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Article

Francisco H. G. Ferreira, Emanuela Galasso, and Mario Negre

“Shared prosperity” is a common phrase in current development policy discourse. Its most widely used operational definition—the growth rate in the average income of the poorest 40% of a country’s population—is a truncated measure of change in social welfare. A related concept, the shared prosperity premium—the difference between the growth rate of the mean for the bottom 40% and the growth rate in the overall mean—is similarly analogous to a measure of change in inequality. This article reviews the relationship between these concepts and the more established ideas of social welfare, poverty, inequality, and mobility. Household survey data can be used to shed light on recent progress in terms of this indicator globally. During 2008–2013, mean incomes for the poorest 40% rose in 60 of the 83 countries for which we have data. In 49 of them, accounting for 65% of the sampled population, it rose faster than overall average incomes, thus narrowing the income gap. In the policy space, there are examples both of “pre-distribution” policies (which promote human capital investment among the poor) and “re-distribution” policies (such as targeted safety nets), which when well-designed have a sound empirical track record of both raising productivity and improving well-being among the poor.

Article

While definitional and measurement problems pose a challenge, there is no doubt that disability affects a noticeable share of the population, the vast majority of whom live in low- and middle-income countries (LMICs). The still comparatively scarce empirical data and evidence suggests that disability is closely associated with poverty and other indicators of economic deprivation at both the country and—if with slightly greater nuance—at the individual/household level. There is also a growing body of evidence documenting the sizeable additional costs incurred by persons with disabilities (PwDs) as a direct or indirect consequence of their disability, underlining the increased risk of PwDs (and the households they are part of) falling under the absolute poverty line in any given LMIC. Looking ahead, there remains considerable scope for more evidence on the causal nature of the link between disability and poverty, as well as on the (cost-)effectiveness of interventions and policies attempting to improve the well-being of PwDs.

Article

Florence Jusot and Sandy Tubeuf

Recent developments in the analysis of inequality in health and healthcare have turned their interest into an explicit normative understanding of the sources of inequalities that calls upon the concept of equality of opportunity. According to this concept, some sources of inequality are more objectionable than others and could represent priorities for policies aiming to reduce inequality in healthcare use, access, or health status. Equality of opportunity draws a distinction between “legitimate” and “illegitimate” sources of inequality. While legitimate sources of differences can be attributed to the consequences of individual effort (i.e. determinants within the individual’s control), illegitimate sources of differences are related to circumstances (i.e. determinants beyond the individual’s responsibility). The study of inequality of opportunity is rooted in social justice research, and the last decade has seen a rapid growth in empirical work using this literature at the core of its approach in both developed and developing countries. Empirical research on inequality of opportunity in health and healthcare is mainly driven by data availability. Most studies in adult populations are based on data from European countries, especially from the UK, while studies analyzing inequalities of opportunity among children are usually based on data from low- or middle-income countries and focus on children under five years old. Regarding the choice of circumstances, most studies have considered social background to be an illegitimate source of inequality in health and healthcare. Geographical dimensions have also been taken into account, but to a lesser extent, and more frequently in studies focusing on children or those based on data from countries outside Europe. Regarding effort variables or legitimate sources of health inequality, there is wide use of smoking-related variables. Regardless of the population, health outcome, and circumstances considered, scholars have provided evidence of illegitimate inequality in health and healthcare. Studies on inequality of opportunity in healthcare are mainly found in children population; this emphasizes the need to tackle inequality as early as possible.

Article

Leandro Prados de la Escosura and Blanca Sánchez-Alonso

In assessments of modern-day Spain’s economic progress and living standards, inadequate natural resources, inefficient institutions, lack of education and entrepreneurship, and foreign dependency are frequently blamed on poor performance up to the mid-20th century, but no persuasive arguments were provided to explain why such adverse circumstances reversed, giving way to the fast transformation that started in the 1950s. Hence, it is necessary to first inquire how much economic progress has been achieved in Spain and what impact it had on living standards and income distribution since the end of the Peninsular War to the present day, and second to provide an interpretation. Research published in the 2010s supports the view that income per person has improved remarkably, driven by increases in labor productivity, which derived, in turn, from a more intense and efficient use of physical and human capital per worker. Exposure to international competition represented a decisive element behind growth performance. From an European perspective, Spain underperformed until 1950. Thereafter, Spain’s economy managed to catch up with more advanced countries until 2007. Although the distribution of the fruits of growth did not follow a linear trend, but a Kuznetsian inverted U pattern, higher levels of income per capita are matched by lower inequality, suggesting that Spaniards’ material wellbeing improved substantially during the modern era.

Article

Brant Abbott and Giovanni Gallipoli

This article focuses on the distribution of human capital and its implications for the accrual of economic resources to individuals and households. Human capital inequality can be thought of as measuring disparity in the ownership of labor factors of production, which are usually compensated in the form of wage income. Earnings inequality is tightly related to human capital inequality. However, it only measures disparity in payments to labor rather than dispersion in the market value of the underlying stocks of human capital. Hence, measures of earnings dispersion provide a partial and incomplete view of the underlying distribution of productive skills and of the income generated by way of them. Despite its shortcomings, a fairly common way to gauge the distributional implications of human capital inequality is to examine the distribution of labor income. While it is not always obvious what accounts for returns to human capital, an established approach in the empirical literature is to decompose measured earnings into permanent and transitory components. A second approach focuses on the lifetime present value of earnings. Lifetime earnings are, by definition, an ex post measure only observable at the end of an individual’s working lifetime. One limitation of this approach is that it assigns a value based on one of the many possible realizations of human capital returns. Arguably, this ignores the option value associated with alternative, but unobserved, potential earning paths that may be valuable ex ante. Hence, ex post lifetime earnings reflect both the genuine value of human capital and the impact of the particular realization of unpredictable shocks (luck). A different but related measure focuses on the ex ante value of expected lifetime earnings, which differs from ex post (realized) lifetime earnings insofar as they account for the value of yet-to-be-realized payoffs along different potential earning paths. Ex ante expectations reflect how much an individual reasonably anticipates earning over the rest of their life based on their current stock of human capital, averaging over possible realizations of luck and other income shifters that may arise. The discounted value of different potential paths of future earnings can be computed using risk-less or state-dependent discount factors.

Article

The interaction between poverty and social policy is an issue of longstanding interest in academic and policy circles. There are active debates on how to measure poverty, including where to draw the threshold determining whether a family is deemed to be living in poverty and how to measure resources available. These decisions have profound impacts on our understanding of the anti-poverty effectiveness of social welfare programs. In the context of the United States, focusing solely on cash income transfers shows little progress against poverty over the past 50 years, but substantive gains are obtained if the resource concept is expanded to include in-kind transfers and refundable tax credits. Beyond poverty, the research literature has examined the effects of social welfare policy on a host of outcomes such as labor supply, consumption, health, wealth, fertility, and marriage. Most of this work finds the disincentive effects of welfare programs on work, saving, and family structure to be small, but the income and consumption smoothing benefits to be sizable, and some recent work has found positive long-term effects of transfer programs on the health and education of children. More research is needed, however, on how to measure poverty, especially in the face of deteriorating quality of household surveys, on the long-term consequences of transfer programs, and on alternative designs of the welfare state.

Article

The Indian Union, from the time of independence from British colonial rule, 1947, until now, has undergone shifts in the trajectory of economic change and the political context of economic change. One of these transitions was a ‘green revolution’ in farming that occurred in the 1970s. In the same decade, Indian migration to the Persian Gulf states began to increase. In the 1980s, the government of India seemed to abandon a strategy of economic development that had relied on public investment in heavy industries and encouraged private enterprise in most fields. These shifts did not always follow announced policy, produced deep impact on economic growth and standards of living, and generated new forms of inequality. Therefore, their causes and consequences are matters of discussion and debate. Most discussions and debates form around three larger questions. First, why was there a turnaround in the pace of economic change in the 1980s? The answer lies in a fortuitous rebalancing of the role of openness and private investment in the economy. Second, why did human development lag achievements in income growth after the turnaround? A preoccupation with state-aided industrialization, the essay answers, entailed neglect of infrastructure and human development, and some of that legacy persisted. If the quality of life failed to improve enough, then a third question follows, why did the democratic political system survive at all if it did not equitably distribute the benefits from growth? In answer, the essay discusses studies that question the extent of the failure.

Article

Marisa Miraldo, Katharina Hauck, Antoine Vernet, and Ana Wheelock

Major medical innovations have greatly increased the efficacy of treatments, improved patient outcomes, and often reduced the cost of medical care. However, innovations do not diffuse uniformly across and within health systems. Due to the high complexity of medical treatment decisions, variations in clinical practice are inherent to healthcare delivery, regardless of technological advances, new ways of working, funding, and burden of disease. In this article we conduct a narrative literature review to identify and discuss peer-reviewed articles presenting a theoretical framework or empirical evidence of the factors associated with the adoption of innovation and clinical practice. We find that variation in innovation adoption and medical practice is associated with multiple factors. First, patients’ characteristics, including medical needs and genetic factors, can crucially affect clinical outcomes and the efficacy of treatments. Moreover, differences in patients’ preferences can be an important source of variation. Medical treatments may need to take such patient characteristics into account if they are to deliver optimal outcomes, and consequently, resulting practice variations should be considered warranted and in the best interests of patients. However, socioeconomic or demographic characteristics, such as ethnicity, income, or gender are often not considered legitimate grounds for differential treatment. Second, physician characteristics—such as socioeconomic profile, training, and work-related characteristics—are equally an influential component of practice variation. In particular, so-called “practice style” and physicians’ attitudes toward risk and innovation adoption are considered a major source of practice variation, but have proven difficult to investigate empirically. Lastly, features of healthcare systems—notably, public coverage of healthcare expenditure, cost-based reimbursement of providers, and service-delivery organization, are generally associated with higher utilization rates and adoption of innovation. Research shows some successful strategies aimed at reducing variation in medical decision-making, such as the use of decision aids, data feedback, benchmarking, clinical practice guidelines, blinded report cards, and pay for performance. But despite these advances, there is uneven diffusion of new technologies and procedures, with potentially severe adverse efficiency and equity implications.

Article

Gabriella Conti, Giacomo Mason, and Stavros Poupakis

Building on early animal studies, 20th-century researchers increasingly explored the fact that early events—ranging from conception to childhood—affect a child’s health trajectory in the long-term. By the 21st century, a wide body of research had emerged, incorporating the original fetal origins hypothesis into the developmental origins of health and disease. Evidence from Organization for Economic Cooperation and Development (OECD) countries suggests that health inequalities are strongly correlated with many dimensions of socioeconomic status, such as educational attainment, and that they tend to increase with age and carry stark intergenerational implications. Different economic theories have been developed to rationalize this evidence, with an overarching comprehensive framework still lacking. Existing models widely rely on human capital theory, which has given rise to separate dynamic models of adult and child health capital within a production function framework. A large body of empirical evidence has also found support for the developmental origins of inequalities in health. On the one hand, studies exploiting quasi-random exposure to adverse events have shown long-term physical and mental health impacts of exposure to early shocks, including pandemics or maternal illness, famine, malnutrition, stress, vitamin deficiencies, maltreatment, pollution, and economic recessions. On the other hand, studies from the 20th century have shown that early interventions of various content and delivery formats improve life course health. Further, given that the most socioeconomically disadvantaged groups show the greatest gains, such measures can potentially reduce health inequalities. However, studies of long-term impacts as well as the mechanisms via which shocks or policies affect health, and the dynamic interaction among them, are still lacking. Mapping the complexities of those early event dynamics is an important avenue for future research.

Article

In the early 21st century, the U.S. economy stood at or very near the top of any ranking of the world’s economies, more obviously so in terms of gross domestic product (GDP), but also when measured by GDP per capita. The current standing of any country reflects three things: how well off it was when it began modern economic growth, how long it has been growing, and how rapidly productivity increased each year. Americans are inclined to think that it was the last of these items that accounted for their country’s success. And there is some truth to the notion that America’s lofty status was due to the continual increases in the efficiency of its factors of production—but that is not the whole story. The rate at which the U.S. economy has grown over its long history—roughly 1.5% per year measured by output per capita—has been modest in comparison with most other advanced nations. The high value of GDP per capita in the United States is due in no small part to the fact that it was already among the world’s highest back in the early 19th century, when the new nation was poised to begin modern economic growth. The United States was also an early starter, so has experienced growth for a very long time—longer than almost every other nation in the world. The sustained growth in real GDP per capita began sometime in the period 1790 to 1860, although the exact timing of the transition, and even its nature, are still uncertain. Continual efforts to improve the statistical record have narrowed down the time frame in which the transition took place and improved our understanding of the forces that facilitated the transition, but questions remain. In order to understand how the United States made the transition from a slow-growing British colony to a more rapidly advancing, free-standing economy, it is necessary to know more precisely when it made that transition.

Article

Taxation and public spending are key policy levers the state has in its power to change the distribution of income determined both by market forces and institutions and the prevailing distribution of wealth and property. One of the most commonly used methods to measure the distributional impact of a country’s taxes and public spending is fiscal incidence analysis. Rooted in the field of public finance, fiscal incidence analysis is designed to measure who bears the burden of taxes and who receives the benefits of government spending, and who are the gainers and losers of particular tax reforms or changes to welfare programs. Fiscal incidence analysis can be used to assess the redistributive impact of a fiscal system as a whole or changes of specific fiscal instruments. In particular, fiscal incidence analysis is used to address the following questions: Who bears the burden of taxation and who receives the benefits of public spending? How much income redistribution is being accomplished through taxation and public spending? What is the impact of taxation and public spending on poverty and the poor? How equalizing are specific taxes and government welfare programs? How progressive are spending on education and health? How effective are taxes and government spending in reducing inequality and poverty? Who are the losers and winners of tax and welfare programs reforms? A sample of key indicators meant to address these questions are discussed here. Real time analysis of winners and losers plays an important role in shaping the policy debate in a number of countries. In practice, fiscal incidence analysis is the method utilized to allocate taxes and public spending to households so that one can compare incomes before taxes and transfers with incomes after them. Standard fiscal incidence analysis just looks at what is paid and what is received without assessing the behavioral responses that taxes and public spending may trigger on individuals or households. This is often referred to as the “accounting approach.” Although the theory is quite straightforward, its application can be fraught with complications. The salient ones are discussed here. While ignoring behavioral responses and general equilibrium effects is a limitation of the accounting approach, the effects calculated with this method are considered a reasonable approximation of the short-run welfare impact. Fiscal incidence analysis, however, can be designed to include behavioral responses as well as general equilibrium and intertemporal effects. This article focuses on the implementation of fiscal incidence analysis using the accounting approach.