Person:
Wagstaff, Adam

Development Research Group

Fields of Specialization

Health Economics (health financing, health insurance, health and poverty, health equity, health system reform, hospitals), Income Distribution and Redistribution, Bibliometrics, Asia (China, Vietnam, India)

ORCID

0000-0003-4442-5070

External Links

Datasets, books
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Development Research Group

Last updated: February 1, 2023

Biography

Adam Wagstaff was Research Manager in the Development Research Group (Human Development) from 2009 until his passing in May 2020. His DPhil in economics was from the University of York and, before joining the Bank, he was a Professor of Economics at the University of Sussex. He was an associate editor of the Journal of Health Economics for 20 years and published extensively on a variety of aspects of the field, including health financing and health systems reform; health, equity and poverty; the valuation of health; the demand for and production of health; efficiency measurement; and illicit drugs and drug enforcement. Much of his recent work had been on health insurance, health financing, vulnerability and health shocks, and provider payment reform. He had extensive experience of China and Vietnam but also worked on countries in Africa, Latin America, South Asia, and Europe and Central Asia, as well as other countries in East Asia. Outside health economics, he published on efficiency measurement in the public sector, the measurement of trade union power, the redistributive effect and sources of progressivity of the personal income tax, and the redistributive effect of economic growth.

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Publication Search Results

Now showing 1 - 10 of 93

Improving Effective Coverage in Health: Do Financial Incentives Work?
(Washington, DC: World Bank, 2022-05-11) de Walque, Damien; Kandpal, Eeshani; Wagstaff, Adam; Friedman, Jed; Neelsen, Sven; Piatti-Fünfkirchen, Moritz; Sautmann, Anja; Shapira, Gil; Van de Poel, Ellen
In many low- and middle-income countries, health coverage has improved dramatically in the last two decades, but health outcomes have not. As such, effective coverage -- a measure of service delivery that meets a minimum standard of quality -- remains unacceptably low. This Policy Research Report examines one specific policy approach to improving effective coverage: financial incentives in the form of performance-based financing (PBF) or financial incentives to health workers on the front lines. The report draws on a rich set of rigorous studies and new analysis. When compared to business-as-usual, in low-income settings with centralized health systems PBF can result in substantial gains in effective coverage. However, the relative benefits of PBF are less clear when it is compared to two alternative approaches, decentralized facility financing which provides operating budget to frontline health services with facility autonomy on allocation, and demand-side financial support for health services (i.e., conditional cash transfers and vouchers). While PBF often results in improvements on the margins, closing the substantial gaps in effective health coverage is not yet within reach for many countries. Nonetheless, there are important lessons learned and experiences from the roll-out of PBF over the last decade which can guide health policies into the future.
Financial Incentives to Increase Utilization of Reproductive, Maternal, and Child Health Services in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis
(World Bank, Washington, DC, 2021-10) Neelsen, Sven; de Walque, Damien; Friedman, Jed; Wagstaff, Adam
Financial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. There is, however, weak evidence that mean effect sizes are somewhat smaller for performance-based financing than for voucher and conditional cash transfer programs, and that the increase in income, rather than the incentive itself, drives coverage improvements. Financial incentives improve reproductive, maternal, and child health service coverage. If future research confirms the preliminary finding that performance-based financing has smaller effects, voucher and conditional cash transfer programs are the preferred policy option among incentive interventions to achieve higher reproductive, maternal, and child health service coverage. The relative effectiveness and efficiency of incentives compared with unconditional increases of provider and household incomes, however, need to be studied further.
Out-of-Pocket Expenditures on Health: A Global Stocktake
(Published by Oxford University Press on behalf of the World Bank, 2020-07) Wagstaff, Adam; Smitz, Marc
This paper provides an overview of research on out-of-pocket health expenditures by reviewing the various summary measures and the results of multi-country studies using these measures. The paper presents estimates for 146 countries from all World Bank income groups for all summary measures, along with correlations between the summary measures and macroeconomic and health system indicators. Large differences emerge across countries in per capita out-of-pocket expenditures in 2011 international dollars, driven in large part by differences in per capita income and the share of GDP spent on health. The two measures of dispersion or risk—the coefficient of variation and Q90/Q50—are only weakly correlated across countries and not explained by our macroeconomic and health system indicators. Considerable variation emerges in the out-of-pocket health expenditure budget share, which is highly correlated with the incidence of “catastrophic expenditures”. Out-of-pocket expenditures tend to be regressive and catastrophic expenditures tend to be concentrated among the poor when expenditures are assessed relative to income, while expenditures tend to be progressive and catastrophic expenditures tend to be concentrated among the rich when expenditures are assessed relative to consumption. At the extreme poverty line of $1.90-a-day, most impoverishment due to out-of-pocket expenditures occurs among low-income countries.
Toward Successful Development Policies: Insights from Research in Development Economics
(World Bank, Washington, DC, 2020-01) Artuc, Erhan; Cull, Robert; Dasgupta, Susmita; Fattal, Roberto; Filmer, Deon; Gine, Xavier; Jacoby, Hanan; Jolliffe, Dean; Kee, Hiau Looi; Klapper, Leora; Kraay, Aart; Loayza, Norman; Mckenzie, David; Ozler, Berk; Rao, Vijayendra; Rijkers, Bob; Schmukler, Sergio L.; Toman, Michael; Wagstaff, Adam; Woolcock, Michael
What major insights have emerged from development economics in the past decade, and how do they matter for the World Bank? This challenging question was recently posed by World Bank Group President David Malpass to the staff of the Development Research Group. This paper assembles a set of 13 short, nontechnical briefing notes prepared in response to this request, summarizing a selection of major insights in development economics in the past decade. The notes synthesize evidence from recent research on how policies should be designed, implemented, and evaluated, and provide illustrations of what works and what does not in selected policy areas.
The 2019 Update of the Health Equity and Financial Protection Indicators Database: An Overview
(World Bank, Washington, DC, 2019-06) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc; Neelsen, Sven
This paper outlines changes that have been made in the 2019 version of the Health Equity and Financial Protection Indicators database. On the financial protection side, the changes include an increase in the number of indicators from five to 14; revisions to several previous data points, reflecting the analysis of new surveys (or adaptations thereof); and refinements to the estimation of out-of-pocket expenditures. On the health equity side, the 2019 database includes 198 more data points than the 9,733 in the 2018 database, reflecting the addition of 535 new datapoints, and the dropping of 337 previously included data points now considered to be substandard.
Out-of-Pocket Expenditures on Health: A Global Stocktake
(World Bank, Washington, DC, 2019-04) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc
This paper provides an overview of research on out-of-pocket health expenditures, reviewing the various summary measures and the results of multi-country studies using these measures. The paper presents estimates for 146 countries from all World Bank income groups for all summary measures, along with correlations between the summary measures and macroeconomic and health system indicators. Large differences emerge across countries in per capita out-of-pocket expenditures in 2011 international dollars, driven in large part by differences in per capita income and the share of gross domestic product spent on health. The two measures of dispersion or risk -- the coefficient of variation and Q90/Q50 -- are only weakly correlated across countries and not explained by the macroeconomic and health system indicators. Considerable variation emerges in the out-of-pocket health expenditure budget share, which is highly correlated with the incidence of "catastrophic" expenditures. Out-of-pocket expenditures tend to be regressive and catastrophic expenditures tend to be concentrated among the poor when expenditures are assessed relative to income, while expenditures tend to be progressive and catastrophic expenditures tend to be concentrated among the rich when expenditures are assessed relative to consumption. At the extreme poverty line of $1.90-a-day, most impoverishment due to out-of-pocket expenditures occurs among low-income countries.
Catastrophic Medical Expenditures: Reflections on Three Issues
(World Bank, Washington, DC, 2018-11) Wagstaff, Adam
The ‘basic’ approach to 'catastrophic' medical expenses (where expenses are related to consumption or income) indicates whether expenses cause a large percentage reduction in living standards. By contrast, the 'ability-to-pay approach' (where expenses are related to consumption or income less actual expenses on nonmedical necessities or an allowance for them) does not indicate whether expenses are large enough to undermine a household’s ability to purchase nonmedical necessities. If the individual is a borrower after a health shock, the income-based ratio will exceed the consumption-based ratio, while the opposite is true when the individual continues to be a saver after a health shock. In the first case, both ratios will exceed Flores et al.'s more theoretically correct ratio, with the income-based ratio overestimating it by more. But if the individual is still a saver even after a health shock, the income-based ratio will overestimate Flores et al.'s ratio by less and may not overestimate it at all. A lifetime money metric utility approach can capture the lifetime consequences of coping with medical expenses. Under certain assumptions, but not otherwise, it and the Flores et al. approaches are identical, and both are operationalizable without data on how households finance their medical expenses.
Introducing the World Bank’s 2018 Health Equity and Financial Protection Indicators Database
(Elsevier, 2018-10-22) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc-Francois; Neelsen, Sven
Among the many shifts of emphasis that have been evident in global health over the past twenty-five years or so, two stand out: a concern over the poor lagging behind the better off in progress towards global goals; and a concern to look beyond whether people get the services they need to the affordability of the out-of-pocket expenditures associated with these services. The World Bank's 2018 Health equity and financial protection indicators (HEFPI) database is a new global resource for tracking progress on both fronts. It is, in effect, the fourth in the series of such databases. The 2018 database includes eighteen indicators of service use (twelve preventative, six curative) and twenty-eight health outcome indicators. The data are calculated from household surveys, identified mostly through searches of data catalogues and websites of multicountry survey initiatives. The 2018 HEFPI dataset is freely downloadable, and a data visualisation tool is also available. To ensure the data are reproducible, and in line with the guidelines for accurate and transparent health estimates reporting, the authors document their methods thoroughly in a working paper and highlight the differences between their definitions and others; They also provide the essential computer code used to produce the estimates.
The 2018 Health Equity and Financial Protection Indicators Database: Overview and Insights
(World Bank, Washington, DC, 2018-10) Eozenou, Patrick; Wagstaff, Adam; Smitz, Marc; Neelsen, Sven
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.
The Aggregate Income Losses from Childhood Stunting and the Returns to a Nutrition Intervention Aimed at Reducing Stunting
(World Bank, Washington, DC, 2018-08) Galasso, Emanuela; Wagstaff, Adam
This paper undertakes two calculations, one for all developing countries, the other for 34 developing countries that together account for 90 percent of the world's stunted children. The first calculation asks how much lower a country's per capita income is today as a result of some of its workers having been stunted in childhood. The analysis uses a development accounting framework, relying on micro-econometric estimates of the effects of childhood stunting on adult wages, through the effects on years of schooling, cognitive skills, and height, parsing out the relative contribution of each set of returns to avoid double counting. The estimates show that, on average, the per capita income penalty from stunting is around 7 percent. The second calculation estimates the economic value and the costs associated with scaling up a package of nutrition interventions using the same methodology and set of assumptions used in the first calculation. The analysis considers a package of 10 nutrition interventions for which data are available on the effects and costs. The estimated rate-of-return from gradually introducing this program over a period of 10 years in the 34 countries is17 percent, and the corresponding benefit-cost ratio is 15:1.