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The Determinants of Canadian Provincial Health Expenditures: Evidence from Dynamic Panel PRELIMINARY FIRAT BILGEL * University of Saskatchewan ABSTRACT The aim of this paper is to reveal the magnitude of the income elasticity of health expenditure in Canadian Provinces. Health can be seen as a luxury good if the income elasticity exceeds unity and as a necessity good if the income elasticity is below unity. It can be further postulated that if the income elasticity of health expenditure is less than one, then a high priority has not been given to the public health sector among the goals for social and economic development. Panel data on real per capita GDP, relative price of health care, proportion of publicly funded health expenditure, the share of senior population, life expectancy at birth and real per capita transfers from federal government for 10 provinces have been used to investigate the determinants of Canadian real per capita provincial total, private and government health expenditures for the period 1975- 2002. The evidence in this paper supports that health appears to be a luxury for Manitoba and British Columbia whereas necessity for other provinces. However, from a national perspective health is not a luxury for Canada. Keywords: health expenditure, dynamic panel, income elasticity * e-mail: [email protected]
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The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

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Page 1: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

The Determinants of Canadian Provincial

Health Expenditures: Evidence from

Dynamic Panel

PRELIMINARY

FIRAT BILGEL*

University of Saskatchewan

ABSTRACT

The aim of this paper is to reveal the magnitude of the income elasticity of health expenditure in Canadian Provinces. Health can be seen as a luxury good if the income elasticity exceeds unity and as a necessity good if the income elasticity is below unity. It can be further postulated that if the income elasticity of health expenditure is less than one, then a high priority has not been given to the public health sector among the goals for social and economic development. Panel data on real per capita GDP, relative price of health care, proportion of publicly funded health expenditure, the share of senior population, life expectancy at birth and real per capita transfers from federal government for 10 provinces have been used to investigate the determinants of Canadian real per capita provincial total, private and government health expenditures for the period 1975-2002. The evidence in this paper supports that health appears to be a luxury for Manitoba and British Columbia whereas necessity for other provinces. However, from a national perspective health is not a luxury for Canada.

Keywords: health expenditure, dynamic panel, income elasticity

* e-mail: [email protected]

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1. INTRODUCTION

The aim of this paper is to reveal the magnitude of the income elasticity of health

expenditure in Canada. Health can be seen as a luxury good if the responsiveness is

sensitive to income changes (i.e. the income elasticity exceeds unity) and as a necessity

good if the responsiveness is insensitive to income changes (i.e. the income elasticity is

below unity). This concept was introduced by J.P Newhouse (1977). Another

interpretation of this notion can be found in Kyriopoulos and Souliotis (2002):

“If the income elasticity of HE is less than one, then the public health sector does

not have a high priority among the goals for social and economic development.”

1.1 Canadian Literature on Health Expenditures

The analysis of the determinants of health expenditures (henceforth HE) has been

very tempting for both applied econometricians and health economists for the past thirty

years. Nevertheless, there is no consensus on which methods to use, how to proceed and

what type of data to analyze. This may have occurred due to lack of strong theoretical

guidance. The pioneering studies emphasize the importance of national income in

explaining HE along with a selection of non-income variables, some of them are the

relative price of health care, the proportion of the population over 65, urbanization rate

and the publicly funded proportion of HE. While the significance of these non-income

variables depends on the structure of health sector and population, GDP accounts for

most of the variation in health care expenditure – see Parkin et al. (1987).

There exist few studies focused on Canadian health expenditures. Di Matteo and Di

Matteo (1998, henceforth DD) examined the determinants of Canadian provincial

government health expenditures within pooled time-series cross-section framework for

the period 1965-1991. The determinants of provincial government health expenditures

are found to be the real per capita provincial income, the share of senior population and

real per capita federal transfers. Although the issue of stationarity is not addressed, they

reported that the income elasticity of government health care spending is 0.77. Di Matteo

(2000) focused on the public and private Canadian health expenditures over the period

1975-1996. The health expenditures are examined both as total and as sub-expenditure

categories such as hospital, physician and drug spending. His findings of the major

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determinants of public-private mix are per capita income, the share of individual income

held by the top quintile of the income distribution and federal health transfers.

Di Matteo (2003) compared parametric and nonparametric estimation methods for the

U.S states, the Canadian provinces and the OECD countries. He concluded that

parametric approaches lead to unreliable estimates of the income elasticity of health

expenditure and its magnitude is highly dependent on the level of analysis. In the latter,

national level analyses lead to estimates greater than one. Ariste and Carr (2001,

henceforth AC) used provincial data on real per capita income, the proportion of the

population over the age of 65 and the ratio of the deficit/surplus to GDP to explain the

real per capita government health expenditures by examining the non-stationarity of the

variables and the cointegrating relationships. They have found that variables, both

individually and collectively are non-stationary and possibly non-cointegrated. However,

the coefficient of the aging structure appeared to be insignificant compared to the

significant coefficient that DD found in their study. AC also extended their study to

examine the Baumol effect. They have found that health is a necessity good with income

elasticity of health spending of 0.88.

2. DATA AND METHODOLOGY

I will consider few points that are not considered by DD and AC. First, if the relative

price of health care is known to have an influence on HE (see Bac and Le Pen, 2000 for

example) and the failure to take into account this variable as one of the determinants, will

ultimately lead to specification bias and incorrect estimates due to combined income and

price effects. It should be noted that the income coefficient due to the exclusion of the

health price variable may be biased either upward or downward. Second, the previous

studies on the determinants of Canadian provincial health expenditures can be

characterized by the lack of dynamics. This paper aims to show that the dynamics of

health expenditures should not be neglected for the purposes of modeling and policy

implications. Third, I will examine the determinants of provincial health expenditures

under total, government and private health expenditures. This will enable to see the

differing responsiveness against the income and price changes for government and

private sector as well as total health sector. Fourth, I will incorporate other factors that

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are not considered in these analyses, such as life expectancy at birth and the public share

of health expenditures.

Finally, concerning unit roots Atkins and Sidhu (2002) state that if the series under

consideration are not weakly stationary (i.e. the series contain at least one unit root)

which is the case in most regional and international comparisons, then the traditional

econometric analysis is not valid. Failure to achieve weak stationarity will cast doubt on

the statistical significance of the coefficients and their reliability. Even if the economic

theory weakly provides guidance on the relationship between HE and its various

determinants, statistical theory shows that the mean and the variance of the underlying

series should be time invariant to make appropriate inferences. On the other hand, if the

series are weakly stationary at level, then the traditional approach can be applied.

The data covers 10 provinces in Canada for the time period 1975-2002 which makes

the total of 280 pooled observations. The provincial total, the provincial private and the

provincial government health expenditures are taken from the Canadian Institute for

Health Information website (www.cihi.ca). These variables are deflated by the provincial

CPI index (1992=100) and divided by the provincial population to obtain real per capita

provincial total (h), real per capita provincial private (pr) and real per capita provincial

government (g) health expenditures. The share of the provincial public health expenditure

(s) is obtained by dividing the real provincial public health expenditures to real provincial

total health expenditures. Transfers from federal government to provinces, provincial

medical CPI (1992=100), provincial proportion of the population over the age of 65

(p65), life expectancy at birth (x) and the provincial GDP are collected from CANSIM.

The provincial GDP and the transfers from the federal government to provinces are

deflated by the provincial CPI index (1992=100) and divided by the provincial

population to obtain the real provincial per capita GDP (y) and the real per capita

transfers from the federal government (f) respectively. The provincial medical CPI is

divided by the provincial GDP implicit price index (1992=100) to obtain the relative

price of health care (r) for each province.

The methodology followed in this paper is as follows: Section 3 provides evidence on

the stationarity of the series with province-by-province and panel unit root tests. Section

4 makes an introduction to dynamic health expenditure models and investigates the

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reasoning behind the relationship between health spending and its selected determinants.

Section 5 discusses the results and the relevant policy implications and section 6

concludes with directions for future research.

3. PROVINCE BY PROVINCE AND PANEL UNIT ROOT TESTS

Unit root1 is a severe problem in the sense that if the appropriate tests are not

employed, the inferences drawn might possibly be misleading and “seemingly good”

results may occur because of a common trend rather than true economic relationship. I

will first consider Augmented Dickey-Fuller (ADF) unit root test proposed by Dickey

and Fuller (1979) under the null of unit root with its extension to panel by Im et al. (2003,

henceforth IPS) and KPSS test proposed by Kwiatkowski et al. (1992) under the null of

stationarity with its extension to panel by Hadri (2000). See the appendix for technical

discussion on individual and panel unit root tests.

3.3 Unit Root Results

The ADF results show that for most of the series of health expenditures, GDP and

share of public health expenditures, the null hypothesis of unit root cannot be rejected.

Concerning total health expenditures, the null can only be rejected for New Brunswick,

Prince Edward and British Columbia. In the case of GDP, this null can only be rejected

for Prince Edward and British Columbia. The IPS panel tbar-statistics show that all of the

variables can be described as group stationary. The ADF and IPS results are shown in

table 1. It should be emphasized that concerning the IPS test, the chosen lag order or lag

criteria greatly affects the individual unit root statistics in favor of rejecting the null

hypothesis of unit root.

The KPSS individual unit root tests show that for most of the series except the share

of senior population, the null of trend stationarity cannot be rejected. However, Hadri’s

panel unit root tests show that the null hypothesis of either level or trend stationary can be

rejected for all the series at the 5% significance level. This result might be induced from

1 A model should be treated and interpreted over stationary forms of the variables. A common problem in time series is the existence of unit root. Most economic time series are classified as being integrated of order d, denoted as I(d), that is the series must be differenced d times in order to become stationary. Otherwise, a problem known as spurious regression occurs.

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the fact that the test proposed by Hadri is valid under sequential limit in which ∞→T

followed by ∞→N . The results are displayed in table 2.

The first problem that appears in unit root testing is whether to include a time trend or

not. While Hansen and King (1996) postulated that ADF regression should include a

linear trend, McKoskey and Selden (1998) argued that it should not. This paper argues

that most macroeconomic variables have tendency to increase over time, therefore it may

be more appropriate, where conventional, to include a deterministic component into unit

root testing. However, some variables may not evolve around a trend component at all,

yet may appear stationary. Economic theory does not help so as to whether include a

linear trend or not. At this point, we should rely on the statistical significance of the linear

trend. The decision to include such deterministic components is more or less heuristic.

Karlsson and Löthgren (2000) warn that unit root test such as IPS has high power in

panels with large T therefore researchers might mistakenly conclude that the whole panel

is stationary even though most of individual series are nonstationary and the converse is

true if T is small. This argument is reconciled for both unit root test that I have

undertaken. The decision concerning unit roots is inconclusive. For the IPS test, a

significant fraction of the series is individually nonstationary but they appear to be

stationary as panel. However, for Hadri’s test, a significant fraction of the series is

individually stationary but they all appear to be nonstationary as panel. A careful

assessment of individual and panel unit root tests should be done to identify the order of

integration of the variables with confidence. However, this is beyond the scope of this

paper. It should be underlined that the presence of structural breaks is not considered by

the unit root tests due to short time span of the series.

Our primary concern is whether the relationship between the Canadian HE and its

determinants would be spurious or not if one analyzes this relationship in levels of the

variables. From an economic point of view, shocks to the Canadian health sector have

temporary effects which are quickly absorbed to recover the initial level rather than

effects that alter the level of expenditure permanently. Thus, it is more appropriate to

represent the relationship between HE and its determinants assuming that the panel is

weakly stationary and that the regression is unlikely to be spurious in level. Further, even

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if this is not the true case, any indication of spurious regression can be captured by the

estimation results.

4. MODELS OF HEALTH EXPENDITURE

4.1 Factors Affecting Health Expenditure

Before introducing the models, this section discusses the reasons behind the inclusion

of the selected factors in the analysis of provincial health expenditures. The early studies

on the determinants of health expenditures concluded that income is the major

explanatory factor of HE. The economic approach argues that other things being equal,

the amount of health expenditure should depend on what an individual is capable of

spending. Therefore, it is expected that provinces with higher income should be able to

spend more on health given other decision factors.

Spending decisions concerning health are not solely affected by the income level but

also by the price of health care. In the case of higher out-of-pocket payments, decisions

rely on the price level. However, health care has special characteristics that are not

similar to those of other “goods”. The government is heavily involved into the delivery

of health and its supervision, attaching health sector a complex working mechanism. On

the other hand, health is a non-storable good and its delivery cannot be delayed. Such

features blur the price-spending relation and pose problems about our expectations of the

magnitude of the price effect and its sign2. This variable is particularly included in the

analysis to separate income and price effects. From the economic point of view, the

failure to include the price variable, if effective, results in misleading inference regarding

policy prescriptions.

With few countries being exception, health care decisions and a considerable volume

of health spending are driven by the governments and public institutions. Therefore, we

expect the share of publicly funded health expenditure to affect health spending.

However, as Roberts (1999) pointed out, both theory and empirical evidence are

contradictory regarding the magnitude and the sign of this effect.

2 The first counter argument to its inclusion is that the consumers do never face prices for the health services they receive and therefore this variable may be completely irrelevant for the analysis. The second one is the price of health is heavily subsidized in Canada so that even its effect is not zero, it should be almost zero or negligible.

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The share of senior population is considered to be another explanatory factor of HE

by the fact that elderly population consume health at a higher rate than others and the

depreciation rate of health is an increasing function of age (Grossman, 1972). Especially

for those of age 65 (regarded as the lower bound of ageing) and over higher and

prolonged periods of cost are involved. The treatment of senior population involves

complexity and is not fully realized in most of the cases. Diabetes, cardiovascular

diseases are few to mention that require relatively technical knowledge and equipment for

treatment and diagnosis. The delivery of health services to elderly population is therefore

associated with higher spending on health.

The relationship between HE and health status indicators is much of a controversy.

The reason to include health status indicator arises from the question whether there is

correlation between expenditure and health level. Life expectancy at birth stands as an

appropriate measure of indicator of health status for Canada which might also capture the

efficiency of necessary health services for elderly population. The previous studies show

that there appears to be no correlation between HE and health status in the OECD

countries (Kyriopoulos and Souliotis, 2002).

The last factor considered is Federal transfers to provincial governments. This

variable is included primarily to reconcile its significance presented by DD. Besides the a

priori expectation that a higher volume of federal transfers increase health expenditures

at the government level, its effect is likely to be smaller than what is found by DD.

4.2 Dynamic Panel Models

This section presents the dynamics of provincial health expenditures. All the models

presented are modeled under one-way error component model due to our focus on the

provincial differences in health expenditures rather than differences across time. It is first

assumed that these differences can be captured by the differences in the endowments. In

this case, these differences in the intercepts cannot be thought as independent of other

variables. I will only consider explicit models for government health expenditures.

The dynamic models considered are of such form:

itittiit Xhh εβρα +++= −'

1, with itiit υµε +=

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i denotes the provinces and t denotes time, β is a K x 1 vector where K is the

number of explanatory variables, X is a K x NT matrix of income and a selection of non-

income variables, µi is the province specific parameter and υit is the stochastic

disturbance term.

4.2.1 Health Expenditures under Slope Homogeneity

This sub-section starts off by the assumption that the coefficients are constant over

time and homogeneous across provinces. Although some parameters are unlikely to differ

substantially across provinces, the assumption of homogeneity is still strong and

restrictive.

Consider the following model for the government:

ititittiittiitiit prffgyg υββββρβµα ++++++++= −− 65lnlnlnlnln)(ln 541,321,1 (4.1)

where ln denotes the natural logarithm.

Baltagi (2001) demonstrated that under dynamic panel models with fixed effects

(4.1), the lagged dependent variable, lngi,t-1 is correlated with the disturbance even if the

disturbances are not auto-correlated. This problem results in biased and inconsistent OLS

estimates. To overcome this problem, the estimation is done via Instrumental Variables

(IV). Following Arellano (1989), lngi,t-2 is uncorrelated with the error term and

appropriate as an instrument for lngi,t-1.

From (4.1), the respective long-run income and price elasticity of government health

expenditures are:

ρβ−

=Ε1

1, yg

; ρ

β−

=Ε1

4,rg

Whereas the long-run elasticity of government health expenditure with respect to federal

transfers is:

ρββ

−+

=Ε1

32, fg

Equation (4.1) can be written in such form that the estimated parameters are direct

long-run elasticities. This transformation is due to Bewley (1979). Subtracting tig .lnρ on

both sides and reparameterize β vector to give:

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itititititititiit fgprfyg ωφφφφ +∆Φ−∆Φ+++−+Γ= lnln65lnlnlnln 214321 (4.2)

The constant term in (4.2) can be seen as the steady-state mean for province i, if we let T

go large. The Bewley transformation now includes both level and differenced variables.

However, this transformation also requires IV estimation due to the correlation between

transformed explanatory variables and the error term.

4.2.2 Health Expenditures under Slope Heterogeneity

Currently, most of the studies of health care expenditure are based on the OECD

health data set and some of those studies introduce that there are substantial differences in

the structure of health sectors and demographics in the OECD countries and argue that

imposing slope homogeneity is unrealistic and may lead to misleading coefficients

(Roberts, 1999). Baltagi (2001) discusses briefly that in data field literature where T is

large compared to N, the fixed effects estimation in dynamic panels may lead to large

bias if the parameters are heterogeneous. For the Canadian case, it is argued that some

parameters are unlikely to substantially differ across provinces, but there may be

significant differences in the income parameter due to differences in earnings. To

introduce slope heterogeneity, consider the following dynamic heterogeneous model

analogous to (4.2):

itititiiit zyg υγφ +++Γ= '' lnln (4.3)

where the parameters are the long-run responses as defined earlier, zit consist of variables

with homogeneous parameters and we have introduced the subscript i for φ, allowing the

long-run effects of income to differ randomly across provinces such that:

ii 1ηφφ +=

η1i has zero mean, constant covariance and the average long-run coefficients are:

∑=

=10

1101

iiφφ

Pesaran and Smith (1995, henceforth PS) postulated that the dynamic pooled

estimation, even if the estimation is via IV gives inconsistent, biased and misleading

estimates when the parameters are heterogeneous. The size of this bias depends on ρ, φ,

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var(φ) and the autoregressive roots of lnyit assuming a stationary AR(1) data generating

process of lnyit given in the appendix of PS. They instead suggested that cross-section

estimation provides consistent estimates of the long-run effects. However in my case, the

cross-section estimation3 will not improve over pooled estimation because N is very

small.

5. RESULTS & POLICY IMPLICATIONS

The estimations based on (4.1) are displayed in table 3. The assumption made about

the differences in the endowments has been incorporated into the models via fixed

effects4. The results show that income, federal transfers and the share of senior

population have statistically significant effects on total HE. The results also show that the

dynamics of HE should not be ignored as they play a significant role in the adjustment

process of explanatory variables. An interesting result, found in total and private health

expenditures models is that the life expectancy at birth has positive, statistically

significant effect on HE.

Before analyzing the precise effects of those variables, we should confine ourselves

to the reparameterized models we made use of, based on Bewley (1979) to directly

estimate the average long-run effects of the explanatory variables. This

reparameterization enables to assess the significance of long-run effects and their

standard errors. Table 4 reports the results. Income, federal transfers, the share of senior

population and life expectancy at birth has positive significant long-run effects on total

HE. However, the long-run effect of the relative price of health care appeared to be

insignificant in the preliminary estimation and therefore removed from the equations. The

insignificance of price effect might have occurred to due the fact that, discarding private 3 Since the number of cross sections is 10 and the number of explanatory variables is 6, the law of large numbers is invalid and some tests are not computable. Due to this problem, the mean group estimation suggested by PS, which involves estimating separate regressions for each province when T is large and averaging the coefficients over provinces, is used as an alternative method and a benchmark to compare with the average long-run effects obtained from pooled estimation. The pooled estimator slightly overestimates the average long-run effects of income compared to the mean group estimator. The results are available upon request. 4 We have performed F-test to test the joint significance of the individual fixed effects under the null hypothesis, Ho: µ1 = µ2 = ..... = µ10 = 0. The F-test turned out to be 5.26, 7.83 and 35.85 for total, government and private HE respectively, resulting in favor of rejecting the null hypothesis. Therefore, the models can be characterized by allowing the intercept to differ across provinces. For all models, the explanatory power and the Durbin-Watson statistics are fairly high.

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sector, health care is free of charge in Canada and therefore price may be irrelevant to the

consumer. In his seminal work, Newhouse (1977) argued that for this reason, price may

not be an important factor in explaining health expenditures. The long-run income

elasticity of total health expenditure is 0.61 whereas the long-run elasticity of total health

expenditures with respect to federal transfers is 0.077. The effect of the share of senior

population appeared to be very small, even negligible.

Concerning the government HE, all long-run effects are significant. The long-run

income elasticity of government health expenditure is 0.78. On the contrary of the

previous studies, the evidence suggests that the effect of the share of senior population is

neither high as it is previously realized by DD5, nor insignificant as argued by AC. If the

proportion of the population over the age of 65 goes up by 1 percent, the government

health expenditures increase on average only by 0.018 percent.

The estimation for private health expenditures has given the most sensible results.

The long-run income elasticity of private health expenditures is found to be 0.46, being

much lower than those of total and government HE. For the relative prices, the long-run

price elasticity turned out to be significant and positive. This result requires explanation.

A possible argument supports the changing role of both public and private health sectors

and the shifting needs of patients. The lags in the adaptation of new technology, the time

spent between diagnosis and treatment and the concern for long-term care have led the

Canadians to shift the growing demand toward alternatives. The Canadian Medical

Association-sponsored poll on user fees reported that 57 percent supported user fees

(Irvine and Ferguson, 2002). These may explain the positive relation between prices and

private health expenditures. However, the provincial governments face the full price of

health services even though this cost is not projected on patients through billings.

Regardless of this fact, the provision of health care is not free and there are long-term

issues in financing of public health (see Brown, 1991).

The share of public HE is included into the analysis of private sector to evaluate a

potential trade-off between private and public health expenditures and its size. Our

findings indicate a significant, negligible negative trade-off between the share of public

5 According to DD, the impact of the share of the population over the age of 65 on government health expenditures is found to be 0.81 whereas AC found no evidence on its significance.

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HE and private HE. However, this negative trade-off does not tell us about whether this

shift toward spending more on public services is due to changes in the quality of services

or not. Therefore, the evidence of this negative trade-off is of low quality.

A distinction should be made between the effects of variables that represent

demographic structure and health status. An increasing share of senior population implies

increasing health expenditures due to rising costs of treatment of the elderly. However,

increasing life expectancy or health status in this matter implies increasing health

expenditures due to rising needs for long-term care. As mentioned at the beginning of this

section, the interesting result found was the significance of life expectancy at birth on

health expenditures. But the magnitude of health status effect is very small. In case of a

one year increase in life expectancy, the private health expenditures increase by

3.5/10000. This suggests that there is a positive but negligible effect on health

expenditures resulting from the rising needs for long-term care. In this case, the analysis

confirms that these long-term needs are to be met by spending on private medical

services rather than public services. These findings are consistent with the evolving

medical needs of the Canadians for alternative treatments that are “neglected” by the

public health sector (see Klatt, 2000).

There appears to be substantial differences in the long-run elasticities if we allow the

income parameter to be heterogeneous. Figure 1 displays this variation.

Figure 1: The long-run income elasticity of health expenditure under slope heterogeneity

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.802.00

NF PE NS NB QC ON MN SK AB BC

Government Total Private

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The long-run income elasticity of government HE is higher than the income elasticity of

total HE for most of the provinces. After allowing for heterogeneity, the income elasticity

of total HE for Quebec, Saskatchewan and Alberta appeared to be insignificant. The

findings show that the fixed effect estimator after allowing for heterogeneity

overestimates the average long-run effects in comparison to homogenous models.

The evidence in this paper suggests that health appears to be a luxury for Manitoba

and British Columbia whereas necessity for other provinces. However, from a national

perspective the evidence supports that health is not a luxury for Canada and the

determination of health spending in that matter is dominated by the needs rather than the

ability to pay. This is what Culyer (1988) was referring to as “the Bioengineering view”.

The “according to needs” argument supported by our results is also consistent with the

fact that physicians have a high-degree of control over the decisions about the medical

services that their patients need.

6.CONCLUSION

This study aimed at revealing the magnitude of income elasticity and the impact of

non-income determinants of health expenditures in Canadian provinces using panel data

on per capita GDP, relative price of health care, the share of public health expenditures,

share of senior population, per capita federal transfers and life expectancy at birth, over

the period 1975-2002.

The main differences captured in this study are summarized as follows:

• The relation between health expenditure and its determinants is of dynamic

structure.

• The relative price of health appears to have influence on private health

expenditures.

• The effects of non-income variables on health spending are very small, even

negligible.

• There appears to be a trivial correlation between health spending and health

status.

• After allowing the effect of income to be heterogeneous, health is a luxury for

some provinces and necessity for others.

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15

The models showed that most of the variation in provincial health expenditures can

be explained by the current values of the explanatory variables as well as lags of health

expenditures. Under the assumption of homogenous parameters, the income elasticity of

health expenditure is below unity. This result is consistent with the previous studies at the

point that the regional or national estimates are usually below one.

The first difficulty encountered in this paper was the indecision whether the panel can

be described as stationary or not. The IPS and Hadri’s panel unit root tests have given

contradictory result regarding the unit root problem. Most of the panel unit root tests are

based on and therefore valid only under joint or sequential limit theory and I have

presented evidence on the fact that these tests are known to render the researcher with

conflicting results due to their high/low power in certain cases. Based on this fact, I have

argued that the effects of shocks to Canadian public sector can be best characterized as

temporary rather than permanent. Furthermore, our results following the approach which

can be seen as “traditional” appeared to be sensible and viable. However, a thorough and

careful assessment of panel unit root problem is needed to be addressed.

A second point for future research lies in more advanced econometric techniques to

reconsider the soundness of macroeconomic health policies. Regarding policy

implications, AC argued that if health is a luxury (i.e. the income elasticity is greater than

one), the health sector will consume a larger share of national income therefore

governments will allocate a larger share of their revenues to health expenditures, at the

expense of other sectors. However, the last part of this argument cannot be reconciled

based on this type of study due to the unknown nature of the relationship among various

sectors in Canada. This paper argues that if health is a luxury, a multi-equation

framework6 may serve for the purpose of revealing whether a greater allocation of

government revenues will take place at the expense of other sectors.

What are not needed are further studies of the effects of quantitative measures on

health expenditures. The standard measures appeared to be the determinants of health

expenditures are so far, known to every researcher in this area. What is not known is the

6 Such analysis, for instance, may examine the determinants of expenditures of various sectors within a system of equations to conclude that there is a trade-off between those sectors.

Page 16: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

16

precise effect of measures that are indicators of the quality of life and health. Therefore,

the next generation of international or regional comparisons of health expenditure should

base their analysis on the effects of qualitative measures that are truly responsible for the

persistent increase or disparities in health expenditures.

REFERENCES

Arellano, M. (1989) “A Note on the Anderson-Hsiao Estimator for Panel Data”, Economics Letters, 31: 337-341 Ariste, R. and Carr, J. (2001) “New Considerations on the Empirical Analysis of Health Expenditures in Canada: 1966 – 1998”, Health Canada Applied Research and Analysis Directorate

Atkins, F. and Sidhu, N. (2002) “Unit Roots and Alternative Hypotheses in Health Care Econometrics”, University of Calgary, Department of Economics working papers

Bac, C. and Le Pen, Y. (2002) “An International Comparison of Health Care Expenditure Determinants”, 10th International Conference on Panel Data, Berlin

Baltagi, B. H. (2001) “Econometric Analysis of Panel Data”, Second Edition, Wiley & Sons

Bewley, R.A. (1979) “The direct estimation of equilibrium response in a linear model”, Economics Letters, 3: 357-361

Brown, M.C. (1991) “Health economics and Policy: Problems and prescriptions”, Toronto, McClelland & Stewart

Culyer, A.J. (1988) “Health Care Expenditures in Canada: Myth and Reality; Past and Future”, Canadian Tax Paper no: 82 (Canadian Tax Foundation) Di Matteo, L. (2000) “The Determinants of the Public-Private Mix in Canadian Health Care Expenditures: 1975 – 1996”, Journal of Health Policy, 52: 87-112

Di Matteo, L. (2003) “The Income Elasticity of Health Care Spending: A Comparison of Parametric and Nonparametric Approaches”, European Journal of Health Economics, 4: 20-29

Di Matteo, L. and Di Matteo, R. (1998) “Evidence on the Determinants of Canadian Provincial Government Health Expenditures: 1965-1991”, Journal of Health Economics, 17: 211-228

Page 17: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

17

Dickey, D.A, Fuller, W.A (1979) “Distribution of the estimators for auto-regressive time-series with a unit root”, Journal of the American Statistical Association”, 74: 427-431 Grossman, M. (1972) “On the Concept of Health Capital and the Demand for Health”, Journal of Political Economy, 80: 223-255

Hadri, K. (2000) “Testing for Stationarity in Heterogeneous Panel Data”, Econometrics Journal, 3: 148-161 Hansen, P. and King, A. (1996) “The Determinants of Health Care Expenditure: A Cointegrating Approach”, Journal of Health Economics, 15: 127-137

Im, S.K., Pesaran, M.H., Shin, Y. (2003) “Testing for Unit Roots in Heterogeneous Panels”, Journal of Econometrics, 115: 53-74

Irvine, B., Ferguson, S. (2002) “Background Briefing: The Canadian Health Care System”, online: http://www.civitas.org.uk/pdf/Canada.pdf Karlsson, S. and Löthgren, M. (2000) “On the power and interpretation of panel unit root tests”, Economics Letters, 66: 249-255 Klatt, I. (2000) “Understanding the Canadian Health System”, online: http://www.cfp-ca.org/pdf/understanding_canadian_healthcare.pdf Kyriopoulos, P. and Souliotis, K. (2002) “Health Care Expenditures in the OECD Countries”, Reading Module, National School of Public Health, Greece Kwiatkowski, D., Phillips, P., Schmidt, P., Shin, Y. (1992) “Testing the null hypothesis of stationarity against the alternative of unit root”, Journal of Econometrics, 54: 159-178 McCoskey, S.K. and Selden, T.M. (1998) “Health Care Expenditures and GDP: Panel Data Unit Root Test Results”, Journal of Health Economics, 17: 369-376 Newhouse, J.P. (1977) “Medical Care Expenditure: A Cross National Survey” Journal of Human Resources, 12: 112-125 Parkin D., McGuire A., Yule B. (1987) “Aggregate Health Expenditures and National Income: Is Health Care a Luxury Good”, Journal of Health Economics, 6 :109-127 Pesaran, M.H. and Smith, R. (1995) “Estimating Long-run Relationships from Dynamic Heterogeneous Panels”, Journal of Econometrics, 68: 79-113 Roberts, J. (1999) “Sensitivity of Elasticity Estimates for OECD Health Care Spending: Analysis of a Dynamic Heterogeneous Data Field”, Health Economics, 8: 459-472

Page 18: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

18

Tab

le 1

: Pro

vinc

e by

Pro

vinc

e A

DF

τ-st

atis

tics a

nd IP

S Pa

nel t

-bar

stat

istic

Prov

ince

To

tal H

ealth

Exp

endi

ture

G

over

nmen

t Hea

lth E

xpen

ditu

re

Priv

ate

Hea

lth E

xpen

ditu

re

Tran

sfer

from

the

Fede

ral G

ov.

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

New

foun

dlan

d 2

-1.8

41

3 -1

.859

4

-1.9

39

3 -2

.622

Prin

ce E

dwar

d Is

land

2

-3.4

10**

* 4

-1.7

40

2 -3

.586

***

2 -2

.979

Nov

a Sc

otia

2

-2.0

12

3 -2

.126

3

-2.1

76

2 -3

.002

New

Bru

nsw

ick

3 -3

.419

***

3 -2

.821

2

-4.0

62**

1

-2.3

87

Que

bec

4 -2

.551

1

-2.5

47

2 -2

.207

2

-3.5

55**

*

Ont

ario

2

-2.3

91

3 -2

.361

3

-2.5

53

2 -2

.136

Man

itoba

3

-2.8

70

3 -2

.947

3

-2.4

67

1 -2

.241

Sask

atch

ewan

2

-1.7

74

3 -2

.882

2

-3.7

26**

4

-2.0

51

Alb

erta

2

-2.4

42

2 -2

.417

3

-2.7

78

2 -2

.580

Brit

ish

Col

umbi

a 4

-3.8

32**

3

-3.2

01

2 -2

.067

2

-2.8

53

Pane

l t –

bar

stat

istic

-2.6

54**

-2.5

39**

*

-2.7

56**

-2.6

40**

Not

e: A

DF

regr

essi

ons i

nclu

de li

near

tren

d. *

, **

and

***

repr

esen

t 1%

, 5%

and

10%

sign

ifica

nce

leve

ls re

spec

tivel

y. T

he 1

%, 5

% a

nd 1

0% c

ritic

al v

alue

s of t

he IP

S t-b

ar te

st sta

tistic

are

-2.7

9, -2

.60

and

-2.

51 re

spec

tivel

y T

able

1: P

rovi

nce

by P

rovi

nce

AD

F τ-

stat

istic

s and

IPS

Pane

l t-b

ar st

atis

tic (c

ont’

d)

Prov

ince

G

DP

Rel

ativ

e Pr

ice

of H

ealth

Li

fe E

xpec

tanc

y at

Birt

h Sh

are

of S

enio

r Pop

ulat

ion

Shar

e Pu

blic

Hea

lth E

xpen

ditu

re

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

La

g or

der

τ-sta

tistic

New

foun

dlan

d 3

-2.3

64

3 -3

.956

* 2

-4.0

31**

1

-0.0

52

3 -2

.828

Prin

ce E

dwar

d Is

land

0

-3.5

16**

* 3

-4.4

02*

1 -3

.486

***

2 -1

.711

2

-3.3

95**

*

Nov

a Sc

otia

3

-1.7

23

1 -4

.767

* 1

-3.0

41

2 -3

.904

* 3

-1.9

74

New

Bru

nsw

ick

0 -3

.071

1

-2.1

01

1 -2

.380

2

-2.9

21

3 -3

.739

**

Que

bec

2 -2

.547

1

-1.2

64

1 -2

.864

2

-1.6

67

2 -2

.647

Ont

ario

2

-2.9

00

2 -1

.796

1

-2.7

76

3 -2

.749

2

-1.5

38

Man

itoba

3

-2.3

47

1 -1

.522

2

-1.8

05

3 -2

.904

2

-2.2

55

Sask

atch

ewan

2

-1.1

86

4 -1

.852

1

-1.5

72

3 -1

.521

3

-2.8

51

Alb

erta

1

-2.0

78

2 -2

.242

3

-3.2

20

2 -0

.857

2

-2.1

78

Brit

ish

Col

umbi

a 3

-4.0

82**

2

-1.8

92

3 -3

.480

***

3 -1

.619

2

-3.6

32**

Pane

l t –

bar

stat

istic

-2.5

82**

*

-2.5

79*

-2

.865

*

-1.9

905*

*

-2.7

13**

Not

e:

re

pres

ents

that

the

AD

F re

gres

sions

do

not i

nclu

de li

near

tren

d. *

, **

and

***

repr

esen

t 1%

, 5%

and

10%

sign

ifica

nce

leve

ls re

spec

tivel

y. T

he 1

%, 5

% a

nd 1

0% c

ritic

al v

alue

s of t

he IP

S t-b

ar te

st

statis

tic a

re -2

.21,

-1.9

9 an

d -1

.89

resp

ectiv

ely.

Page 19: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

19

Tab

le 2

: Pro

vinc

e by

Pro

vinc

e K

PSS

η-st

atis

tics a

nd H

adri

’s P

anel

Tes

t sta

tistic

und

er st

atio

nari

ty

Prov

ince

To

tal H

ealth

Exp

endi

ture

l 4 =

3

Gov

. Hea

lth E

xpen

ditu

re

l 4 =

3

Priv

ate

Hea

lth E

xpen

ditu

re

l 4 =

3

Tran

sfer

s fro

m th

e Fe

dera

l Gov

.

l 4 =

3

η τ

η µ

η τ

η µ

η τ

η µ

η τ

η µ

New

foun

dlan

d 0.

112

0.78

0**

0.08

9 0.

779*

* 0.

112

0.21

9 0.

112

0.37

2

Prin

ce E

dwar

d Is

land

0.

066

0.79

0**

0.07

4 0.

771*

* 0.

066

0.67

5**

0.09

1 0.

244

Nov

a Sc

otia

0.

140

0.76

7**

0.12

5 0.

741*

* 0.

131

0.78

6**

0.09

2 0.

231

New

Bru

nsw

ick

0.17

3**

0.77

1**

0.16

1**

0.76

5**

0.15

8**

0.76

0**

0.12

6 0.

126

Que

bec

0.09

8 0.

791*

* 0.

113

0.74

5**

0.09

5 0.

776*

* 0.

074

0.47

0**

Ont

ario

0.

155*

* 0.

774*

* 0.

151*

* 0.

697*

* 0.

126

0.80

6**

0.12

6 0.

287

Man

itoba

0.

115

0.77

6**

0.10

8 0.

734*

* 0.

091

0.77

1**

0.14

3 0.

290

Sask

atch

ewan

0.

132

0.76

2**

0.13

3 0.

686*

* 0.

091

0.74

7**

0.13

6 0.

215

Alb

erta

0.

128

0.67

2**

0.13

0 0.

463

0.05

7 0.

794*

* 0.

148*

* 0.

327

Brit

ish

Col

umbi

a 0.

100

0.79

5**

0.09

1 0.

778*

* 0.

054

0.79

4**

0.11

2 0.

302

Had

ri Pa

nel S

tatis

tic

4.97

3**

12.7

8**

4.51

6**

11.8

8**

2.97

3**

12.4

0**

3.76

**

2.86

**

Not

e: η

τ and

ηµ a

re th

e tre

nd a

nd th

e le

vel s

tatio

narit

y ca

ses r

espe

ctiv

ely.

The

5%

crit

ical

val

ue o

f the

Had

ri Pa

nel s

tatis

tic is

1.6

45. *

* de

note

s 5%

sign

ifica

nce

leve

l.

Tab

le 2

: Pro

vinc

e by

Pro

vinc

e K

PSS

η-st

atis

tics a

nd H

adri

’s P

anel

Tes

t sta

tistic

und

er st

atio

nari

ty (c

ont’

d)

Prov

ince

G

DP

l 4 =

3

Rel

ativ

e Pr

ice

of H

ealth

l 4 =

3

Life

Exp

ecta

ncy

at B

irth

l 4 =

3

Shar

e of

sen

ior p

opul

atio

n

l 4 =

3

Shar

e of

Pub

lic H

ealth

Exp

endi

ture

l 4 =

3

η τ

η µ

η τ

η µ

η τ

η µ

η τ

η µ

η τ

η µ

New

foun

dlan

d 0.

089

0.67

7**

0.18

1**

0.53

4**

0.08

8 0.

624*

* 0.

098

0.80

5**

0.08

7 0.

527*

*

Prin

ce E

dwar

d Is

land

0.

110

0.66

0**

0.17

1**

0.61

5**

0.10

1 0.

604*

* 0.

185*

* 0.

737*

* 0.

067

0.07

8

Nov

a Sc

otia

0.

167*

* 0.

625*

* 0.

182*

* 0.

576*

* 0.

133

0.64

3**

0.20

7**

0.79

1**

0.09

4 0.

740*

*

New

Bru

nsw

ick

0.11

3 0.

652*

* 0.

123

0.63

3**

0.16

6**

0.62

6**

0.20

2**

0.79

6**

0.10

0 0.

648*

*

Que

bec

0.07

6 0.

628*

* 0.

101

0.71

7**

0.12

7 0.

643*

* 0.

153*

* 0.

807*

* 0.

098

0.74

6**

Ont

ario

0.

066

0.58

8**

0.13

9 0.

709*

* 0.

117

0.64

4**

0.19

3**

0.79

8**

0.14

3 0.

690*

*

Man

itoba

0.

106

0.59

7**

0.12

6 0.

597*

* 0.

153*

* 0.

605*

* 0.

205*

* 0.

751*

* 0.

097

0.46

5**

Sask

atch

ewan

0.

158*

* 0.

450

0.17

0**

0.58

5**

0.14

0 0.

585*

* 0.

147*

* 0.

773*

* 0.

124

0.21

5

Alb

erta

0.

122

0.22

3 0.

177*

* 0.

566*

* 0.

145

0.63

2**

0.12

2 0.

763*

* 0.

143

0.62

4**

Brit

ish

Col

umbi

a 0.

046

0.63

7**

0.14

5 0.

459

0.11

0 0.

643*

* 0.

185*

* 0.

749*

* 0.

085

0.36

4

Had

ri Pa

nel S

tatis

tic

4.05

1**

11.8

7**

7.93

2**

9.01

**

4.68

**

9.72

**

8.43

**

13.1

4**

2.29

7**

8.40

6**

Not

e: η

τ and

ηµ a

re th

e tre

nd a

nd th

e le

vel s

tatio

narit

y ca

ses r

espe

ctiv

ely.

The

5%

crit

ical

val

ue o

f the

Had

ri Pa

nel s

tatis

tic is

1.6

45. *

* de

note

s 5%

sign

ifica

nce

leve

l.

Page 20: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

20

Tab

le 3

: Dyn

amic

Reg

ress

ion

Resu

lts, [

1977

– 2

002]

M

etho

d: In

strum

enta

l Var

iabl

es, o

ne-w

ay fi

xed

effe

cts e

rror

com

pone

nt m

odel

Var

iabl

e

Tota

l Hea

lth E

xpen

ditu

res

Gov

ernm

ent H

ealth

Exp

endi

ture

s Pr

ivat

e H

ealth

Exp

endi

ture

s

Coe

ffici

ent (

s.e)

P –

valu

es

Coe

ffici

ent (

s.e)

P –

valu

es

Coe

ffici

ent (

s.e)

P –

valu

es

GD

P 0.

20 (0

.024

)0.

0000

0.27

(0.0

40)

0.00

000.

141

(0.0

34)

0.00

01Pr

ice

of H

ealth

Car

e

0.

144

(0.0

23)

0.00

00Fe

dera

l Tra

nsfe

rs

0.02

5 (0

.009

)0.

0101

0.04

9(0

.014

)0.

0008

Shar

e of

Pub

lic H

.E

-0.0

29 (0

.001

2)0.

0000

Shar

e of

Sen

ior P

opul

atio

n 0.

011

(0.0

03)

0.00

130.

006

(0.0

03)

0.06

100.

030

(0.0

05)

0.00

00Li

fe E

xpec

tanc

y at

Birt

h 0.

008

(0.0

03)

0.00

61

0.02

6 (0

.004

)0.

0000

Lagg

ed G

DP

0.20

(0.0

33)

0.00

00La

gged

Dep

ende

nt V

aria

ble a

0.

67 (0

.030

)0.

0000

0.64

2 (0

.043

)0.

0000

0.24

7 (0

.028

)0.

0000

Con

stan

ts

New

foun

dlan

d -0

.461

5 0.

0640

-0

.535

6 0.

0211

1.

2213

0.

0001

P

rince

Edw

ard

Isla

nd

-0.4

990

0.04

18

-0.5

879

0.01

16

1.13

36

0.00

02

Nov

a Sc

otia

-0

.502

8 0.

0408

-0

.603

3 0.

0100

1.

1036

0.

0004

N

ew B

runs

wic

k -0

.493

6 0.

0460

-0

.585

9 0.

0123

1.

1460

0.

0002

Q

uebe

c -0

.501

3 0.

0434

-0

.585

7 0.

0125

1.

1221

0.

0004

O

ntar

io

-0.5

117

0.03

93

-0.6

100

0.00

98

1.05

93

0.00

09

Man

itoba

-0

.512

4 0.

0372

-0

.599

6 0.

0109

1.

0913

0.

0005

S

aska

tche

wan

-0

.544

8 0.

0271

-0

.613

6 0.

0091

1.

0174

0.

0012

A

lber

ta

-0.5

278

0.03

91

-0.6

392

0.00

84

1.08

98

0.00

10

Brit

ish C

olum

bia

-0.5

147

0.03

70

-0.5

787

0.01

29

1.05

53

0.00

09

R2 =

0.9

9

R2 =

0.9

9

R2 =

0.9

9

a:

two-

perio

d la

gged

val

ue in

leve

l is u

sed

as a

n in

strum

ent

Page 21: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

21

Tab

le 4

: Dire

ct L

ong-

run

Estim

ates

usin

g Be

wle

y tra

nsfo

rmat

ion,

[197

7 –

2002

]

M

etho

d: In

strum

enta

l Var

iabl

es, o

ne-w

ay fi

xed

effe

cts e

rror

com

pone

nt m

odel

Var

iabl

e

Tota

l Hea

lth E

xpen

ditu

res

Gov

ernm

ent H

ealth

Exp

endi

ture

s Pr

ivat

e H

ealth

Exp

endi

ture

s

Coe

ffici

ent (

s.e)

P –

valu

es

Coe

ffici

ent (

s.e)

P –

valu

es

Coe

ffici

ent (

s.e)

P –

valu

es

GD

P 0.

61 (0

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Page 22: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

22

APPENDIX:

3.1 Test of Null of Unit Root

The Augmented Dickey-Fuller test can be shown by the following model:

∑=

−− +∆+−++=∆iK

jitjtijitiiiiit xxtx

1,,1,)1( εβρδα εit C i.i.d (0, σ2)

where variable t is time trend, t = 1,……,T and j = 1,......,K. K is the number of lags,

determined such that the error term is autocorrelation free.

IPS proposed a fixed T, fixed N panel unit root test based on the average of the ADF test statistics:

∑=

=N

iiNT N

t1

1 τ i = 1,.….,10

where τi is the ADF test statistic for ith province.

The test statistic has a non-normal distribution and the critical values are supplied by IPS. The null

hypothesis that all series contain unit root is tested against the alternative that some series are

stationary.

Ho: ρi = 1 for all i

HA: ρi < 1 i = 1, 2, …, N1 where N1 is a subset of N

A particular lag order is determined for each of the series instead of choosing a common lag order to

avoid misleading ADF statistics resulting from autocorrelation.

3.2 Test of Null of Stationarity

The KPSS unit root test unlikely the ADF, constructs the null hypothesis of stationarity against the

alternative of unit root. This ensures that the null will be rejected only when there is strong evidence

against it. Due to Kwiatkowski et al. (1992), a time series can be decomposed into three components, a

deterministic trend, a random walk and a stationary error:

titiiti rtx ,,, εθ ++= (1)

where t captures the deterministic trend and ri,t is a random walk:

tititi urr ,1,, += − ui,t C i.i.d (0, σu2) (2)

The test statistic is a one-sided LM statistic under the null of level stationary (Ho: θi = 0) with the

errors being iid in eq. (1). The LM test statistic is defined as:

Page 23: The determinants of Canadian provincial health expenditures: evidence from a dynamic panel

23

)(ˆ/1 2,

1

2,2 lS

T i

T

ttii εση ∑

==

where T is the sample size, )(ˆ 2 liσ is the estimate of the error variance, l is the lag truncation parameter7

and Si,t is the partial sums of the residuals, ∑=

=t

jjitiS

1,, ε̂ . The KPPS test makes a nonparametric

correction of the estimate of the error variance such that:

∑∑∑+=

−==

+−+=

T

ststiti

l

s

T

ttii lTT

l1

,,11

2,

2, ˆˆ

12121)(ˆ εεεσε

The extension of the KPSS test for panel data has been realized by Hadri (2000). The panel LM

test statistic is defined as the mean of the individual test statistics under the null of level stationary:

∑=

=N

iiN

ML1

1ˆ ηµ

The null hypothesis of level or trend stationarity is tested against the alternative of unit root in panel.

Under the assumptions that E[ui,t] = E[εi,t] = 0, ui,t and εi,t are i.i.d across i and over t, the test statistic

has the following limiting distribution:

)1,0()ˆ(

NMLN

Z ⇒−

µµµ ζ

ξ

where ⇒ represents weak convergence in distribution, ξµ , ζµ are mean and variance of the standard

Brownian bridge ∫1

0

2 )( drrV . The computed numerical values of ξµ, ζµ are 1/6 and 1/45 for the level

case and 1/15 and 11/6300 for the trend case respectively. The major shortcoming of Hadri’s panel unit

root test is that, the test statistic does not remain valid under small N and moderate T.

7 Lag truncation is set to integer [4(T/100)1/4] to correct the estimate of the error variance.