have less access to (and make less use of) health services, lose rank.<sup>26</sup> The consequence is that individuals who are less likely to use health services get concentrated in the lower quintiles under the new ranking, whereas households with better access and greater utilization concentrate in higher quintiles. The effect of this is to increase inequality. While this explains some of the observed patterns, the impact on the distribution of outpatient visits to health centers and health posts is less clear. However, primary-level health facilities are far less concentrated in urban and southern areas than hospitals. As a consequence, curative visits to health centers and health posts are less likely to be correlated with the re-ranking, which, as we have seen, is largely spatial in nature.

# **5. Discussion and Conclusions**

This paper has shown that in Mozambique, the choice of welfare indicator has a large and significant impact on socioeconomic inequalities in service utilization and on the “perceived” incidence of public spending. The analysis suggests that, relative to consumption, the asset index overestimates SES for households in urban and more economically developed areas. The most important reasons for this overestimation appears to be the lack of a spatial price deflator in the construction of the asset index, and the complementarity of some assets and housing characteristics with public infrastructure. The differences between consumption and the asset index are systematically correlated with the utilization of health services, resulting in a significant difference between measured inequality for the two measures of SES. In other words, the paper shows that we can reach very different conclusions about the “same” issue depending on how we define socioeconomic status. This conclusion can be contrasted with Wagstaff and Watanabe (2003), who find that the choice of welfare indicator makes little difference to measured inequality in wasting and stunting in 19 countries. While the results by Wagstaff and Watanabe (2003) provide a degree of confidence about the robustness of health equity analysis to the choice of welfare indicator, the purpose of this paper has been to warn against excessive confidence, and to show that, at least in some contexts, the choice of welfare indicator can drive conclusions in important ways.

It is natural to ask which measure is better. Consumption has more theoretical grounding as a measure of welfare, and will therefore often be the preferred measure of SES. On the other hand, a strong case can also be made—on both conceptual and practical grounds—in favor of a wealth or asset index to measure household living standards. In general, however, it is not possible to provide a definite answer to which welfare indicator is preferable. Indeed, it may be argued that the observed differences in measured inequality simply reflect the fact that consumption and the asset index measure different things, or at least are different proxies for the same underlying variable of interest, and that there are good reasons to be concerned about inequalities along both measures of SES. In any event, the choice of indicator is typically driven by data availability rather than conceptual

> 26 Health services are undoubtedly more readily available in urban areas. Even for the rural areas, the southern provinces are, in general, better served in terms of health facility infrastructure and staffing. For example on the basis of recent health staff data, the population per health worker ranges from just over 2,000 to 2,606 in Maputo, Gaza, Inhambane, and Sofala, which can be compared with 5,995 for Zambezia and 3,606 for Cabo Delgado (MoH/SDC).

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