outpatient and inpatient services

however, the NPER notes that most values are clustered in the lower half of the graph regardless of the stunting level, and that a full benefit incidence analysis (BIA) is necessary to draw any conclusions.

Ideally, a BIA can be performed as part of the PER to reveal inequity in the allocation and use of health resources.23 The BIA combines the cost of providing public services with information on their use to generate distributions of the benefit of government spending. It is used to provide insights into what extent governments spend on services that improve the lives of the poor. The basic premise of a BIA is that the poor are disadvantaged in gaining access to important basic services (for example, nutrition) that would help them escape poverty. It suggests an active role for the government to provide these services to poor and vulnerable groups (Demery 2000).

A BIA requires data on government spending on a service, public use of the service, and the socioeconomic characteristics of the population using the service. Government spending data are typically obtained either from the ministry of finance (FMIS/IFMIS) or the relevant line ministry. It can be challenging to access disaggregated spending data by administrative level because not all countries have comprehensive spending data on nutrition services. The second and third types of data—the use of the service, and socioeconomic characteristics of the population using the service—can be obtained from household surveys. For instance, a BIA of health services could use surveys such as Demographic and Health Surveys and Living Standards Surveys that include health-related indicators, although there are some data limitations to compute service use rates and rank service users by socioeconomic quintile.24

The BIA is applied in the health sector largely to assess the appropriateness of the distribution of benefits from using health services relative to the need for care. The BIA can be presented in several different ways, including through a concentration index or a dominance test.25 For example, as part of the Zambia health sector PER, a BIA was commissioned to assess the distributional impact of health reforms on public spending and equity using the Zambia Household Expenditure and Utilization Survey. The BIA results show that the distribution of benefits for both inpatient and outpatient services at all public health facilities

TABLE 3.8 Example from the Zambia health sector PER: BIA results on the distribution of outpatient and inpatient services

OUTPATIENT INPATIENT

PROVIDER/FACILITY TYPE Public

Tertiary (3rd-level) hospitals

General (2nd-level) hospitals

District (1st-level) hospitals

Health centers

CI SE DT CI SE DT

0.523*** 0.065 – 0.528*** 0.044 –0.385*** 0.032 – 0.222*** 0.033 –0.091** 0.037 – –0.090* 0.052 + 0.013 0.018 n-Dom –0.179*** 0.022 +

All hospitals (3rd+2nd+1st) 0.214*** 0.024 – 0.243*** 0.015 –

All health facilities (hospitals and health centers) 0.046** 0.018 – 0.160*** 0.017 –

All health facilities (inpatient and outpatient) 0.059*** 0.018 –Mission health facilities –0.106 0.068 + –0.158* 0.091 + Private health facilities 0.686*** 0.027 – 0.804*** 0.071 –

Source: World Bank 2019b. Note: BIA = benefit incidence analysis; CI = concentration index; DT = dominance test; n-Dom = nondominance; PER = public expenditure review; SE = standard error; – means that the 45-degree line dominates (pro-rich); + means that the concentration curve dominates (pro-poor). *p < 0.1 **p < 0.05 ***p < 0.01.