In the decade 2000-2010, decision-makers in developing countries and aid agencies have given higher priority to the health sector, as demonstrated by a sharp global increase in development aid allocated to the health sector, which almost tripled from 2001 to 2005. This reprioritized health sector funding and the correlative volume of health expenditure is evidently much needed, but it potentially masks two central issues. The first one is that the supposed link between health expenditure and a population’s health status remains highly debatable, at least in comparable countries (Berthélemy, 2008). The second is the risk of losing sight of the initial objective — poverty reduction — as attention becomes increasingly focused on average health performances and away from the distribution of access to health.

2 This article is focused specifically on distribution of access to health and the related equity issues. Our aim is to determine whether health expenditure can influence the degree of concentration of access to health services. Due to publication space and data limitations, our investigations remain limited to child and mother health. Child and mother health is more easily studied than other health problems as better data is available. Demographic and Health Surveys (DHS) in particular deliver a broad panel of indicators on child and mother health. Data collected through DHS were recently used by World Bank researchers (Gwatkin et al., 2007) to build indicators of health concentration. This data is also the core source of information for our work.

3 Even restricted to child and mother health, the subject addressed here remains vast, as the datasets studied concern both health status and access to health services. We therefore honed our analysis onto the question of access to health services, as it gives the best reflection of the consequences of health expenditure in terms of equity. In comparison, indicators on health status are influenced by many other variables unrelated to health policy, such as nutrition.

4 Literature on the issue of health distribution in developing countries has two major focuses. One school studies the within-population distribution of the benefits from public health spending. This “benefit incidence analysis” approach has been used to show that the public health policies are often regressive rather than progressive, and are only very rarely pro-poor. Findings like this clearly challenge the adequacy of health policies from a poverty reduction standpoint. However, since the benefit incidence literature only considers public expenditure, it does not directly address the question of access to health, and furthermore, it considers issues of inequality instead of equity. To fill this gap, various authors, many inspired by Wagstaff et al. (1991), have proposed to directly focus on indicators highlighting concentration of access to health and care services. Our paper belongs to this second branch of the literature, of which the report by Gwatkin et al. (2007) is the best recent illustration.
The article is organized as follows. Section 2 begins with a brief recap on the stylized facts on the distributive aspects of health expenditure and access to health services in developing countries. Section 3 goes on to analyze the distribution of access to health services by quintile. This analysis shows that health expenditure has little influence on the distribution of access to health among quintiles. It also shows that access to health care is significantly influenced by household socioeconomic factors, i.e. access to education (mother’s education) and wealth. Finally, it shows that good governance influences the distribution of access to public-sponsored health services towards better equity. Section 4 takes a methodological look at the available measures of health concentration. Section 5 extends on section 3 by analyzing the variables explaining the concentration of access to health services, which confirms to a large extent the previous results. Section 6 concludes.