metadata: authors: 0: author: Wagstaff, Adam;Wagstaff,Robert Adam Stephen
1: author: Eozenou,Patrick Hoang-Vu
2: author: Neelsen,Sven
3: author: Smitz,Marc-Francois
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docna: 0: docna: The 2018 Health Equity and Financial
            Protection Indicators Database : Overview and Insights
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Health Economics & Finance,Disease Control & Prevention,Law and Justice Institutions
teratopic: Industry,Health, Nutrition and Population,Law and Development
abstracts: cdata!: The 2018 database on Health Equity and
            Financial Protection indicators provides data on equity in
            the delivery of health service interventions and health
            outcomes, and on financial protection in health. This paper
            provides a brief history of the database, gives an overview
            of the contents of the 2018 version of the database, and
            then gets into the details of the construction of its two
            sides -- the health equity side and the financial protection
            side. The paper also provides illustrative uses of the
            database, including the extent of and trends in inequity in
            maternal and child health intervention coverage, the extent
            of inequities in women's cancer screening and inpatient
            care utilization, and trends and inequalities in the
            incidence of catastrophic health expenditures.
repnme: repnme: The 2018 Health Equity and Financial
            Protection Indicators Database : Overview and Insights
display_title: The 2018 Health Equity and Financial
            Protection Indicators Database : Overview and Insights
listing_relative_url: /research/2018/10/30505471/2018-health-equity-financial-protection-indicators-database-overview-insights
topicv3: Health Equity m1326151 1288,Hypertension m1327277 1432,Health, Nutrition and Population m1327755 621,Mortality m1504365 3661,Health m1504661 3480
publishtoextweb_dt: 2018-10-22T00:00:00Z
historic_topic: Industry,Health, Nutrition and Population,Law and Development
no_of_pages: 64
author_keys: 0: author_key: 142270
1: author_key: 1175217
2: author_key: 1435450
3: author_key: 931141
model_extractions: WPS8577 Policy Research Working Paper 8577 The 2018 Health Equity and Financial Protection Indicators Database Overview and Insights _Adam Wagstaff Patrick Eozenou Sven Neelsen Marc Smitz_ Development Research Group & Health Nutrition and Population Global Practice October 2018
Policy Research Working Paper 8577

# **Abstract**

The 2018 database on Health Equity and Financial Protection indicators provides data on equity in the delivery of health service interventions and health outcomes, and on financial protection in health. This paper provides a brief history of the database, gives an overview of the contents of the 2018 version of the database, and then gets into the details of the construction of its two sides—the health equity side and the financial protection side. The paper also provides illustrative uses of the database, including the extent of and trends in inequity in maternal and child health intervention coverage, the extent of inequities in women’s cancer screening and inpatient care utilization, and trends and inequalities in the incidence of catastrophic health expenditures.

This paper is a product of the Development Research Group and the Health Nutrition and Population Global Practice. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank. org/research. The lead author may be contacted at awagstaff@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# The 2018 Health Equity and Financial Protection Indicators Database: Overview and Insights

Adam Wagstaff<sup>a*</sup> , Patrick Eozenou<sup>b</sup> , Sven Neelsen<sup>b</sup> , and Marc Smitz<sup>b</sup> a Development Research Group, The World Bank, 1818 H Street, NW, Washington DC 20433, USA b Health, Nutrition and Population Global Practice, The World Bank, 1818 H Street, NW, Washington DC 20433, USA

**Keywords:** Health indicators; health equity; health and inequality; out-of-pocket health expenditures; financial protection; health and poverty; millennium development goals; sustainable development goals; universal health coverage; non-communicable diseases

**JEL codes:** I1, I3, J13
2

# **Acknowledgments**

We are indebted to the task team leaders of the 2000, 2007 and 2012 databases, Davidson Gwatkin and Caryn Bredenkamp, without whose efforts the 2018 database would not have been possible. We are grateful to Leander Buisman who assisted in the processing of the microdata, to Caryn Bredenkamp, Tania Dmytraczenko, Olivier Dupriez, Rose Mungai, Minh Cong Nguyen, Marco Ranzani, Aparnaa Somanathan, Ajay Tandon and Joao Pedro Wagner De Azevedo who provided access to microdata, and to Qinghua Zhao for help with PovcalNet. We are grateful to Rantimi Adetunji, Nastassha Arreza, Amanda Kerr, Lingrui Liu, Jie Ren and Margarida Rodrigues for their tireless research assistance. We acknowledge the contributions of our collaborators on several projects whose ideas helped shape the 2018 database, including Daniel Cotlear, Tania Dmytraczenko and Owen Smith at the World Bank, Gabriela Flores at WHO Geneva, and Gisele Almeida at PAHO/WHO. Finally, we are grateful to Michele Gragnolati, Christoph Kurowski and Magnus Lindelow for their support, and to Tony Fujs, Karthik Ramanathan and Tariq Khokhar for engineering the online products. The findings, interpretations and conclusions expressed in this paper are entirely those of the authors, and do not necessarily represent the views of the World Bank, its Executive Directors, or the governments of the countries they represent.

# **Accessing the database**

A portal version of the 2018 database with visualization functionality can be accessed at <u>http://datatopics.worldbank.org/health-equity-and-financial-protection/. The data set itself can be</u> accessed and downloaded, indicator by indicator, or in its entirety, from <u>https://datacatalog.worldbank.org/node/142861 from which model Stata ‘do’ files can be downloaded</u> to replicate the datapoints in the HEFPI data set.

# **Citing the database**

The reference citation for the data is: Wagstaff, Adam, Eozenou, Patrick, Neelsen, Sven and Smitz, Marc. 2018. The Health Equity and Financial Protection Indicators Database 2018. World Bank: Washington, DC.

* Corresponding author: Adam Wagstaff. Development Research Group, The World Bank, 1818 H Street, NW, Washington DC 20433, USA. Tel: +1 202 473 0566, awagstaff@worldbank.org
3

# **List of Abbreviations**

|ANC|Antenatal care|
|---|---|
|ARI|Acute respiratory infection|
|BCG|Bacillus Calmette–Guérin|
|BMI|Body Mass Index|
|CATA|Catastrophic (health) expenditures|
|CPI|Consumer price index|
|CWIQ|Core Welfare Indicators Questionnaire|
|DDH|World Bank Development Data Hub|
|DHS|Demographic and Health Survey|
|E123|Enquêtes 1-2-3|
|EAPPOV|East Asia & Pacific harmonized household survey collection|
|ECAPOV|Europe & Central Asia harmonized household survey collection|
|ECHP|European Community Household Panel|
|EHIS|European Health Interview Survey|
|EUROSTAT-HBS|Eurostat Household Budget Survey|
|FP|Financial protection|
|HBS|Household Budget Survey|
|HEFPI|Health Equity and Financial Protection Indicators|
|HEIDE|Household Expenditure and Income Data for Transitional Economies|
|HIES|Household Income & Expenditure Survey|
|ICP|International Comparison Program|
|IFG|Impaired fasting glycaemia|
|IFLS|Indonesia Family Life Survey|
|IMPOV|Impoverishing (health) expenditures|
|IMR|Infant mortality rate|
|IP|Inpatient|
|ISSP|International Social Survey Program|
|ITN|Insecticide treated bed net|
|LAM|Lactational amenorrhea method|
|LCUs|Local currency units|
|LIS|Luxembourg Income Study|
|LMIC|Low and middle-income country|
|LSMS|Living Standards Measurement Study|
|LWS|Luxembourg Wealth Study|
|MCH|Maternal and child health|
|MCSS|Multi-Country Survey Study on Health and Responsiveness|
|MDGs|Millennium Development Goals|
|MICS|Multiple Indicator Cluster Survey|
|MMR|Measles-Mumps-Rubella|
|MNAPOV|Middle East & North Africa harmonized household survey collection|
|NCD|Noncommunicable disease|
|OECD|Organization for Economic Co-operation and Development|
|ORS|Oral Rehydration Salts|
4

|PAP|Cervical cancer screening|
|---|---|
|PCA|Principal components analysis|
|PL|Poverty Line|
|PPP|Purchasing power parity|
|RHS|Reproductive Health Survey|
|SAGE|Study on global AGEing and adult health|
|SARLF|South Asia Labor Flagship harmonized survey collection|
|SARMD|South Asia harmonized household survey collection|
|SBA|Skilled birth attendance|
|SDGs|Sustainable Development Goals|
|SEDLAC|Socio-Economic Database for Latin America and the Caribbean|
|SHES|Standardized household expenditure surveys|
|SHIP|Sub-Saharan Africa harmonized household survey collection|
|STEPS|Stepwise Approach to Surveillance|
|U5MR|Under-5 mortality rate|
|UHC|Universal Health Coverage|
|UK-GHS|United Kingdom General Household Survey|
|UN|United Nations|
|UNICEF|United Nations Children's Fund|
|UNICO|Universal Health Coverage Study Series|
|US$|United States Dollars|
|US-NHIS|United States National Health Interview Survey|
|WB|World Bank|
|WDI|World Development Indicators|
|WEO|World Economic Outlook|
|WHO|World Health Organization|
|WHS|World Health Survey|
5

# **Introduction**

Among the many shifts of emphasis that have been evident in global health over the last 25 years or so, two stand out. One is the concern over equity: there has been a growing realization that the poor continue to lag behind the better off in receipt of key health interventions and health outcomes, and that international goals couched in terms of population averages could perfectly possibly be met without faster progress among the poor. The other is a concern over out-of-pocket health spending: getting people the health interventions they need is one part of the overall goal of any health system; the other is to ensure that families do not end up impoverished or otherwise suffer financial hardship by paying large sums of money out-of-pocket to ensure family members get the services they need. Neither of these concerns was reflected in the Millennium Development Goals (MDGs), which focused on population averages and made no mention of out-of-pocket expenses. By contrast, both are reflected in the Sustainable Development Goals (SDGs): the SDG equity commitment to ‘leave no one behind’ calls for data that are disaggregated by inter alia living standards; and the SDG commitment to universal health coverage (UHC) explicitly includes a commitment to ‘financial risk protection’.

This paper provides an overview of an international database on Health Equity and Financial Protection Indicators (HEFPI). The data set provides data on the delivery of health service interventions, health outcomes, and ‘financial protection’ in health, at both the population level and for subpopulations defined by household living standards. The data are computed from well-known household surveys that have been conducted by, or in partnership with, national governments, such as the Demographic and Health Survey (DHS) and the Living Standards Measurement Study (LSMS). None of our data comes from official reports by national governments, in part because such data do not lend themselves to disaggregation by household living standards, and in part because of concerns about accuracy, especially where governments do not face incentives to report accurate numbers (Murray et al. 2003; Lim et al. 2008; Sandefur and Glassman 2015; World Bank n.d.). Where we have been able to access the raw microdata from household surveys, we have done so.
6 Sometimes this was because there was no estimate reported in the survey report or online tool. But often it was because indicator definitions can vary from one survey ‘family’ to another, and sometimes even within a survey family, either over time or between the survey report and the online tool. Although we have re-analyzed the raw microdata, the estimates we report are simply harmonized direct (re)calculations of the quantities reported in the survey reports and online tools. In line with the growing concerns about the use of modeling in global health data sets (AbouZahr et al. 2017; Boerma et al. 2018), we do not predict missing data – we do not produce forecasts for country-years where there is no survey.<sup>1</sup> The downside is that our data set is, as a result, full of gaps. The upside is that, insofar as the surveys we use are reliable, differences over time or across countries ought to reflect reality rather than modeling assumptions; conversely, when real changes occur on the ground, they ought to get reflected in our numbers, rather than being smoothed away by the modeling process. Our data set is freely downloadable, and a data visualization tool is also available.<sup>2</sup> To ensure our data are reproducible, and in line with GATHER (Guidelines for Accurate and Transparent Health Estimates Reporting) (Stevens et al. 2016), we document thoroughly our methods and highlight the differences between our definitions and others’, and provide the essential computer code that ought to make it possible for anyone trying to reproduce our results to do so.<sup>3</sup> The GATHER table showing pages where the various parts of the database construction process are recorded, is included as Table A2 in the Annex.

The HEFPI database can be used to analyze a variety of topics. With the database one can see not just how the population fares but also how different ‘wealth’ or income groups fare on the indicators used in global goals, such as the MDGs and the SDGs: the database allows ‘snapshot’ comparisons as well as comparisons of trends (cf. Wagstaff 2002; Victora et al. 2003; Wagstaff et al. 2014). One can zoom in on a specific topic, such as child malnutrition, and see whether inequalities

> 1 Nor do we replace estimates directly calculated from the survey microdata by modeled estimates. 2 See frontmatter. 3 See frontmatter.
7 have narrowed over time (cf. Bredenkamp et al. 2014). One can document changes and differences in ‘financial protection’ in health; one can see, for example, whether the incidence of ‘catastrophic’ and ‘impoverishing’ health expenditures varies across countries (cf. Wagstaff and Eozenou 2014) or has changed over time in a specific country, before or after a reform, or relative to trends in neighboring countries. One can analyze (equality in) service coverage and financial protection simultaneously under the UHC umbrella (cf. Wagstaff et al. 2015; Wagstaff et al. 2016). More generally, the database is likely to be useful for analyzing any health system regarding how well it does in terms of delivering health services and improving health outcomes, but not compromising families’ ability to pay for goods and services other than health care.

This paper provides a brief history of the HEFPI database, gives an overview of the contents of the 2018 version of the database, and then gets into the detail of the construction of its two sides – the health equity side, and the financial protection side. It also provides illustrative uses of the data set.

# **A brief history of the HEFPI database**

The 2018 HEFPI database is, in effect, the fourth in a series of similar World Bank databases, all of which draw exclusively on data from household surveys – see Figure 1. The first two (Gwatkin et al. 2000; Gwatkin et al. 2007) showed gaps within and between countries on various indicators of service coverage and health outcomes in the MDG areas of maternal and child health (MCH), and communicable disease. The 2000 data set covered just 42 countries and drew data from just 42 surveys in the Demographic and Health Survey (DHS) family. More DHS surveys were added in 2007. The 2012 database (Bredenkamp et al. 2012b, c, d, e, a) also included data from UNICEF’s Multiple Indicator Cluster Survey (MICS) and the World Health Organization’s (WHO’s) World Health Survey (WHS). Data on service coverage and health outcomes in all three databases were presented for the population and for ‘wealth’ quintiles, the latter being formed by applying principal components analysis (PCA) to a variety of indicators capturing the ownership of assets (e.g. car and
8 television) and the characteristics of the household’s home (e.g. type of floor and roof) as proposed by Filmer and Pritchett (1999, 2001). The 2012 database also expanded the range of the health data: it included indicators of adult health, including noncommunicable disease (NCD) indicators, covering: health status, e.g. arthritis; risky behavior, e.g. smoking; preventive care, e.g. cervical cancer screening; and receipt of curative care, e.g. inpatient admissions. The 2012 database also expanded the range of countries, going from 95 countries in the developing world to 109 countries at all levels of development. Finally, the 2012 database expanded the scope of the exercise from just health equity to health equity and financial protection: the new indicators included covered both catastrophic health expenditures and impoverishing health expenditures (cf. Wagstaff and van Doorslaer 2003).

<u>Figure 1: Evolution of the World Bank’s Data on Health Equity and Financial Protection</u>

|**2000**|**2007**|**2012**|**2018**|
|---|---|---|---|
|42 countries – all<br>developing<br>countries|56 countries – all<br>developing<br>countries|109 countries –<br>incl. some high‐<br>income|193 countries –<br>goal is global<br>coverage|
|42 surveys – all|95 surveys – all|285 surveys –|1,654 surveys –|
|DHS|DHS|DHS, MICS &<br>WHS|DHS, MICS, WHS,<br>LSMS, HBS, etc.|
|34 indicators – all<br>services or<br>outcomes|115 indicators –<br>all services or<br>outcomes|73 indicators –<br>incl. 4 FP<br>indicators|51 indicators –<br>incl. more NCD<br>and FP indicators|
|Focus on equity<br>in MDG<br>indicators|Focus on equity<br>in MDG<br>indicators|Not just MDG<br>indicators – some<br>NCD and FP<br>indicators|Levels of and<br>equity in MDG<br>and SDG<br>indicators, incl.<br>FP|

The 2018 edition of the HEFPI database continues this broadening-out. In addition to the ‘traditional’ MCH and communicable disease indicators from the DHS and MICS, it includes more data on adult NCD indicators, drawing on data from the WHS, the DHS, the Stepwise Approach to Surveillance (STEPS) surveys, and many other regional and national surveys. In addition, the database expands dramatically the number of financial protection datapoints – from 54 to 563. This expansion builds on World Bank research on monitoring progress towards UHC – initially in Latin
9 America (with PAHO) (Wagstaff et al. 2015), then in the Universal Health Coverage Study Series (UNICO) countries (Wagstaff et al. 2016), and more recently globally (with WHO) (Wagstaff et al. 2018a; Wagstaff et al. 2018b). The 2018 HEFPI data set includes the datapoints contributed by the World Bank to the joint 2017 WHO-World Bank data set (80% of the total), but also many others generated (by the World Bank) since. With the new datapoints, the financial protection part of the 2018 HEFPI data set is larger than the 2017 WHO-World Bank data set and covers more countries. On both the health equity and financial protection sides of the HEFPI database, the country coverage has expanded as well – from 109 countries in 2012 to 193. The number of household surveys used has increased even more dramatically – from 285 in 2012 to over 1,600.

The datapoints in the 2018 HEFPI data set, like those in the previous three data sets, have, wherever possible, been computed from the original microdata. For some surveys, this was not possible, and we have had to make do either with published reports (as in the case, for example, of the STEPS surveys) or with studies by researchers who have used the same methods as us (see e.g. Van Doorslaer and Masseria 2004; Van Doorslaer et al. 2006a). One goal behind re-analyzing the original microdata was to ensure maximum consistency across surveys, countries and years. Sometimes, this means that our data are not identical to those on the websites and in the reports of the organizations that produced the microdata. For example, we use the same (2006) standards for childhood stunting and underweight in all surveys. The DHS reports, by contrast, use whatever standard was in force at the time the survey was done. In addition to ensuring consistency, there was a second reason to re-analyze the microdata: to ensure we have data for different ‘wealth’ or income groups, and a summary measure of inequality, namely the concentration index and its standard error (Kakwani et al. 1997).

# **Overview of the 2018 HEFPI database**

Figure 2 gives an overview of the 2018 HEFPI database in terms of indicators. The darker shaded boxes contain indicators used already in the MDGs. The lighter shaded boxes contain
10 indicators that did not feature in the MDGs, but do feature in, or are consistent with, the SDGs. To make way for the newer indicators, and for the extensive financial protection data, some of the MDG-era indicators included in previous versions of the HEFPI database have been retired. The retained MDG-era indicators feature prominently in the official and supplemental MDG monitoring indicators (Wagstaff and Claeson 2004), as well as in indicator lists for current global goalmonitoring exercises, such as the ‘Countdown to 2030 for Maternal, Newborn, and Child Survival’ (cf. Victora et al. 2015) and the SDGs (e.g. SDG target 2 on ending hunger and improving nutrition and SDG 3.8 on achieving UHC).<sup>4</sup> The SDG-era indicators also feature in current global goalmonitoring exercises, including broad exercises like the SDGs, as well as in more specific exercises like the UN General Assembly’s 2011 Political Declaration on NCDs.<sup>5</sup>

> 4 The SDG indicators are listed at <u>https://unstats.un.org/sdgs/indicators/indicators-list/.</u> 5 The indicators being used to monitor progress on the NCDs are listed at <u>http://www.who.int/nmh/global_monitoring_framework/en/.</u>
11

# <u>Figure 2: Structure of the 2018 HEFPI database</u>

<!-- Start of picture text --> Health Equity and<br>Financial Protection<br>Health equity Financial Protection<br>Service coverage Health outcomes Catastrophic expenditures Impoverishing<br>(CATA) expenditures (IMPOV)<br>Prevention Treatment MDG era SDG era CATA 10% IMPOV $1.90-a-day, and<br>other $ PLs<br>MDG era SDG era MDG era SDG era Infant mortality (IMR) Adult BMI CATA25% IMPOV 60% median per<br>capita consumption<br>Cervical cancer screening Skilled birth attendance Under-five mortality<br>Antenatal visits (4+) Inpatient admissions Adult overweight<br>(PAP) (SBA) (U5MR)<br>Treatment of child with<br>Child immunization Breast cancer screening acute respiratory infection Treatment for hypertension Stunting among under-5s Adult obesity<br>(ARI)<br>Sleeping under insecticide- Treatment of child with Treatment for Underweight among<br>treated bednet Hypertension testing diarrhea diabetes under-5s Adult height<br>Prevalence of raised blood<br>Contraception prevalence Cholesterol testing HIV prevalence<br>pressure<br>Raised blood glucose and<br>Family planning demands<br>satisfied Diabetes testing impaired fasting glycaemia<br>(IFG)<br>Condom use during risky<br>intercourse<br><!-- End of picture text --> Figure 3 shows the surveys used in the 2018 HEFPI database, where the size of each block is proportional to the fraction of total datapoints contributed by the survey in question. In contrast to the 2000 database, which was based entirely on DHS surveys, the 2018 database uses a variety of different surveys, albeit still, for the most part, highly standardized surveys from a few multicountry programs. For the MDG-era health service coverage and health outcome indicators, the DHS accounts for the majority of datapoints, but the MICS and the WHS are also important sources, contributing over 30% of the MDG-era service coverage datapoints. For the SDG-era health service coverage and health outcome indicators, the DHS is also an important source, but other sources are also important. These include the STEPS and the WHS, as well as the European Community Household Panel (ECHP), the International Social Survey Program (ISSP), the Eurobarometer, and
<!-- Start of picture text --> COV; MDG CATA; SDG<br>HBS<br>escs [ass[e_ [rs].||p |<br>eee<br>2p a<br>EJ<br>oF<br>DHS 2<br>az=<br>OUT; MDG<br>WHS<br>-—T TTT} was<br><!-- End of picture text -->
<!-- Start of picture text --> 0-33 © NN33.66 = cc-100 ioo- No data<br>eS ae<br>oy cs -“J é es \<br>As.<br>t :<br><!-- End of picture text -->
14 Claeson 2004), the ‘Countdown to 2030 for Maternal, Newborn, and Child Survival’ (cf. Victora et al. 2015), the SDGs,<sup>6</sup> the STEPS<sup>7</sup> indicators and other NCD indicators used to track progress relating to the UN General Assembly’s 2011 Political Declaration on NCDs,<sup>8</sup> and the ongoing discussions relating to the measurement of service coverage in the context of UHC<sup>9</sup> (cf. Boerma et al. 2014a; Boerma et al. 2014b; Hogan et al. 2018). We include 18 indicators of health service utilization, of which 12 are preventative and 6 curative. The other 28 indicators are health and anthropometric outcomes for both adults and children.

# <u>Data search and data sources</u>

We set out to assemble as large a data set as possible of household surveys. To this end, we undertook inventories of the microdata catalogs of the International Household Survey Network<sup>10</sup> and the World Bank,<sup>11</sup> the Institute of Health Metrics’ Global Health Data Exchange,<sup>12</sup> and several household survey collections. We also searched for household surveys online. This search identified 1,153 surveys from 193 countries – see Figure 5. The surveys include country-specific surveys as well as multi-country household survey collections, notably the DHS, the ECHP, the Eurobarometer, the European Health Interview Survey (EHIS), the LSMS, the Multi-Country Survey Study on Health and Responsiveness (MCSS), the MICS, the Reproductive Health Survey (RHS), the STEPS, the World Bank’s Europe and Central Asia Household Health Survey, and the WHS. Table 4 summarizes the key details of these survey ‘families’. For 863 of the surveys identified, we were able

> 6 The SDG indicators are listed at <u>https://unstats.un.org/sdgs/indicators/indicators-list/.</u>

> 7 STEPS survey reports and fact sheets are available at <u>http://www.who.int/ncds/surveillance/steps/en/.</u> 8 The indicators being used to monitor progress on the NCDs are listed at <u>http://www.who.int/nmh/global_monitoring_framework/en/.</u> 9 See also the discussions of UHC service coverage indicators at <u>http://www.who.int/healthinfo/universal_health_coverage/UHC_Meeting_Nov2015_Report.pdf.</u> 10 http://www.ihsn.org/.

> 11 http://microdata.worldbank.org/index.php/home.

> 12 http://ghdx.healthdata.org/.
15 to obtain the microdata and compute by ourselves the numbers included in the database. For the remaining 290 surveys (e.g. the STEPS), the microdata were inaccessible. In this case, we extracted information from survey reports, and in a few cases from research papers authored by researchers who had used the same methods we use.<sup>13</sup> All datapoints in the data set are labeled with their data source in the referenceid variable – see annex for naming conventions.

# <u>Figure 5: Data sources for the health equity part of the 2018 HEFPI database</u>

<!-- Start of picture text --> 1,153 surveys<br>identified<br>227 DHS 118 STEPS<br>114 MICS 101 ECHP<br>70 WHS 43 Eurobarometer<br>39 EHIS 35 MCSS<br>352 other national or<br>32 ISSP<br>multicountry surveys<br>863 accessible and<br>290 inaccessible, summary data taken from publication, e.g. STEPS<br>microdata analyzed<br><!-- End of picture text --> 13 E.g. van Doorslaer and Masseria (2004) and van Doorslaer et al. (2006a).
16

# <u>Table 1: Health equity: Service coverage (prevention)</u>

||Indicator|<br>Definition|Main Data Source|
|---|---|---|---|
||Pregnancies with 4 or more<br>antenatal care visits(% of total)|Percentage of most recent births in last two years with at least 4 antenatal care visits (women age<br>18-49 at the time of the survey)|<br>DHS, MICS, WHS|
||Immunization, full (% of children<br>ages 15-23 months)|Percentage of children age 15-23 months who received Bacillus Calmette–Guérin (BCG),<br>measles/Measles-Mumps-Rubella (MMR), 3 doses of polio (excluding polio given at birth) and 3<br>doses of diphtheria-pertussis-tetanus (DPT)/Pentavalent vaccinations, either verified by<br>vaccination card or byrecall of respondent|DHS, MICS|
||Immunization, measles (% of<br>children ages 15-23 months)|Percentage of children age 15-23 months who received measles or MMR vaccination, either<br>verified byvaccination card or byrecall of respondent|DHS, MICS, WHS|
|**_MDG_**|Use of insecticide-treated bed nets<br>(% of under-5 population)|Percentage of children under 5 who slept under an insecticide treated bed net (ITN) the night<br>before the survey. A bed net is considered treated if it a) is a long-lasting treated net, b) a pre-<br>treated net that was purchased or soaked in insecticides less than 12 months ago, or c) a non-pre-<br>treated net which was soaked in insecticides less than 12 months ago. MICS 2 data points (MICS<br>surveyspre-2002)consider bed nets treated if theywere_ever_treated.)|DHS, MICS|
||Contraceptive prevalence, modern<br>methods (% of women ages 15-49)|Percentage of women age 15-49 who are married or live in union and currently use a modern<br>method of contraception. Modern methods are defined as female sterilization, male sterilization,<br>the contraceptive pill, intrauterine contraceptive device (IUD), injectables, implants, female<br>condom, male condom, diaphragm, contraceptive foam and contraceptive jelly, lactational<br>amenorrhea method (LAM), emergency contraception, country-specific modern methods and other<br>modern contraceptive methods respondent mentioned.|DHS, MICS|
||Unmet need for contraception (% of<br>women ages 15-49)|Percentage of women age 15-49 who are married or live in union who do not want to become<br>pregnant but are not usingcontraception(revised definition byBradleyet al.(2012)).<sup>14</sup>|DHS|
||Condom use in last intercourse (%<br>of female at riskpopulation)|Percentage of women age 18-49 who had more than one sexual partner in the last 12 months and<br>used a condom duringlast intercourse|DHS, MICS,<sup>15</sup>WHS|
|**_G_**|Pap smear in last 5 years|Percentage of women who received a pap smear in the last 5 years (preferably age 30-49 but age<br>groups may vary)|DHS, EHIS,<br>Eurobarometer,<br>STEPS, US-NHIS,<br>WHS|
|**_SD_**|Mammography in last 2 years|Percentage of women who received a mammogram in the last 2 years (preferably age 50-69 but<br>age groups may vary)|DHS, EHIS,<br>Eurobarometer,<br>SAGE, STEPS, US-<br>NHIS, WHS|

> 14 A flowchart showing how our _unmet need_ variable is constructed is available at https://dhsprogram.com/topics/upload/Figure-2-Revised-unmet-need-definition-flowchart- <u>Bradley-et-al-AS25.pdf. Further methodological details and code are available at https://dhsprogram.com/topics/Unmet-Need.cfm.</u>

> 15 Our _condom use in last intercourse_ data do not include points from the MICS 3 wave because unlike subsequent waves, MICS 3 only collected sexual intercourse data for women aged 15-24.
17

|Indicator|Definition|Main Data Source|
|---|---|---|
|Blood pressure measured in last 12<br>months (% of population age 18 and<br>older)|Percentage of population over 18 having their blood pressure measured by health professional in<br>the last year|Eurobarometer|
|Cholesterol measured in last five<br>years (% of population at risk of<br>high cholesterol)|Percentage of adult population at risk (overweight or obese and older than 20, male and older<br>than 34) having their cholesterol levels measured in the last 5 years|EHIS|
|Blood sugar measured in last 5<br>years (% of population at risk of<br>diabetes)|Percentage of population aged 40-69 at increased risk of diabetes (overweight, obese) having their<br>blood sugar measured in the last 5 years|EHIS|
18

# <u>Table 2: Health equity: Service coverage (treatment)</u>

|||Indicator|Definition|Main Data Source|
|---|---|---|---|---|
|||Births attended by skilled health<br>staff (% of total)|Percentage of most recent births in last 2 years attended by any skilled health personnel (women<br>age 18-49 at the time of the survey). Definition of_skilled_varies by country and survey but always<br>includes doctor, nurse, midwife and auxiliarymidwife).|DHS, MICS, WHS|
||**_MDG_**|Acute respiratory infections treated<br>(% of children under 5 with cough<br>_and_rapid breathing)|Percentage of children under 5 with cough and rapid breathing in the two weeks preceding the<br>survey (DHS, WHS) who had a consultation with a formal health care provider (excluding<br>pharmacies and visits to ‘other’ health care providers). MICS data points use sample of children<br>under 5 with cough and rapid breathing in the 2 weeks preceding the survey which_originated_<br>_from the chest_. The definition of_formal_health care providers varies by country and data source.|DHS, MICS|
|**_ENT_**||Diarrhea treatment (% of children<br>under 5 with diarrhea who received<br>ORS)|Percentage of children under 5 with diarrhea in the 2 weeks before the survey who were given<br>oral rehydration salts (ORS)|DHS, MICS|
|**_TREATM_**|**_SDG_**|Inpatient care use in last 12 months<br>(% of population age 18 and older)|Percentage of population age 18 and older using inpatient care in the last 12 months|DHS, ECHP,<br>ENAHO,<br>Eurobarometer,<br>EHIS, ISSP, LSMS,<br>MCSS, US-NHIS,<br>SLC, SUSENAS, UK-<br>GHS, WHS|
|||Treated for high blood pressure (%<br>of adultpopulation)|Percentage of adult population being treated for high blood pressure (age-range may vary)|Eurobarometer,<br>EHIS|
|||Treated for raised blood glucose or<br>diabetes (% of adult population)|Percentage of adult population being treated for raised blood glucose or diabetes (age-range may<br>vary)|DHS,<br>Eurobarometer,<br>EHIS|
19

# <u>Table 3: Health equity: Outcomes</u>

||Indicator|<br>Definition|Main Data Source|
|---|---|---|---|
||Mortality rate, infant (deaths per<br>1,000 live births)|Deaths of children before their 1st birthday per 1,000 live births. Sample: children born up to 5 years<br>before the survey for full population mortality estimates, and up to 10 years before the survey for<br>wealth quintile specific mortality estimates|DHS|
|**_G_**|Mortality rate, under-5 (deaths<br>per 1,000 live births)|Deaths of children before their 5th birthday per 1,000 live births. Sample: children born up to 5 years<br>before the survey for full population mortality estimates, and up to 10 years before the survey for<br>wealth quintile specific mortality estimates|DHS|
|**_MD_**|Prevalence of stunting, height for<br>age (% of children under 5)|Percentage of children under 5 with a Height-for-Age z-score <-2 standard deviations from the<br>reference median (z-score calculated using WHO 2006 Child Growth Standards)|DHS, MICS|
||Prevalence of underweight,<br>weight for age (% of children<br>under 5)|Percentage of children under 5 with a Weight-for-Age z-score <-2 standard deviations from the<br>reference median (z-score calculated using WHO 2006 Child Growth Standards)|DHS, MICS|
||Prevalence of HIV, total (% of<br>population ages 15-49)|Percentage of population age 15-49 who had blood tests that are positive for HIV1 or HIV2|DHS|
||Height in meters, adults (age 18<br>and older)|Mean height in meters of population aged 18 and older|ECHP, ISSP, WHS|
||Height in meters, men (age 18<br>and older)|Mean height in meters of males aged 18 and older|ECHP, ISSP, WHS|
||Height in meters, women (age 18<br>and older)|Mean height in meters of females aged 18 and older|ECHP, ISSP, WHS|
||Height in meters, women (age 15-<br>49)|Mean height in meters of females aged 15-49|DHS|
||BMI, adults (age 18 and older)|Mean BMI of population aged 18 or older|ECHP, EHIS, ISSP,<br>STEPS, WHS|
||BMI, men (age 18 and older)|Mean BMI of male population aged 18 or older|ECHP, EHIS, ISSP,<br>STEPS, WHS|
|**_G_**|BMI, women (age 18 and older)|Mean BMI of female population aged 18 or older|ECHP, EHIS, ISSP,<br>STEPS, WHS|
|**_SD_**|BMI, women (age 15-49)|Mean BMI of female population aged 15-49 (excludes currently pregnant women and women having<br>given birth in the three months preceding the survey)|DHS|
||Prevalence of overweight, BMI (%<br>of population 18 and older)|<br>Percentage of population aged 18 or older with BMI above 25|ECHP, EHIS, ISSP,<br>STEPS, WHS|
||Prevalence of overweight among<br>men, BMI (% of males 18 and<br>older)|Percentage of male population aged 18 or older with BMI above 25|ECHP, EHIS, ISSP,<br>STEPS, WHS|
||Prevalence of overweight among<br>women, BMI (% of females age 18<br>and older)|Percentage of female population aged 18 or older with BMI above 25|ECHP, EHIS, ISSP,<br>STEPS, WHS|
||Prevalence of overweight among<br>women, BMI (% of females age<br>15-49)|Percentage of female population aged 15-49 with BMI above 25 (excludes currently pregnant women<br>and women having given birth in the three months preceding the survey)|DHS|
||Prevalence of obesity, BMI (% of<br>population 18 and older)|Percentage of population aged 18 or older with BMI above 30|ECHP, EHIS, ISSP,<br>STEPS, WHS|
20

|Indicator|Definition|Main Data Source|
|---|---|---|
|Prevalence of obesity among men,<br>BMI (% of males ages 18 and<br>older)|Percentage of males aged 18 and older with BMI above 30|ECHP, EHIS, ISSP,<br>STEPS, WHS|
|Prevalence of obesity among<br>women, BMI (% of females ages<br>18 and older)|Percentage of females aged 18 and older with BMI above 30|ECHP, EHIS, ISSP,<br>STEPS, WHS|
|Prevalence of obesity among<br>women, BMI (% of females age<br>15-49)|Percentage of females aged 15-49 with BMI above 30 (excludes currently pregnant women and women<br>having given birth in the three months preceding the survey)|DHS|
|Mean diastolic blood pressure,<br>adult population (mmHg)|Mean diastolic blood pressure (mmHg) in adult population (age-range may vary)|DHS, STEPS|
|Mean systolic blood pressure,<br>adult population (mmHg)|Mean systolic blood pressure (mmHg) in adult population (age-range may vary)|DHS, STEPS|
|High blood pressure or being<br>treated for high blood pressure<br>(% of adult population)|Percentage of adult population with high blood pressure or on treatment for high blood pressure (age-<br>range may vary)|DHS, STEPS|
|Mean fasting blood glucose, adult<br>population (mmol/L)|Mean fasting blood glucose (mmol/L) in adult population (age-range may vary)|STEPS|
|Impaired fasting glycaemia (% of<br>adult population)|Percentage of adult population with impaired fasting glycaemia (age-range may vary)|STEPS|
|Mean cholesterol, adult<br>population (mmol/L)|Mean cholesterol (mmol/L) in adult population (age-range may vary)|STEPS|
|High cholesterol or on treatment<br>for high cholesterol (% of adult<br>population)|Percentage of adult population with high cholesterol or on treatment for high cholesterol (age-range<br>may vary)|STEPS|
21 <u>Table 4: Survey ‘families’ used in health equity side of HEFPI database</u>

|Survey<br>|Title in full<br>|<br>Core topics<br>|<br>No. of countries<br>|<br>History<br>|<br>Data collection<br>method<br>|Sample size<br>|Further<br>information on<br>data and access<br>|
|---|---|---|---|---|---|---|---|
|DHS|Demographic<br>and Health<br>Survey|Population, health, and<br>nutrition, with a focus on<br>reproductive, maternal and<br>child health|91 low and middle-income<br>countries (LMIC), 74 in<br>HEFPI (data sets with<br>restricted access and those<br>collected before 1990<br>excluded, several collected<br>from 2016 to be added)|Ongoing, dating<br>back to 1984.<br>First HEFPI<br>data from 1990<br>(Phase 2)|Face-to-face<br>interviews,<br>physical<br>measurements,<br>biochemical<br>measurements|Typically<br>4,000-<br>15,000<br>households|https://dhsprogra<br>m.com/|
|ECHP|European<br>Community<br>Household Panel|Multipurpose panel survey with<br>adult health module|15 European high-income<br>countries, 14 in HEFPI<br>(Germany micro-data not<br>available)|1994-2001|Face-to-face<br>interviews|Typically<br>4,000-<br>12,000<br>adults|http://ec.europa.e<br>u/eurostat/web/m<br>icrodata/europea<br>n-community-<br>household-panel|
|EHIS|European Health<br>Interview Survey|Adult self-perceived health,<br>chronic conditions, disease<br>specific morbidity, physical and<br>sensory functional limitations,<br>hospitalization, consultations,<br>unmet needs, use of medicines,<br>preventive actions, height and<br>weight, health behaviors|31 middle and high-income<br>countries (European Union,<br>Iceland, Norway, and<br>Turkey), 20 in HEFPI (data<br>sets with restricted access<br>excluded)|Ongoing, dating<br>back to 2006|Face-to-face<br>interviews|Typically<br>1,000-<br>10,000<br>adults|http://ec.europa.e<br>u/eurostat/web/m<br>icrodata/europea<br>n-health-<br>interview-survey|
|Eurobaro<br>meter|Eurobarometer|Multipurpose survey with<br>changing focus, adult health<br>module in 2003 and 2006|28 European high and<br>middle-income countries, all<br>in HEFPI|Ongoing, since<br>1974, health<br>modules in 2003<br>and 2006|Face-to-face<br>interviews|Typically<br>1,000<br>adults|http://ec.europa.e<br>u/commfrontoffic<br>e/publicopinion/in<br>dex.cfm/General/i<br>ndex|
|ISSP|International<br>Social Survey<br>Program|Multipurpose survey with<br>changing focus, adult health<br>module in 2011|32 middle and high-income<br>countries in 2011 wave, all in<br>HEFPI|Ongoing since<br>1985, health<br>module in 2011|Face-to-face<br>interviews,<br>telephone<br>interviews,<br>postal and web<br>surveys|Typically<br>1,000-2,500<br>adults|https://www.gesis<br>.org/issp/modules/<br>issp-modules-by-<br>topic/health-and-<br>health-care/|
22

|Survey<br>|Title in full<br>|Core topics<br>|No. of countries<br>|History<br>|Data collection<br>method<br>|Sample size<br>|Further<br>information on<br>data and access<br>|
|---|---|---|---|---|---|---|---|
|MCSS|Multi-Country<br>Survey Study on<br>Health and<br>Responsiveness|Adult health state descriptions,<br>health conditions, screening,<br>health state valuations, health<br>system responsiveness, adult<br>mortality|60 countries of all income<br>levels and worldwide, 35 in<br>HEFPI (postal surveys<br>excluded, several countries to<br>be added)|2000-2001|Face-to-face<br>interviews,<br>telephone<br>interviews,<br>postal survey|Typically<br>600-6,000<br>adults|http://apps.who.i<br>nt/healthinfo/syst<br>ems/surveydata/i<br>ndex.php/catalog/<br>mcss/about|
|MICS|Multiple<br>Indicator Cluster<br>Survey|Population, health, and<br>nutrition, with a focus on<br>reproductive, maternal and<br>child health|108 LMIC with completed<br>surveys, 89 with available<br>data, 73 in HEFPI (MICS 5 to<br>be added, a number of earlier<br>wave surveys to be added)|Ongoing since<br>1995, first<br>HEFPI data<br>from 1999|Face-to-face<br>interviews,<br>physical<br>measurements|On average<br>11,000<br>households<br>in MICS 5<br>wave|http://mics.unicef.<br>org/|
|STEPS|Stepwise<br>Approach to<br>Surveillance|Adult non-communicable<br>disease-related health status<br>and health behaviors|111 LMIC, 94 in HEFPI<br>(subnational surveys<br>excluded, several to be added)|Ongoing, dating<br>back to 2001|Face-to-face<br>interviews,<br>physical<br>measurements,<br>biochemical<br>measurements|Typically<br>1,000-<br>10,000<br>adults|http://www.who.i<br>nt/ncds/surveilla<br>nce/steps/en/|
|WHS|World Health<br>Survey|Health expenditure, health<br>insurance coverage, adult<br>health state descriptions,<br>health state valuation, risk<br>factors, chronic conditions,<br>mortality, health care<br>utilization, health systems<br>responsiveness and social<br>capital.|70 countries of all income<br>levels and worldwide, all in<br>HEFPI|2002-2004|Face-to-face<br>interviews|Typically<br>between<br>1,000 and<br>8,000<br>adults|http://www.who.i<br>nt/healthinfo/sur<br>vey/en/|

All surveys (we use) are nationally representative household surveys
23

# <u>Indicator definitions</u>

Tables 1, 2 and 3 also show the definitions of the indicators. In choosing exact definitions of indicators, we have been guided by the same initiatives that guided us in our choice of indicators (see above), but also by the constraints imposed by the data and a desire to have a common definition irrespective of the data source. Our definitions sometimes differ from those used in reports and online tools derived from the same surveys we have used (e.g. DHS reports,<sup>16</sup> DHS STATcompiler,<sup>17</sup> MICS reports,<sup>18</sup> UNICEF website,<sup>19</sup> the WHS reports,<sup>20</sup> and the World Bank’s ‘Health, Nutrition and Population Statistics by Wealth Quintile’ databank,<sup>21</sup> which contains the data from the DHS and MICS reports), and from the WHO’s Health Equity Monitor<sup>22</sup> which also contains summary statistics at the population level and for wealth quintiles based on analysis of microdata from the DHS and MICS surveys. We summarize the differences in definitions between our definitions and others’ in Annex Table A1. Important examples to highlight include:  Generally, when computing percentages of the population covered by certain services (e.g. fully immunized), we exclude cases with missing information from the denominator. The DHS and MICS reports, by contrast, typically do not, and instead treat missing values the same as if the respondent had answered _No_ when asked about having accessed the respective service. As a result, DHS and MICS reports typically have a lower service coverage rates than us.

> 16 <u>https://dhsprogram.com/publications/publication-search.cfm?type=5.</u>

> 17 <u>https://www.statcompiler.com/en/.</u>

> 18 <u>http://mics.unicef.org/surveys.</u>

> 19 See https://data.unicef.org/. Population rates are also available for some indicators and some MICS surveys via the MICS COMPILER tool at http://www.micscompiler.org/.

> 20 <u>http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/whs/about.</u>

> 21 <u>http://databank.worldbank.org/data/source/health-nutrition-and-population-statistics-by-wealth-quintile. These data can be</u> more conveniently imported into Stata using the Stata module WBOPENDATA (Azevedo 2016).

> 22 Data available at http://www.who.int/gho/health_equity/en/0 and indicator definitions at <u>http://www.equidade.org/resources/indicators.pdf.</u>
24

- We always compute skilled birth attendance and antenatal care utilization rates for births in the past two years. The comparison databases, by contrast, use births in the reference period of the original survey question – e.g. births over the last 5 years for DHS, over the last year in the second MICS wave, and over the last 2 years from the third MICS wave onwards.

- We apply a consistent definition of full immunization in terms of both required vaccines and the age by which a child has to have received them to be considered fully immunized, whereas the vaccines and age-groups vary within and across the DHS and MICS comparison databases. For example, some MICS surveys measure full immunization at age 18-29 months and others at age 12-23 months, whereas we consistently use the 15-23 months age-group.<sup>23</sup> Also, full immunization rates in the MICS comparison databases vary in whether they consider pentavalent vaccination as an alternative to standard DPT vaccination, while we consistently consider it an alternative.

- As mentioned above, we use a consistent definition of ARI (cough and rapid breathing) across all DHS surveys to define the sample for which we compute our ARI treatment indicator.<sup>24</sup>

- We use a consistent definition of modern contraception methods across all surveys in the database which includes the lactational amenorrhea method (LAM). LAM is considered a modern method in STATcompiler and DHS reports but not in MICS reports and the MICS data in WHO’s Health Equity Monitor.

> 23 We depart from the 12-23 months age-group that is used in most DHS and MICS reports to account for the fact that immunization schedule age-ranges for the first dose of measles vaccination vary internationally from 9 to 15 months. Countries with higher measles prevalence are recommended to immunize children at an earlier age, despite the vaccines being more effective when administered later (World Health Organization 2017).

> 24 Our definition of appropriate care-seeking for children with ARIs excludes _other_ public or private providers since it is unclear if a medical consultation took place.
25

- We use the same WHO 2006 standards for childhood stunting and underweight in all surveys, whereas the DHS and MICS reports use whatever standard was in force at the time the survey was done. The change of standards apparently makes a difference (Ergo et al. 2009).

# <u>Indicator computation</u>

With the exception of the infant and under-5 mortality rates, which we calculate using the same life-table synthetic-cohort probability method employed in DHS reports and programmed in the Stata module SYNCMRATES (Masset 2016), and the childhood anthropometric z-score indicators from the MICS, which are computed throughout using 2006 WHO growth standards and programmed in WHO’s package IGROWUP,<sup>25</sup> all indicators are based on simple population-weighted means of variables constructed from the questions in the survey.<sup>26</sup> Where an indicator is available in more than one survey for a given year, we average over all data points.<sup>27</sup> Sometimes the way the data were collected in the surveys prevented us from achieving 100% consistency of definition across surveys. For a number of indicators such as pap smear and mammogram rates, and blood pressure and cholesterol levels, the sampled age-ranges differ (see notes in Tables 1-3). For other indicators, we could not fully eliminate _conceptual_ inconsistencies. For example, the MICS only asks about care-seeking for children with coughing _and_ rapid breathing if the caretaker reports that the respiratory problems originate from the chest. For MICS data, our

> 25 Program and documentation can be downloaded from http://www.who.int/childgrowth/software/en/. For the DHS, we use the 2006 WHO growth standard z-scores provided in the datasets to compute rates of childhood stunting and underweight. 26 Generally, construction of both the health equity and financial protection sides of the data set follows the methods summarized in O’Donnell et al. (2008).

> 27 We apply a different aggregation rule for our cancer screening variables – pap smear and mammography – when we have multiple data points for a given year that differ in terms of the age-range of the women for whom the surveys obtained screening rates. The rule we apply here is as follows: Our preferred age-ranges are 30-49 for pap smears and 50-69 for mammography. If for a given year, data are only available for another than the preferred age-range, we use the data point which minimizes the absolute difference between the number of years of the data point’s age-range which are outside the preferred age-range (inclusion errors) and the number of years of the preferred age-range which are not included in the data point’s age-range (exclusion errors). If, for instance, pap smear data for a given year are only available for women aged 25-44 and 35-59, we would choose the 25-44 data point (both age-ranges have an exclusion error of five years, but the inclusion error for the 35-59 age-range is ten years compared to five years for the 25-44 age-range).
26 acute respiratory infection (ARI) treatment variable is therefore only defined for the subgroup of children who experience cough and breathing difficulties coming from the chest. By contrast, many DHS do not include a question on where the respiratory problems originate, and the medical care seeking question is asked for _all_ children with cough _or_ breathing problems. The absence of a question on whether the breathing problems come from the chest prevents us from computing an ARI treatment variable for the DHS that is identical to that of the MICS. We are, however, able to obtain an ARI treatment variable that is consistent across all DHSs by defining ARIs (and thus the sample for which the treatment variable is computed) as having a cough which coincides with difficulties breathing.<sup>28</sup> Other indicators for which we do not achieve full consistency are 4+ antenatal care visits, children under 5 sleeping under insecticide-treated bed nets and measles immunization.<sup>29</sup> In some cases where the original survey questions differ, we try to harmonize indicators using an ex post adjustment of the population (and quintile) rates. Specifically, we flag and subsequently adjust cancer screening and inpatient utilization rates whenever the reported recall period differs from our preferred recall period: 5 years for pap smears and 2 years for mammograms according to WHO recommended screening intervals for our preferred age-groups 30-49 (pap smears) and 50-69 (mammograms) (World Health Organization 2013a, 2014), and 12 months as the most

> 28 ARI treatment rates constructed from WHS data are substantially higher than those obtained from DHS and MICS. We suspect these differences to be due to divergences in the survey methodology: Among other things, WHS data are only available for the _first_ health care seeking response if the _youngest_ child under 5 in the household suffered an ARI, whereas DHS and MICS ARI treatment data come from _all_ health care seeking responses of _all_ children under 5 with an ARI in a household. The HEFPI database therefore does not include ARI treatment data from the WHS.

> 29 For antenatal care, the MICS 2 antenatal care visit data only refer to visits to a _specific provider_ , whereas all later MICS waves and all DHSs do not impose this limitation. For all DHSs and all MICSs from 2002 onwards, a bed net is considered treated if it a) is a long-lasting treated net, b) a pre-treated net that was purchased or soaked in insecticides less than 12 months ago, or c) a non-pre-treated net which was soaked in insecticides less than 12 months ago. By contrast, data limitations in the MICS 2 wave (collected before 2002) restrict our definition of treated nets to those _ever_ treated. For antenatal care, the MICS 2 antenatal care visit data only refer to visits to a specific list of providers, whereas all later MICS waves and all DHSs do not impose this limitation. WHS measles immunization data are only available for the _younges_ t child in the household, whereas our DHS and MICS measles immunization data come from _all_ children under 5 in a household.
27 frequently used (and, we would argue, most sensible) recall period for inpatient care. Concretely, when a survey reported pap-smear (mammogram) utilization data for a recall period other than 5 (2) years, we transform the reported utilization rates to a 5 (2) year recall using the formula for the probability of an event over multiple trials, 1 ��1 �x�<sup>�/�</sup> , where _x_ is the percentage of women obtaining pap smears (mammograms) over the survey’s reported recall period _z_ (in years), and _y_ is our preferred recall period of 5 (2) years.<sup>30</sup> To obtain the adjustment factors for inpatient care data with less than 12 months recall, we exploit the availability of both 4-week and 12-month recall inpatient utilization data in the MCSS. Using the observed 4-week and 12-month inpatient utilization rates across 54 MCSS countries, and assuming zero utilization at time zero, we fit a nonlinear model of the relationship between time and utilization.<sup>31</sup> We then use the model to estimate hypothetical utilization rates for 2-week, 3-month, and 6-month recall periods. The adjustment factors are obtained by dividing the observed 12-month utilization rate by the respective estimated rates (and the observed 4-week rate).<sup>32</sup> Finally, the observed rate for the respective shorter recall period is multiplied with its adjustment factor to estimate the 12-month utilization rate.

# <u>Data processing process</u>

Figure 6 summarizes the data-processing steps. Whenever possible, we first generate from the raw household survey microdata. In these microdata sets, we generate a standardized or harmonized microdata set that contains our standardized indicators. The rates for each survey are then compared to the rates reported elsewhere in a quality-control exercise (see below for further details). Rejected datapoints are dropped. The remaining datapoints are consolidated into a ‘meso data set’, which has one row per survey-indicator combination, e.g. Armenia/2010/DHS/cervical

> 30 For surveys where the recall period is unspecified (‘Have you _ever_ had a pap smear/mammogram?’), we assume z� ������ � β, where α and β are the upper and lower bounds, respectively, of the age-group for which the survey question is asked (e.g. 49 and 30 for pap smear, and 69 and 50 for mammograms).

> 31 The fitted model takes the form y = -4E-05x2 + 0.0044x.

> 32 The adjustment factors to a 12-month recall utilization rate are 14.82 for 2-week, 7.58 for 4-week, 2.54 for 3-month and 1.47 for 6-month recall.
28 cancer screening. If the raw microdata are not available, we make use of summary statistics in existing reports and papers.

- <u>Figure 6: HEFPI health equity data processing steps</u>

<!-- Start of picture text --> Identify HH surveys<br>Access HH surveys<br>Compute harmonized variables<br>Compute population and quintile mean outcomes, CIs and their SEs<br>Collapse micro‐data to country‐year‐indicator level<br>Conduct data quality checks<br>Drop rejected datapoints Get population and quintile means from published work where microdata inaccessible<br>Merge data from publications into meso data<br>HEFPI HE meso data set<br><!-- End of picture text -->

# <u>Comparisons across subpopulations</u>

The HEFPI database presents not only sample averages but also subpopulation averages and measures of inequality. Households are ranked by either household per capita consumption or income or the Filmer-Pritchett (1999, 2001) wealth index. Subsequent to Gwatkin et al. (2000), the organization responsible for the DHS (then Macro International) decided to include the wealth index in each public-release DHS data set; UNICEF, which is responsible for the MICS, subsequently decided to do the same with the MICS. A handful of earlier MICS surveys<sup>33</sup> and the WHS do not include a wealth index. We therefore created wealth indices for these surveys using principal component analysis (PCA). For the MICS surveys, we included the same asset variables as the

> 33 Namely the Comoros 2000, Lesotho 2000, Eswatini (formerly Swaziland) 2000, Iraq 2006, and Djibouti 2006.
29 standard MICS wealth index, and for the WHS we used all the questions on assets available in the WHS survey.

Averages are presented for each quintile of households; because the number of births and child deaths are not equal across household wealth quintiles, there are typically more children in the lower wealth quintiles. The poorest quintile thus contains 20 percent of households but typically more than 20 percent of children.

In addition to presenting the quintile means, the 2018 HEFPI database, like previous HEFPI databases, also includes the concentration index and its standard error (Kakwani et al. 1997). This captures the degree of inequality (by wealth) in each indicator. A negative value indicates, on average, higher values among the poor; a positive value indicates, on average, higher values among the better off. The minimum is -1, and the maximum is +1. The concentration index and its standard error were computed using individual-level data via the Stata module CONINDEX (O'Donnell et al. 2015, 2016), with per capita household consumption or income or the wealth index as the ranking variable; it is therefore not affected by the fact that the quintiles are quintiles of households. When quintiles were very small, the quintile mean is not included in the data set. A quintile-specific datapoint is excluded if the sample size in any quintile was less than the following thresholds: 250 per quintile for infant and child mortality estimates and 25 per quintile for all other indicators; this follows the practice of Gwatkin et al. (2007).

# <u>Data-quality checks</u>

On the health equity side of the HEFPI data set, our quality checks involve checking population and quintile specific rates from DHS and MICS against rates published by WHO’s Health Equity Monitor, MICS reports, DHS STATcompiler and World Bank’s ‘Health, Nutrition and Population Statistics by Wealth Quintile’ databank whenever our and the publishers’ indicator definitions align (e.g. for the infant mortality and diarrhea treatment indicators on STATcompiler,
30 see Annex Table A1). We noted and investigated discrepancies, and corrected any coding mistakes. No datapoints were excluded – we are sure any discrepancies are due to definition differences.

However, even when indicator definitions are identical, for many country-year-surveyindicator combinations, we do not have a published number to compare ours with: STATcompiler does not tabulate all indicators by wealth; older MICS surveys do not tabulate any indicators by wealth; and some surveys are not (yet) included on the DHS STATcompiler and MICS reports. For surveys other than the DHS and MICS, there are no equivalents of DHS STATcompiler and MICS reports. In these cases, and DHS and MICS surveys without published data population and quintile rates, we ran some basic checks, the most important of which involved making sure that population rates were within a reasonable interval, e.g. proportion indicators should be in the interval [0, 1], under-five mortality should not be above 400 per 1,000, systolic blood pressure should be in the interval (90, 250), cholesterol (in mmol per L) should be in the interval (3, 8), women’s weight (in kg) should be in the interval (40, 120), and men’s height (in meters) should be in the interval (1.3, 2.8). None of our datapoints failed these basic checks; therefore, no datapoints were excluded.

# <u>Illustrations using the health equity data</u>

Figure7 shows inequalities across wealth quintiles in immunization for selected African countries in the 1990s. The gaps are much larger in some countries than others. But the figure also illustrates how even the better off in some countries do poorly. For example, children in the richest 20% of the population in Ghana were being immunized at the same rate (65%) as the poorest 20% of children in Kenya.
31

# <u>Figure 7: Immunization inequalities in selected African countries in the 1990s</u>

<!-- Start of picture text --> 4 Chad; 1996 24<br>Cote d'Ivoire; 1994 38 80<br>Ghana; 1993 16 65<br>Kenya; 1993 65 87<br>Mali; 1995 17 57<br>0 10 20 30 40 50 60 70 80 90 100<br>Poorest quintile Richest quintile<br><!-- End of picture text --> Figure 8 shows trends in MCH inequalities between the 1990s and 2010s for a panel of 25 countries that have complete data for the 1990s, the 2000s and the 2010s. For some indicators (e.g. immunization and the treatment of ARI), the rate for the richest 20% has barely changed, reflecting in part the fact the rate was already high, while the rate for the poorest 20% has increased, thereby closing the gap between the poor and better off. For other indicators (e.g. ANC and the treatment of diarrhea), we see increases among both the poorest 20% and the richest 20%, even if the proportionate increase is typically still larger for the poorest 20%.
32

# <u>Figure 8: Trends in MCH inequalities from the 1990s to the 2010s</u>

<!-- Start of picture text --> Richest quintile 1990s<br>Poorest quintile 2010s<br>Richest quintile 2010s<br>Poorest quintile 1990s<br>ANC 31 45 69 77<br>Immunization 37 51 667<br>SBA 24 40 77 89<br>Treat Acute Resp. Infection 40 46 61 65<br>Treat Diarrhea 28 38 44 55<br>Met Need for Family Planning 67 7375 80<br>0 10 20 30 40 50 60 70 80 90 100<br>25 countries with data for 1990s, 2000s and 2010s<br><!-- End of picture text --> Figure 9 shows averages across country income groups in 8 service coverage indicators used in two recent studies of progress towards UHC (Wagstaff et al. 2015; Wagstaff et al. 2016). Unsurprisingly, high-income countries have higher service coverage rates than middle-income countries which in turn have higher rates than low-income countries. The gaps are especially marked for the two cancer screening variables. Also shown in Figure 9 are the values for Thailand and Zimbabwe, which have higher values on most indicators than their peers.
33

# <u>Figure 9: Levels of coverage of select service coverage indicators by level of development</u>

<!-- Start of picture text --> High income Upper middle inc Lower middle inc Low income Thailand Zimbabwe<br>Mammogram<br>100<br>80<br>IP admission PAP smear<br>60<br>40<br>20<br>Treat Diarrhea 0 ANC<br>Treat ARI Full immunization<br>SBA<br><!-- End of picture text --> Inpatient admission in last year as % of equivalent WHO benchmark (~9%) Finally, Figure 10 compares levels of and inequalities in inpatient (IP) admission rates and pap smears between low- and high-income countries. In the latter, inpatient admission rates are higher among the poorest 20% of the population, reflecting the greater need for inpatient care (van Doorslaer et al. 1992; van Doorslaer et al. 2000). Moreover, in high-income countries, there is little evidence of underutilization – even the top income group is admitted at a rate that is in line with the WHO benchmark of 0.1 inpatient admissions per capita (World Health Organization 2013b), which translates into just over 0.09 persons per capita having at least one admission per year. In lowincome countries, by contrast, the income gradient is reversed, and even the richest 20% of the population, on average, underutilize inpatient care according to the WHO benchmark. In the case of pap smears, we see a positive gradient in both low- and high-income countries. However, in the highincome countries, even the poorest 20% are getting screened at a rate of over 70%. In low-income countries, by contrast, even the richest 20% are getting screened at barely 10%.
34 <u>Figure 10: Levels and inequalities in inpatient admission rates and pap smears compared</u>

# **Inpatient admission last 12 months**

# **Pap smear last 5 yrs, women age 30‐49**

<!-- Start of picture text --> 12% 90%<br>80%<br>10%<br>70%<br>8% 60%<br>50%<br>6%<br>40%<br>4% 30%<br>20%<br>2%<br>10%<br>0% 0%<br>High income countries Low income countries High income countries Low income countries<br>Q1 (poorest) Q2 Q3 Q4 Q5 (richest) Q1 (poorest) Q2 Q3 Q4 Q5 (richest)<br><!-- End of picture text -->

# **Financial protection data**

In this section, we report details of the financial protection part of the 2018 HEFPI data set, listing the indicators included, the reasons for including them, their sources and definitions, how they were computed, how we derived data for different subpopulations, our quality checks, and lastly some illustrations of the use of the data.

## <u>Indicators included</u>

The indicators in the financial protection part of the 2018 HEFPI database (cf. Figure 2) are: (i) the incidence of ‘catastrophic’ health expenditures (health expenditures exceeding a certain percentage, _x_ , of a household’s total consumption or income), and (ii) the incidence of ‘impoverishing’ health expenditures (expenditures without which the household would have been above the poverty line, but because of the expenditures is below the poverty line). Indicator (i) (catastrophic expenditures) is one of the two UHC SDGs (3.8.2). The catastrophic expenditure indicator tells us whether health expenditures cause household consumption or income to fall by more than _x_ percent, while the second tells us whether health expenditures were sufficiently large to push the household
35 into poverty. The two indicators are therefore complements, and the impoverishment indicator sheds light on the poverty SDG (target 1.1). Both indicators are widely used in the literatures on financial protection in health (Wagstaff and van Doorslaer 2003; van Doorslaer et al. 2006b; van Doorslaer et al. 2007; Wagstaff et al. 2018a; Wagstaff et al. 2018b).

Some studies decide whether health expenditures are catastrophic by comparing them to total consumption, while others compare them to total income. Similarly, some studies decide whether health expenditures are impoverishing by comparing income net of health expenditures and income gross of health expenditures, while others compare consumption net and gross of health expenditures. There is no right or wrong approach. However, it is important to keep in mind that total consumption includes health expenditures, and will therefore increase when a health shock occurs if the household finances part of the health expenditure through borrowing or dissaving rather than entirely through cutting back consumption on other budget items. A household with a large health expenditure may therefore appear to be richer (in terms of consumption) than one that incurs only small health expenditures. As a result, we may end up with the rather perverse result that large health expenditures (possibly catastrophic ones, too) are more common among ‘rich’ households, and less common among ‘poor’ households (WHO and World Bank 2017). By contrast, income is not directly affected by health expenditures. (It may be affected indirectly in the sense that the same health shock that causes the health expenditures may also reduce labor income.) Thus, when computing catastrophic and impoverishing health expenditures, and especially when looking at inequality in catastrophic health expenditures, it is probably preferable to use income rather than consumption (WHO and World Bank 2017).

# <u>Data search and data sources</u>

As with the health equity side of the HEFPI database, our goal is to assemble as large a data set as possible of surveys suitable for the analysis of financial protection. Again. we undertook inventories of the microdata catalogs of the International Household Survey Network and the World
36 Bank, and of several household survey collections. We also searched for household surveys online. Through this process, we have so far identified, tried to access and (where possible) vetted 1,752 household survey data sets from 178 countries – see Table 5. We are in the process of identifying, trying to access and vetting other data sets, some of which will be added to the HEFPI data set in due course. Of the 1,752 surveys, 299 are currently inaccessible and 465 lack key variables. The remaining 988 data sets were accessed, many through the World Bank Development Data Hub (DDH).<sup>34</sup> They were then vetted and those that had the necessary information were analyzed; after a series of quality checks (see below for details), 570 data sets were kept.

Most of the surveys are HIES or HBS surveys, or multipurpose household surveys like the LSMS. Very few come from a highly standardized multi-country survey program like the LSMS. However, many of the datapoints come from versions of the microdata that have been harmonized ex post, such as the Luxembourg Income Study (LIS) and various World Bank ex post harmonized data set ‘collections’ (e.g. ECAPOV). Such ex-post harmonization exercises consist of applying a common set of standards and guidelines to the construction of specific variables such as total income, or a consumption aggregate across different data sets. Table 6 summarizes the key details of these survey ‘collections’. Sometimes we have produced and compared results from both the original ‘master’ data set and the ex-post harmonized ‘adaptation’. Indeed, sometimes we have produced and compared estimates from different adaptations. In addition, both masters and adaptations can be updated, so we have recorded the version of each master and adaptation used. All datapoints in the data set are labeled with their data source in the referenceid variable – see annex for naming conventions.

> 34 <u>https://datacatalog.worldbank.org/.</u>
37 <u>Table 5: Data sources for the financial protection part of the 2018 HEFPI database</u>

||Inaccessible|Key variable(s)|missing<br>Analyzed – dro|pped<br>Analyzed – kept|Total|
|---|---|---|---|---|---|
|CWIQ|1|6|||7|
|E123||||2|2|
|EAPPOV|1|||3|4|
|ECAPOV|20|7|14|221|262|
|EUROSTAT|||24|23|47|
|HBS|109|136|1|3|249|
|HEIDE|||6|2|8|
|HIES|164|277|77|158|676|
|LIS|||98|54|152|
|LSMS|2|20|18|11|51|
|MCSS|1||11||12|
|MNAPOV||3|2|11|16|
|SARLF||3|||3|
|SARMD||5|||5|
|SEDLAC||7|||7|
|SHES|1|1|96|58|156|
|SHIP|||20|26|46|
|WHS|||50||50|
|Total|299|465|417|572|1,753|
38 <u>Table 6: Survey ‘collections’ used in financial protection side of HEFPI database</u>

|Collection|<br>Title in full|<br>Type of collection|<br>Institution|<br>Geographic<br>focus|<br>Type of survey(s)|<br>Further information on data and access|
|---|---|---|---|---|---|---|
|CWIQ|Core Welfare<br>Indicators<br>Questionnaire|Multi-country<br>survey initiative<br>– somewhat<br>standardized|World Bank<br>originally, but<br>have been used by<br>other institutions<br>too|<br>Developing<br>world|Multipurpose survey|Some CWIQ surveys publicly accessible via<br>the World Bank Microdata Catalog.<sup>35</sup>More<br>CWIQ surveys can be accessed by World Bank<br>staff via the World Bank Microdata Library.<sup>36</sup><br>See also the Institute for Health Metric’s<br>Global Health Data Exchange (GHDx) entries<br>for CWIQ surveys.<sup>37</sup>|
|E123|Enquêtes 1-2-3|Multi-country<br>survey initiative<br>– somewhat<br>standardized|DIAL Research<br>Unit, France|Developing<br>world|Multipurpose survey|Details available (in French only) on the<br>Enquêtes 1-2-3 page of the DIAL website.<sup>38</sup>|
|EAPPOV|World Bank East<br>Asia & Pacific<br>harmonized<br>household survey<br>collection|Ex post<br>harmonized|World Bank|World Bank’s<br>East Asia &<br>Pacific region|HBS, HIES,<br>multipurpose surveys|Accessible only to World Bank staff via World<br>Bank Microdata Library.|
|ECAPOV|World Bank Europe<br>and Central Asia<br>harmonized<br>household survey<br>collection|Ex post<br>harmonized|World Bank|World Bank’s<br>Europe &<br>Central Asia<br>region|HBS, HIES,<br>multipurpose surveys|Accessible only to World Bank staff via World<br>Bank Microdata Library.|
|EUROSTAT-<br>HBS|Eurostat HBS Public<br>Use Files|Ex post<br>harmonized|European<br>Commission –<br>Eurostat|European<br>Union|HBS|Details available on the Eurostat microdata<br>website.<sup>39</sup>|
|HBS|Household Budget<br>Survey|National survey –<br>raw data|National<br>governments|Global|HBS|Survey-specific|
|HEIDE|World Bank<br>Household<br>Expenditure and<br>Income Data for|Ex post<br>harmonized|World Bank|World Bank’s<br>Europe &<br>Central Asia<br>region|HBS, HIES,<br>multipurpose surveys|Details of the HEIDE data set can be found in<br>the World Bank Microdata Catalog, and can<br>be found by searching for HEIDE in the study<br>description.|

> 35 The World Bank Microdata Catalog can be accessed at <u>http://microdata.worldbank.org/index.php/home</u> and is open access.

> 36 The World Bank Microdata Library can be accessed at <u>http://microdatalib.worldbank.org/index.php/home</u> and is accessible only to World Bank staff.

> 37 Search for CWIQ on the ‘series and systems’ page of the GHDx site at http://ghdx.healthdata.org/series_and_systems.

> 38 The relevant page is http://www.dial.ird.fr/enquetes-statistiques/enquetes-1-2-3.

39 The Eurostat microdata access website is http://ec.europa.eu/eurostat/web/microdata.
39

|Collection|Title in full|Type of collection|Institution|Geographic<br>focus|Type of survey(s)|Further information on data and access|
|---|---|---|---|---|---|---|
||Transitional<br>Economies||||||
|HIES|Household Income &<br>Expenditure Survey|Individual<br>country survey –<br>raw data|National<br>governments|Global|HIES|Survey-specific|
|LIS|Luxembourg Income<br>Study|Ex post<br>harmonized|Luxembourg<br>Income Study|Global, mostly<br>OECD|HBS, HIES,<br>multipurpose surveys|Details of the LIS and how to access the data<br>are at the LIS website.<sup>40</sup>|
|LSMS|World Bank Living<br>Standards<br>Measurement Study|Multi-country<br>survey initiative<br>– somewhat<br>standardized|World Bank|Global,<br>developing<br>countries|Multipurpose<br>surveys|The LSMS project is described at the LSMS<br>website.<sup>41</sup>Most microdata sets are publicly<br>accessible via the World Bank Microdata<br>Catalog.<sup>42</sup>|
|MCSS|WHO Multi-Country<br>Survey Study on<br>Health and<br>Responsiveness|Multi-country<br>survey initiative<br>– highly<br>standardized|World Health<br>Organization|Global|Health survey,<br>including out-of-<br>pocket expenses and<br>some data on<br>household<br>consumption|Details of the survey and how to access the<br>microdata can be found at the MCSS<br>webpage.<sup>43</sup>|
|MNAPOV|World Bank Middle<br>East & North Africa<br>harmonized<br>household survey<br>collection|Ex post<br>harmonized|World Bank|World Bank’s<br>Middle East<br>& North<br>Africa region||Accessible only to World Bank staff via World<br>Bank Microdata Library.|
|SARLF|World Bank South<br>Asia Labor Flagship<br>harmonized survey<br>collection|Variety of<br>surveys in South<br>Asia countries,<br>often raw data|World Bank|World Bank’s<br>South Asia<br>region|Multiple types, many<br>not relevant to the<br>current database|Accessible only to World Bank staff via World<br>Bank Microdata Library.|
|SARMD|World Bank South<br>Asia harmonized<br>household survey<br>collection|Ex post<br>harmonized|World Bank|World Bank’s<br>South Asia<br>region|HBS, HIES,<br>multipurpose surveys|Accessible only to World Bank staff via World<br>Bank Microdata Library.|
|SEDLAC|Socio-Economic<br>Database for Latin<br>America and the<br>Caribbean|Ex post<br>harmonized|CEDLAS and the<br>World Bank|Latin America<br>& Caribbean|HBS, HIES,<br>multipurpose surveys|Details of the SEDLAC project are at the<br>SEDLAC website.<sup>44</sup>Website gives no details<br>of how to access to microdata. World Bank<br>staff can access microdata via the World Bank<br>Microdata Library.|

40 The LIS website is at http://www.lisdatacenter.org/our-data/lis-database/. 41 The LSMS website is at http://www.lisdatacenter.org/our-data/lis-database/. 42 The relevant webpage is http://microdata.worldbank.org/index.php/catalog/lsms. 43 The relevant page is http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/mcss/about. 44 The SEDLAC website is at http://www.cedlas.econo.unlp.edu.ar/wp/en/estadisticas/sedlac/.
40

|Collection|Title in full|Type of collection|Institution|Geographic<br>focus|Type of survey(s)|Further information on data and access|
|---|---|---|---|---|---|---|
|SHES|World Bank<br>standardized<br>household<br>expenditure surveys|Ex post<br>harmonized|World Bank|Global|HBS, HIES,<br>multipurpose surveys|Surveys produced by World Bank’s Data<br>Group as part of the International<br>Comparison program. Accessible only to<br>World Bank staff|
|SHIP|World Bank Sub-<br>Saharan Africa<br>harmonized<br>household survey<br>collection|Ex post<br>harmonized|World Bank|World Bank’s<br>Sub-Saharan<br>Africa region|HBS, HIES,<br>multipurpose surveys|Some publicly accessible via the World Bank<br>Microdata Catalog. Rest accessible only to<br>World Bank staff via World Bank Microdata<br>Library.|
|WHS|WHO World Health<br>Survey|Multi-country<br>survey initiative<br>– highly<br>standardized|World Health<br>Organization|Global|Health survey,<br>including out-of-<br>pocket expenses and<br>some data on<br>household<br>consumption|Details of the WHS survey can be found at the<br>WHS webpage, and access is via the WHO<br>Central Data Catalog.<sup>45</sup>|

45 The WHS webpage is http://www.who.int/healthinfo/survey/en/. The WHO Central Data Catalog is at http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog.
41

# <u>Indicator definitions</u>

The first indicator is the incidence of ‘catastrophic’ health expenditures, defined as health expenditures exceeding a certain percentage, _x_ , of a household’s total consumption or income. The 2018 HEFPI database includes two thresholds for catastrophic expenditures (i.e. _x_ ): 10% and 25%. The SDG 3.8.2 indicator is the 10% threshold.

The second indicator is the incidence of ‘impoverishing’ health expenditures, defined as expenditures without which the household would have been above the poverty line, but because of the expenditures is below the poverty line. In the HEFPI 2018 database, we use two absolute international poverty lines ($1.90-a-day and $3.20-a-day in 2011 purchasing power parity (PPP) dollars) and one relative poverty line (50% of median consumption or income).

# <u>Indicator computation</u>

# _Measuring out-of-pocket health expenditures_

Out-of-pocket spending includes not only payments made by the user at the point of use but also cost-sharing and informal payments, both in kind and in cash, but it excludes payments by a third-party payer.

Many household expenditure surveys include questions on health spending, but, being general surveys, most have some shortcomings in terms of identifying out-of-pocket health spending. First, it is sometimes not clear whether the spending reported is gross or net of any reimbursement by third parties (e.g., private insurance company or government agency), in which case out-of-pocket spending could be overestimated. Whenever possible, health insurance premiums should be excluded from out-of-pocket payments, and reimbursement from any type of health insurance scheme should be included to produce a net estimate of out-of-pocket payments. Second, recall periods are sometimes inappropriate, particularly in general expenditure surveys, in which the last 3 months
42 and the last 12 months are used frequently, periods that are probably too long for items such as outpatient care and medicines. Multipurpose surveys are better in that spending data are gathered via a health module that varies recall period by type of service. Third, variations in comprehensiveness probably exist across surveys. A review of 100 survey questionnaires cited in Wagstaff et al. (2018a) found that, in 80% of surveys, questions were asked about spending on pharmaceutical products, hospital services, medical services, and paramedical services.

# _Measuring income_

Because, as mentioned above, total consumption increases after a health shock and pushes sick households up the consumption distribution while income does not, catastrophic (and impoverishing) payments computed with reference to income are easier to interpret, especially when looking at inequalities in catastrophic payments (Wagstaff et al. 2018a). It is customary to distinguish four main components in the measurement of income: (i) wage income from labor services; (ii) rental income from the supply of land, capital, or other assets; (iii) self-employment income; and (iv) current transfers from government or nongovernment agencies or other households. It is sometimes claimed (cf. e.g. Deaton and Zaidi 2002) that developing-country surveys (including the LSMS surveys) do well on (i) but less well on the other components of income. Recent initiatives such as the FAO RIGA project (Quiñones et al. 2009) are changing this. Sometimes income is not measured at all in developing-country surveys, so using it is not an option. The 2018 HEFPI database uses income rather than consumption for all high-income countries, and for certain upper middle-income countries. For most developing countries, we use consumption. Many of the highincome country datapoints come from ex-post data harmonization efforts like the LIS – see below.

# _Measuring consumption_

Surveys have differed a great deal in the level of detail of their consumption modules. The LSMS surveys, which have been designed and implemented with the explicit objective of measuring living standards, have included somewhere in the region of 20 to 40 food items and a similar number
43 of nonfood items. Because of this heterogeneity, it is not possible to provide general guidelines on how to construct consumption aggregates or to fully account for the methodological challenges and pitfalls in this process.<sup>46</sup> Here, we restrict ourselves to a general overview of the steps of the process. Most surveys collect data on four main classes of consumption: (i) food items, (ii) nonfood, nondurable items, (iii) consumer durables, and (iv) housing.

Consumption is measured with a particular reference period in mind. Although the reference period varies, many surveys aim to accurately measure the total consumption of the household in the past year. In this way, temporary drops in consumption are ignored, and it is still possible to capture changes in living standards of a single individual or household over time. The reference period should be distinguished from the recall period, which refers to the time period for which respondents are asked to report consumption in the survey. Recall periods tend to differ for different types of goods, such that reporting on goods that tend to be purchased infrequently is based on a longer time period. A balance has to be struck between capturing a sufficiently long period so that the consumption during the period is representative of the reference period (year) as a whole and making it sufficiently short such that households can remember expenditures and consumption with reasonable accuracy. Surveys have taken different approaches to striking that balance. In general, there are three steps in the construction of a consumption-based living standards measure: (i) construct an aggregate of different components of consumption (e.g. food consumption, non-food consumption, consumer durables, housing, etc.), (ii) make adjustments for cost of living differences, and (iii) make adjustments for household size and composition. Deaton and Zaidi (2002) provide overarching principles and detailed guidelines for the construction of consumption aggregates.

Moreover, data harmonization efforts are often conducted to ensure that consumption aggregates are comparable across countries and over time, which is crucial for poverty estimation 46 See Deaton and Zaidi (2002) for methodological guidance on the measurement of consumption aggregates.
44 and comparability. In the 2018 HEFPI database, we rely on several data harmonization efforts (see Table 6):

- <u>LIS database. The LIS acquires data sets with income, wealth, employment, and</u> demographic data from many high- and middle-income countries, harmonizes them to enable cross-national comparisons, and makes them publicly available in two databases, the LIS database and the Luxembourg Wealth Study database. For the 2018 HEFPI data set, we use all available datapoints from the LIS database.

- <u>World Bank regional harmonized databases. Regional teams at the World Bank are also</u> working to produce adaptations of raw country level survey data sets using regionally harmonized definitions and aggregation methods (e.g. the ECAPOV data sets for Europe and Central Asia, the EAPPOV data set for East Asia and Pacific, the SHIP for Sub-Saharan Africa, the MNAPOV for Middle East and North Africa, the SEDLAC for Latin America and the Caribbean, and the SARMD for South Asia). These harmonized data sets are used for the global monitoring of poverty by the World Bank. We also use these harmonized data sets whenever possible.

# _Supplemental indicators used in computing absolute impoverishment_

When we measure impoverishment using the absolute $1.90-a-day and $3.20-a-day poverty lines in 2011 PPP dollars, we have to take into account that the survey values are in local currency units (LCUs), and that they refer to the year of the survey which is not necessarily 2011, the year to which the PPP conversion factors that we use refer. The PPP conversion factor tells us the number of LCUs that would have been needed in 2011 to buy the same amounts of goods and services in the country as one US dollar would have bought in the USA in 2011. Multiplying the conversion factor by 1.9 or 3.2 gives us the amount of LCUs that would have been needed in 2011 to buy the same amount of goods and services in the country as US$1.90 or US$3.20 would have bought in the USA. This is the poverty line (per day) in the country in question in 2011. We then need to take into
45 account inflation in the country between the survey date and 2011, for which we need the country’s consumer price index (CPI). Thus, for a survey conducted in year _t_ , we compute the poverty line in LCUs using the formula: where PL������� is the poverty line expressed in $US (either $1.90 or $3.20 in the 2018 HEFPI data set), PPP� is the country’s implied PPP for year _t_ , PPP���� is the country’s PPP for 2011, CPI� is the country’s CPI in year t, and CPI���� is the country’s CPI in 2011. We thus convert prices in the survey year in the country in question to 2011 prices in that country, and then apply the 2011 PPP conversion rate to convert 2011 LCUs of that country into international dollars.

In the 2018 HEFPI database, we use the 2014 version of the 2011 PPP factors produced by the International Comparison Program (ICP). These PPP factors cover 199 countries and are expressed in terms of 2011 prices. We extract the PPP conversion factor series PA.NUS.PRVT.PP from the World Development Indicator (WDI) database. This conversion factor is for private consumption, i.e., household final consumption expenditure. Whenever possible, we rely on the CPI series used by PovcalNet.<sup>47</sup> When the country’s CPI series are not available, we rely on the International Monetary Fund’s World Economic Outlook (WEO) data or on World Bank’s WDI CPI series.

# _Computing the incidence of catastrophic and impoverishing expenditures_

The incidence rates of catastrophic and impoverishing health expenditures are computed using (the code underlying) the Stata module FPRO (Eozenou and Wagstaff 2018). Where health expenditure data are individual-level, the data are aggregated to the household level. A household is defined as incurring catastrophic expenses if its out-of-pocket health expenditures strictly exceed the 47 PovcalNet can be accessed at http://iresearch.worldbank.org/PovcalNet/povOnDemand.aspx.
46 threshold. A household is defined as impoverished if it is not poor based on consumption or income <u>gross of out-of-pocket health expenditures, but is poor based on consumption or income net of out-of-</u> pocket health expenditures. To take into account differences in household size and weights, we use an ‘aweight’ equal to the product of household size and household weight when computing the population-level incidence of (i.e. the percentage of households incurring) catastrophic and impoverishing expenditures.

# <u>Data processing process</u>

The data-processing process begins by generating in the microdata standardized or harmonized variables that correspond to our indicators – see Figure 11. (Surveys that do not allow us to estimate out-of-pocket expenditures and income or (non-health) consumption are, of course, excluded.) Population rates of catastrophic expenditures (CATA) (and, where income is used, rates for specific quintiles) are then computed from each standardized microdata set. The computation of rates of impoverishment (IMPOV) require supplementary data at the national level on PPPs and the CPI; these data are merged into the microdata and the impoverishment rate is then computed. The data are then consolidated into a ‘meso data set’, which has one row per country-year-surveyadaptation-indicator combination, e.g. Estonia/2010/HBS/ECAPOV adaptation/catastrophic expenditures/10% threshold. For quality checking we compare the country-year datapoints to data from other sources (see below for details) and the necessary data are merged into the meso data and then the quality checks are performed. Rejected datapoints are dropped, and the resultant data set is the financial protection HEFPI meso data set.
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- <u>Figure 11: HEFPI financial protection data processing steps</u>

<!-- Start of picture text --> Identify HH surveys<br>Access HH surveys<br>Compute harmonized variables<br>Compute CATA Get PPP and CPI data<br>Merge PPP and CPI data into microdata<br>Compute IMPOV<br>Collapse micro‐data to country‐year‐indicator level Get PovcalNet, WBI and GHED data<br>Merge PovcalNet, WBI and WHO‐NHA data into meso data<br>Conduct data quality checks<br>Drop rejected datapoints<br>HEFPI FP meso data set<br><!-- End of picture text -->

# <u>Comparisons across subpopulations</u>

For the reasons indicated above, and in line with findings reported in the World Bank-WHO 2017 Global Monitoring Report on UHC (WHO and World Bank 2017), we avoid reporting inequalities in catastrophic health expenditures across consumption quintiles, and report inequalities only across income quintiles. Inevitably, therefore, data on inequalities in catastrophic expenditures are available only for high-income and some upper middle-income countries.

Inequalities in the incidence of catastrophic health expenditures are computed using the same code underlying the Stata module FPRO (Eozenou and Wagstaff 2018).

# <u>Data-quality checks</u>

As explained above, on the health equity side of the HEFPI data set, there are published data we can check our results against for some country-year-survey-indicator combinations. This is not the case with the financial protection side of the data set. For sure, there are multi-country studies of catastrophic and impoverishing health expenditures, but these studies vary in the methods they use, and none uses exactly the same methods and data sets we do. The two papers by
48 van Doorslaer et al. (2006b; 2007) come closest to our work, but the poverty line in van Doorslaer et al. (2006b) is the old international poverty line, and in any case the number of surveys analyzed is 11 compared to our 600+ surveys.<sup>48</sup> Therefore, instead of comparing our financial protection results to published numbers, we perform external and internal consistency checks.<sup>49</sup> For the former, we perform three checks to determine the following:

1. Whether the welfare aggregate is aligned with the welfare aggregate reported in PovcalNet. Data sets are flagged if the absolute value of the relative difference between the measure of welfare derived from the survey is more than 10% apart from the value reported in PovcalNet (in log terms).

2. Whether the poverty headcount is aligned with the poverty headcount reported in PovcalNet. Data sets are flagged if the poverty headcount derived from the survey is more than 10 percentage points apart from the value reported in PovcalNet.

3. Whether the budget share of health expenditures derived from the survey is aligned with the aggregate budget share of health out-of-pocket expenditures. Data sets are flagged if the health budget share derived from the survey data is more than 5 percentage points apart from the aggregate budget share for health payments. The aggregate budget share for health is constructed by taking the ratio between aggregate out-of-pocket expenditures expressed in local currency units (in nominal terms for the year of the survey), and aggregate consumption, also expressed in nominal local currency units. The information for aggregate out-of-pocket expenditures is extracted from the WHO Global Health Expenditure Database

> 48 The data in Wagstaff et al. (2018a; 2018b) are not a potential comparator source either, as 80% of the datapoints there come from a preliminary version of the 2018 HEFPI database, the rest coming from WHO. 49 These checks were refined during the collaborative studies with WHO staff (Wagstaff et al. 2018a; Wagstaff et al. 2018b).
49 (GHED), and aggregate consumption is obtained from the World Bank World Development Indicators data set.

These external checks led to the dropping of some survey ‘families’ (notably WHO’s WHS and MCSS survey families) and some survey adaptations for some countries (e.g. LIS for the USA), because some or all of the above flags were raised consistently.

Our internal consistency checks involve examining the full set of datapoints available for each country. When different datapoints were available for a given country-year combination (for example when a datapoint is derived from the raw data, and when there is also another datapoint derived from an adaptation of the raw data set), longitudinal consistency across the different datapoints was favored. For example, in the case of Mexico, the LIS-based estimates were used for all years, since they were the best in terms of the external flags for the vast majority of years, even though for some years they were not the best.

# <u>Illustrations using the financial protection data</u>

Figure 12 shows trends in catastrophic expenditures (using the 10% threshold) in selected countries, all of which have enacted reforms aimed at expanding and deepening health insurance coverage (Wagstaff et al. 2016). In both Indonesia and Georgia, the incidence of catastrophic expenditures has been rising, but the rise has been far more pronounced in Georgia, and the base was higher as well. Despite the recent rise in Indonesia, the rate at the end of the series is still lower than that in the other three countries. In both Mexico and the US, the incidence of catastrophic expenditures has come down, in Mexico’s case the drop apparently happened somewhat after the ‘Seguro Popular’ reform, while in the US the drop apparently began somewhat before the Affordable Care Act or ‘Obamacare’ reform; the drop in Mexico has been more pronounced.
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# <u>Figure 12: Trends in catastrophic expenditures (10% threshold) in selected countries</u>

<!-- Start of picture text --> 35%<br>30%<br>Georgia<br>25%<br>20%<br>15%<br>10%<br>Mexico<br>5%<br>USA<br>Indonesia<br>0%<br>1980 1990 2000 2010 2020<br><!-- End of picture text --> Figure 13 shows median incidence rates of catastrophic health expenditures by income quintile for 35 upper middle-income and high-income countries. On average, the lower income quintiles are over twice as likely to experience catastrophic health expenditures than the top income quintile. The inequalities across consumption quintiles (not shown here) look quite different reflecting the point made earlier about households borrowing and dissaving to finance health expenses, making them look relatively well off in consumption terms.
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# <u>Figure 13: Inequalities in catastrophic health expenditures (10% threshold) by income quintile. Median across 35 upper middle-income and high-income countries</u>

<!-- Start of picture text --> 9%<br>8%<br>7%<br>6%<br>5%<br>4%<br>3%<br>2%<br>1%<br>0%<br>Q1 (lowest income) Q2 Q3 Q4 Q5 (highest income)<br><!-- End of picture text --> Figure 14 shows the incidence of catastrophic health expenditures across the world for the latest year of data, using the 10% threshold. Latin American countries tends to have quite high rates, as do several Asian countries. Many African countries have quite low rates, reflecting in some cases the fact people simply do not receive the health services they need.
<!-- Start of picture text --> 0001-004 Moo4008 oos-o12 go.12+ No data<br>F i” \<br>v. £5 5e.<br><!-- End of picture text -->
53 poverty. The database is a living one: new datapoints are being prepared and will be added when available.