0044-0.0028-0.0005 0.0001-0.0001 0.0000 1.2-0.0008 0.0012 0.0035 0.0040 0.0037 0.0038 1.4 0.0027 0.0050 0.0073 0.0077 0.0074 0.0075 Fgure 11: Total redstrbuton effect as a functon of rsk poolng, varyng the degree of progressvty 0.010 Redstrbuton effect 0.005 0.000-0.005-0.010-0.015-0.020-0.025 Progressvty 0 0.2 0.4 0.6 0.8 1 1.2 1.4-0.030 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 rsk poolng

In summary, we have demonstrated that the IFFC reflects the extent of catastrophc spendng n the populaton, the progressvty of payments and the extent of fnancal rsk poolng. One set of smulatons s not suffcent to demonstrate all the propertes of the dstrbuton of HFC and the IFFC. Further analyses and polcy smulatons for partcular populatons wll be helpful n delneatng ther measurement propertes VII. Estmatng the Dstrbuton of Health Fnancng Contrbuton In order to measure HFC, partcularly across countres, a number of data sources and several smplfyng assumptons are requred. Ths secton frst dscusses data requrements and then provdes detaled nformaton on the mechancs of calculatng HFC usng survey data. These reflect the emprcal work that s presented elsewhere.(xu et al. 2000) The fnal part of ths secton dscusses some of the data lmtatons. A. Data Requrements HFC s based prmarly on nformaton gathered through natonal household surveys, combned wth detaled nformaton on the rules governng taxaton and socal securty payments for health, and Natonal Health Accounts (NHA) estmates.(van Doorslaer E & Wagstaff A 1999) Natonal household surveys are requred that nclude household or ndvdual-level data on ncome, total expendture, and expendture on specfc goods and servces (especally food, out of pocket expendture on health, and prvate health nsurance premums). These data are usually avalable from partcular classes of surveys: Natonal Income and Expendture Surveys (IES) undertaken by most countres on a sporadc bass often wth the prmary purpose of measurng ncome nequalty and basc expendture patterns(pouller JP & Hernandez P 2000); ❾ multpurpose, multlevel surveys such as Lvng Standard Measurement Surveys (LSMS) or the Surveys of Qualty of Lfe undertaken by many developng countres on a sporadc bass, often wth the support of a multlateral agency such as the World Bank; ❾ Natonal Health Surveys or Demographc and Health Surveys (DHS) undertaken regularly by many developed and developng countres and desgned to measure health status, but sometmes also ncludng measures of health spendng; and ❾ Specfc surveys of health expendture that are avalable for only a few countres. These surveys sometmes report spendng on drect (but not ndrect) taxes. Where they do not, government tax documents and other publshed materal s consulted and the tax schedule s used to estmate taxes pad by a household on the bass of ts reported ncome, wealth and consumpton. Ths s complemented wth nformaton regardng socal securty and health nsurance laws that provde nformaton on premums and other contrbutons to the health system. NHA fgures (compled by WHO for all countres) provde estmates of varous components of health expendture from prvate and publc sources.(van Doorslaer E & Wagstaff A 1999) NHA estmates also provde a benchmark to check the relablty of the survey data on health expendtures by comparng them to natonal aggregates. Health Systems Profles that descrbe the structure and fnancng of the health system are also necessary.

B. Estmatng HFC Health expendture, the numerator of HFC, can be estmated wth data from household surveys, tax and socal nsurance schedules and natonal health accounts. The denomnator of HFC requres estmates of effectve ncome and subsstence expendture. The smplest way to estmate effectve ncome s to assume that households do not have access to any mechansms to smooth consumpton. In the terms of equaton (3), Fa and all Ft are assumed to be zero. Expendture s then the best estmate of effectve ncome. For smplcty n the frst round of estmaton we have adopted ths approach; more refned approaches wll be adopted n the future. In a smlar fashon, we have estmated subsstence expendture as smply equal to food expendture. In summary, as an nterm strategy to estmate HFC, we have adopted the followng formula for the contrbuton of household : (9) Total health spendng HFC = Capacty to pay = HS ( EXP + atax Food) The term atax n the denomnator represents taxes pad by the famly that are not ncluded n expendture, plus socal securty contrbutons; the calculaton s explaned n detal below. In the formulas that follow, the subscrpt refers to nformaton at the household level and N refers to nformaton at the natonal level. All fgure are monthly, and where other perods are reported, these are smply scaled. If the survey s conducted over more than one month and the nflaton rate s hgh over these months, all expendtures are deflated to a common month accordng to the Consumer Prce Index (CPI). The numerator of HFC, total household health spendng (HS ), s the sum of prepayment and out of pocket payment to the health system. There are three components n the calculaton of prepayment: prepay = TGSH + SSH * scalar( W) + PRV (10) ( ) The frst component of prepayment (TGSH ), s the share of total government spendng whch s used for health at the natonal level, whch s estmated as the rato of total publc spendng on health (PSH N ) to total government spendng (TGS N ), both net of socal securty payments to health (SSH N ). Ths s then multpled by total government revenue derved from the ndvdual household, to gve an estmate of the household s contrbuton to government spendng on health. The full expresson for TGSH s formalsed as: (11) TGSH = * ( Scalar ( X ) * ( INCTAX + VAT + other ) ) PSH SSH TGS SSH N where (INCTAX + VAT + other) s the estmate of the household s contrbuton to total government revenue. Ths s adjusted by a scalar, X, to take account of the fact that the sum of estmated revenues from all households n the survey may not match the natonal accounts estmates of publc revenues, just as the survey may not provde accurate estmates of total prvate consumpton or GDP. The calculaton of X s descrbed below.

Total government revenue ncorporates all payments towards the fnancng of the health system through tax revenue (manly ncome tax, sales and value-added tax and other taxes) and non-tax revenue. The estmaton of each component depends on the amount of household-level data avalable from the household survey. Usually ncome tax (INCTAX ) and value-added tax (ncludng sales taxes, VAT) contrbutons from households can be calculated drectly from the survey. Excse and property tax payments (other ) are sometmes provded. Whenever ncome tax (INCTAX ) was not avalable drectly from the survey, t was estmated from reported ncome from all sources ncludng salares and non-salary earnngs (n-knd benefts) from all employment (ncludng second job f relevant), combned wth the country s tax schedule nformaton. Not all ndvduals who are subject actually pay ncome tax. A reasonable assumpton s that only the formal sector employees pay ncome tax, and that they can be dentfed usng job classfcaton questons from the survey. Evason cannot be estmated but s assumed to be dffcult for formal sector salares. VAT and excse taxes are easer to assgn to the varous categores of good and servces purchased by the household, by applyng the correspondng tax rates to each famly s expendture pattern usng the survey data. Other taxes (such as corporate tax, mport taxes or property tax), excse and property tax when not reported n the survey, and non-tax revenue are estmated based on the tax nformaton that s avalable n the survey. The scalar X n equaton (11) s used to assgn non-tax and other tax revenue back to the household, accordng to the followng formula: (12) (( TGS SSH ) N / GDPN ) * GDPs Scalar( X ) = ( INCTAX + VAT + other) where GDPs s the estmate of GDP gven by the survey. It s calculated as the weghted sum of all household expendture over the share of total prvate consumpton (PC) to GDP (at the natonal level). When household surveys do not provde weghts, the rato of sample populaton to total populaton s used to nflate the survey expendture data to the country level. EXP (13) GDPs = ( PC / GDP) N We assume that total household consumpton s equvalent to total prvate consumpton. Strctly speakng, ths s not the case snce prvate consumpton s the market value of all goods and servces purchased, or receved as ncome n-knd, by households and nonproft nsttutons (NGOs). The latter part not beng captured n the household survey, we may underestmate total prvate consumpton at the natonal level f the non-proft nsttuton component s large. Substtutng from equaton (13) nto equaton (12) shows that the numerator of (12) s just (14) (TGS SSH)N * SUM EXP/PCN that s, total government non-socal securty revenue adjusted for the dscrepancy between survey and natonal accounts estmates of prvate consumpton. Substtutng

from equaton (12) nto equaton (11) then shows that the estmate of a household s tax contrbuton to fnancng health s just that household s share of reported total tax payments n the survey, adjusted for the dscrepancy wth natonal accounts, multpled by the share of total publc spendng on health to total government spendng, both net of socal securty spendng on health. The second component of prepayment n equaton (10), s the total adjusted socal health nsurance premum of the household: (15) SSH * Scalar( W ) The household socal health nsurance premum (SSH ) s computed usng the same algorthm as for the ncome tax calculaton. Survey data are used f avalable. When ths s not the case, the contrbuton rate (provded n socal securty/socal health nsurance laws) s appled to ndvdual-level data on salares. The assumpton s that only formal sector employees, or full-tme permanent workers, pay socal health nsurance. We assume that the employer s contrbuton s borne by the employees n the form of reduced salares. For the computaton, ths mples that the employer s contrbuton rate should be added to that of that of the employee. Whle ths assumpton s strong, t smplfes the analyss and the comparson across countres and has been used n prevous research (Wagstaff A & Van Doorslaer E 1999). It s mportant to stress that only the porton of socal securty contrbutons attrbutable to health s ncorporated n the calculatons. As wth ncome tax, the socal health nsurance premum s assgned back to the household by summng over all ndvduals n the household who pay socal health nsurance premums. Survey data on socal nsurance contrbutons do not always concde wth NHA data. These dscrepances are essentally the result of under- or over-reportng of socal securty contrbutons n the survey data. Where ths type of reportng bas arses t must be corrected. We use a scalar adjustment to ensure consstency between these two sources. The scalar s computed usng the same adjustment as n X for dscrepances between survey and natonal accounts estmates of GDP. The share of socal securty on health at the natonal level ((SSH/GDP) N ), s dvded by the sum of estmated socal securty contrbutons to health at the household level (SSH ): (16) Scalar( W ) = GDP * ( SSH / GDP) s SSH N The thrd component of prepayment s the total prvate health nsurance premum of the household (PRV ). Household contrbutons to prvate health nsurance are often avalable from the household survey. In some countres, employers also contrbute to the prvate health nsurance on behalf of ther employees. In such cases we nclude the employer s contrbuton f the nformaton s avalable. Where ths nformaton s not avalable, a bas s ntroduced, partcularly n some developed countres where prvate health nsurance s a domnant form of health servce fnancng and the employer subsdses a share of the premum. Where ths nformaton s mssng, we underestmate ths component of prepayment. To avod ntroducng an upward bas n prvate health nsurance premums, refunds or credts granted by nsurance companes n the perod pror to the survey should be deducted from household prvate health nsurance premums for the same perod. Unfortunately, snce the rembursement may refer to payments n an earler perod not covered by the survey,

ths adjustment can lead to negatve estmates of nsurance payments and s stll dffcult to mplement wth short-perod data. We now dscuss the estmaton of out of pocket spendng on health (OOP ) n the HFC numerator. Out of pocket payment ncludes all categores of health-related expenses recorded at the tme the household receved the servce. Typcally these nclude doctor s consultaton fees, purchases of medcaton and hosptal blls. Although spendng on alternatve and/or tradtonal medcne s ncluded n the computaton of out of pocket spendng when t s avalable from the survey, expendture on transport to receve health care servces s excluded 13. Tax deductons for health expendtures are ncorporated mplctly where household survey data are avalable on total ncome taxes. In other cases, ths requres a refnement of the calculatons that s typcally very dffcult gven avalable data and due to the fact that deductons are often applcable over a perod of tme that spans more than a calendar year. The HFC denomnator s a measure of the household s effectve ncome mnus subsstence expendture. The proxy that we use to calculate capacty to pay s total, household per capta expendture (EXP ) net of household per capta food expendture (Food ). The denomnator excludes tax payments except for general tax and socal nsurance payments that can be attrbuted to the household as contrbutons for health. Total household expendture s the amount spent on all goods and servces by the household, ncludng n-knd spendng and the consumpton of household-made products. Ths nformaton s avalable drectly from the household survey and s aggregated to a monthly value. Food s the amount spend on all foodstuffs by the household, ncludng the famly s own food producton. Food expendture was computed by summng all the tems consdered to be non-luxury goods. The defnton excludes expendture on alcoholc beverages, tobacco, and eatng outsde of the household (restaurants). The household s adjusted tax payment and ts contrbuton to socal securty on health (atax ) s calculated usng the followng formula: (17) PSH SSH [( + ) * ( Scalar( X ) 1) + ( + ) * Scalar( X )]* * Scalar( W ) atax = VAT EXCISE INCTAX other + SSH TGS SSH Adjustments are made for household tax payment and socal securty contrbutons. To avod double-countng VAT and excse tax whch s already ncluded n reported expendture, these values are adjusted by the X scalar (defned above). Income tax and other relevant taxes not ntegrated n expendture are also adjusted usng the X scalar for the same reasons as those dscussed above for the numerator. Lkewse, socal securty contrbuton for health s adjusted wth the W scalar. 14 13 Ths assumpton s consstent wth the Natonal Health Accounts method of calculatng out of pocket payments. 14 Note that only socal securty on health s ncluded n atax as the total payment to socal securty was not avalable for some countres.

C. Data Lmtatons Avalable data present several lmtatons, of whch the most serous are related to the recall perod for out of pocket health spendng and for expendture. Most surveys provde ths nformaton on a monthly bass, whch does not gve an adequately long perod over whch to measure the rsk of health expendture. It s mpossble to dscern from a onemonth perod, f hgh health expendture s a repeated ncdent or an solated event. Further, wthout repeated and longer-run measures, t s mpossble to apply an adequate tme horzon to expendtures across all households as we only have data on households that actually spent n a partcular month. If the sample s large enough, and expendture patterns do not dsplay seasonally (an unlkely assumpton), then ths wll not be an ssue. What s requred to answer these questons better are surveys that ask about both monthly expendtures, whch wll tend to mnmse recall bas, and longer perods such as a year. Another mportant pont s that our calculatons do not nclude subsdes. Ths s because very few countres have household-level nformaton on subsdes n the surveys that nclude nformaton on health spendng. The excluson of subsdes could generate bases n both the numerator and the denomnator of HFC. In future analyses, usng partcular countres for whch the necessary data are avalable, we wll explore the ssue of subsdes n greater detal. VIII. Dscusson How the health system s fnanced can have a profound effect on ndvduals access to healthcare and thus on health, health nequaltes, responsveness and responsveness nequaltes. Beyond ths nstrumental role of how a health system s fnanced, we argue that that farness n fnancal contrbuton s an ntrnsc goal of the health system. Farness n fnancal contrbuton s a dfferent construct that the tradtonal focus of the lterature on equty n health fnance, whch measures the extent to whch payments for the health system redstrbute ncome. Takng as gven socety s efforts to redstrbute ncome, some systems are stll fnanced more farly than others. Ths noton of farness should capture the extent to whch the system avods households makng catastrophc payments for health, the extent to whch ndvduals n smlar crcumstances contrbute the same amount and the extent to whch the rch bear some of the costs of the poor. These elements of farness are captured by examnng each household s contrbuton to the health system through taxes, socal nsurance, prvate nsurance and out-ofpocket payments as a share of ts capacty to pay. Capacty to pay s a household s effectve ncome mnus expendture requred for subsstence needs. We argue that when shares of capacty to pay are equalzed across households then a system acheves farness n fnancal contrbuton. The dstrbuton of HFC across households can be summarzed usng an ndex, the IFFC. The dstrbuton of HFC and the summary ndex, the IFFC, have been calculated for a number of countres.(xu et al. 2000)Ths emprcal applcaton of the concepts n ths paper demonstrates the feasblty and utlty of ths measurement. Nevertheless, a number of ssues reman that wll beneft from further work and refnement. These fall naturally nto three types of ssues: estmatng HFC from survey data; alternatve summary ndexes of the dstrbuton of HFC; and sub-natonal applcaton of the analyss of farness n fnancal contrbuton.

Several estmaton ssues need to be addressed. Frst, the workng assumpton that households have no access, n any country, to ther future earnngs so that expendture s a good estmate of effectve ncome needs to be relaxed. As a frst step, the bounds of effectve ncome could be estmated by calculatng consumpton as f the permanent ncome hypothess appled. The senstvty of the dstrbuton of HFC to usng the permanent ncome hypothess estmates could be examned. Second, subsdes, whch can be an mportant component of household ncome n some countres. e.g. housng subsdes, should be estmated f possble. Thrd, nconsstences between household surveys and natonal health accounts need to be nvestgated and solutons standardzed. The IFFC has been desgned as a summary of the dstrbuton of HFC across households to emphasze the rght-hand tal of the dstrbuton households facng catastrophc payments. Further work to nform the selecton of the parameters n the IFFC should nclude measurement of key populaton preferences. In addton to strengthenng the emprcal bass for selectng the parameters n the IFFC, the communcablty of the measure to the general publc, meda and polcy makers needs to be explored. For example, the IFFC s closely related to the fracton of households facng catastrophc spendng, so smpler varants of the IFFC may be adequate for some polcy uses. Future research wll nclude a number of new emprcal applcatons, as well extensons of exstng work to addtonal countres. Usng before and after measures, we wll apply the IFFC to analyse the success of health fnancng reforms n achevng greater farness. IFFC s also hghly applcable to the study of partcular components of health systems, such as: the comparson of farness of the porton of fnance that comes from general taxes or socal nsurance to out of pocket payments; drug spendng as compared to hosptalsaton or other sub-sectors; and, geographc varaton. Another nterestng avenue for future research s to consder the level of farness de jure (based on legslaton or consttutonal rghts) versus de facto gven the actual dstrbuton of health payments, where the latter do not depend on assumng that de jure provsons actually determne households contrbutons.

References Ando A & Modglan F 1963, "The Lfe Cycle Hypothess of Savng: Aggreate Implcaton and Tests", Amercan economc revew, vol. 53, pp. 55-84. Aronson JR, Johnson P, & Lambert PJ 1994, "Re-drstrbutve Effect and Unequal Income Tax Treatment", The Economc Journal, vol. 104, pp. 262-270. Baker JL & van der Gaag J. Equty n Health Care and Health Care Fnancng: Evdence From Fve Developng Countres. Equty n the Fnance and Delvery of Health Care: An Internatonal Perspectve, 356-395. 1993. Ref Type: Journal (Full) Behrman, P. Health Sector Reform n Developng Countres: Makng Health Development Sustanable. 1995. Ref Type: Generc Deaton A & Muellbauer J 1980, Economcs and Consumer Behavour Cambrdge Unversty Press. Frenk J, Lozano R, & González Block MA. 1994, "Economía y Salud: Propuesta para el Avance del Sstema de Salud en Méxco.Informe Fnal.", Fundacón Mexcana para la Salud. Fredman M 1957, A Theory of the Consumpton Functon, Prnceton Unversty Press. Fuchs V.R. Who Shall Lve? Health, Economcs, and Socal Choce. 1988. Ref Type: Generc Gakdou, E. E., Frenk, J., & Murray, C. J. L. 2000, Measurng preferences on health system performance assessment, World Health Organzaton, Geneva, Swtzerland, 20. Gonzalez Per E & Parker S 1999, Equty n the Fnance and Delvery of Health Care: Results from Mexco. Hausman Danel M 2000, Why not just ask? "Emprcal Ethcs and the Role of Ethcal Reflecton". Holahan J & Zedlewsk S 2000, "Who Pays for Health Care n the Unted States? Implcatons for Health Care Reform", Inquryno. 29, pp. 231-248. Hotchkss DR, RousJJ, Karmacharya K, & Sangraula P 1998, "Household Health Expendtures n Nepal:Implcatons for Health Care Fnancng Reform", Health Polcy.Plan., vol. 13,no. 4, pp. 371-383. Iglehart J.K. The Amercan Health Care System-Expendtures. 1999. Ref Type: Generc Kakwan K 1977, "Measurement of Tax Progressty: An Internatonal Comparson", The Economc Journal, vol. 87, pp. 71-80.

Kakwan K, Wagstaff A, & Van Doorslaer E 1997, "Soco-Economc Inequaltes n Health:Measurement,Computaton and Statscal Inference.", Oxford Revew of Economc Polcy, vol. 77, pp. 87-103. Kakwan N., W. A. V. D. E. 1997, "Soco Economc Inequaltes n Health: Measurement, Computaton and Statstcal Inference", Journal of Econometrcs, vol. 1997, pp. 87-103. Larson DR, Hndson P, & Hauqutz A 1995, "Equty of Health Care n Australa", Socal Scence and Medcne, vol. 41,no. 4, pp. 475-482. Lasprlla E, ObandoC, & Encalad E Lasprlla C 1999, Health Sector Inequaltes and Poverty n Ecuador. Londoño, J. & Frenk, J. Structured Pluralsm: Towards an Innovatve Model for Health System Reform n Latn Amerca. 1997. Ref Type: Generc Murray CJL & Frenk J. A WHO framework for health system performance assessment. 1999. Geneva, World Health Organzaton. Global Programme on Evdence for Health Polcy Dscusson Paper No. 6. Ref Type: Generc Pannarunotha, S. & Mlls, A. 1997, "The poor pay more: health-related nequalty n Thaland", Soc Sc Med, vol. 44,no. 12, pp. 1781-1790. Pauly MV 1992, "Farness and Feasblty n Natonal Health Care Systems", Health Econmcs, vol. 1,no. 93. Pouller JP & Hernandez P 2000, Estmates of Natonal Health Accounts. Aggregates for 191 countres n 1997. Rasell E, Bernsten J, & Tang K 1994, "The Impact of Health Care Fnancng on Famly Budgets.", Internatonal Journal of Health Servces, vol. 24, pp. 691-714. Sen A 1981, Poverty and Famnes: An Essay on Enttlement and Deprvaton. Sen A 1984, Goods and People. Sen A 1985, The Standard of Lvng. Streeten P, Burkh S, Al Haq M, Hcks N, & Stewart F 1981, Frst Thngs Frst: Meetng Basc Needs n Developng Countres, Oxford Unversty Press. Suarez RM 1999, Summary of Results and Polcy Implcatons Health Systems Inequaltes and Poverty n Latn Amerca and the Carbbean. Valladares R & Barllas E 1999, Health Sector Inequaltes and Poverty n Guatemala. Van Doorslaer E & Wagstaff A 1999, "The Re-drstrbutve Effect of Health Care Fnancng n Twelve OECD Countres.", Journal of Health Economcs, vol. 18, pp. 291-313.

Wagstaff A & Van Doorslaer E 1992, "Equty n the Delvery of Health Care: Some Internatonal Comparsons", Journal of Health Economcs, vol. 11, pp. 389-411. Wagstaff A & Van Doorslaer E 1993, Equty n the Fnance and Delvery of Health Care:An Internatonal Perspectve Oxford Medcal Publcatons. Wagstaff A & Van Doorslaer E 1998, "Equty n Health Fnance and Delvery,". Wagstaff A & Van Doorslaer E 1999, "Equty n the Fnance of Health Care: Some Further nternatonal Comparsons", Journal of Health Economcs, vol. 18, pp. 263-290. Wagstaff A., Van Doorslaer E, & Pac P 1989, "Equty n the Fnance and Delvery of Health Care: Some Tentatve Cross-Country Comparsons", Oxford Revew of Economc Polcy, vol. 5, pp. 89-112. World Health Organzaton 2000, World Health Report 2000: Health Systems: Improvng Performance, World Health Organzaton, Geneva, Swtzerland. Xu, K., Lydon, P., Ortz de Iturbde, J., Musgrove, P., Knaul, F., Kawabata, K., Florez, C. E., John, J., Wbulpolprasert, S., Waters, H., & Tansel, A. 2000, Analyss of the farness of fnancal contrbuton n 21 countres, World Health Organzaton, Geneva, Swtzerland, 25.