The Relationship between Environmental Performance Index, Economic Growth and Public Health Expenditures: Panel Cointegration Approach

Document Type : Original Article


1 Assistance Professor of Health Economics, Faculty of Management and Human Science, Chabahar Maritime University, Chabahar, Iran

2 Assistance Professor of Economics, Faculty of Management and Human Science, Chabahar Maritime University, Chabahar, Iran


Introduction: Economic growth has a direct impact on public health expenditures; also, it
indirectly affects public health expenditures through the environment’s quality. Therefore,
this study aimed to investigate the relationship between environmental performance index,
economic growth, and public health expenditures in countries with high and very high
human development index.
Methods: The present descriptive-analytical and applied study was performed on 16 countries
with high and very high human development index. The time-series data required for the
years 2006-2018 were extracted from the World Bank and United Nations database and
environmental performance index extracted from the Yale University website. Im, Pesaran
and Shin (IPS), Levin, Lin, and Chu (LLC), Augmented Dickey–Fuller (ADF)– Fisher, and
Phillips-Perron (PP)–Fisher tests for stationary and Pedroni and Kao tests for cointegration
were used. The study model was estimated by the DOLS cointegration method in Eviews 10
Results: The mean environmental performance index for selected countries with very high
and high human development index was 79.04 and 64.71, respectively; also, the elasticity of
public health expenditures to gross national production, environmental performance index,
physician supply, and urbanization ratio were 0.96, -2.41, 0.441 and 0.448, respectively.
Conclusion: Increasing economic growth, urbanization ratio, and physician supply had
a positive effect, and improving environmental performance index had a negative effect
on public health expenditures. Therefore, to reduce public health expenditures, policies
are recommended to maintain environmental sustainability and reduce environmental
pollutants, and to invest in advanced equipment to purify pollutant gases. Maintaining and
increasing economic growth is also essential for adopting policies to increase physicians and
invest in health infrastructure.


1. Hao Y, Liu S, Lu ZN, Huang J, Zhao M. The impact of environmental pollution on public health expenditure: dynamic panel analysis based on Chinese provincial data. Environ Sci Pollut Res Int. 2018;25(19):18853-65. doi: 10.1007/s11356-018-2095-y.
2. Khan SAR, Zhang Y, Kumar A, Zavadskas E,Streimikiene D. Measuring the impact of renewableenergy, public health expenditure, logistics,and environmental performance on sustainableeconomic growth. Sustainable Development.2020;28(4):833-43. doi:10.1002/sd.2034.
3. El Morabet R. Effects of Outdoor Air Pollution on Human Health. In: Nriagu J, editor. Encyclopedia of Environmental Health (Second Edition). Oxford: Elsevier; 2019. p. 278-86. doi: 10.1016/ B978-0-12-409548-9.11509-X.
4. Badulescu D, Simut R, Badulescu A, Badulescu AV. The Relative Effects of Economic Growth, Environmental Pollution and Non Communicable Diseases on Health Expenditures in European Union Countries. Int J Environ Res Public Health. 2019;16(24). doi: 10.3390/ ijerph16245115.
5. Boachie MK, Mensah IO, Sobiesuo P, Immurana M, Iddrisu A-A, Kyei-Brobbey I. Determinants of public health expenditure in Ghana: a cointegration analysis. Journal of Behavioural Economics, Finance, Entrepreneurship, Accounting and Transport. 2014;2(2):35-40.
6. Raeissi P, Harati-Khalilabad T, Rezapour A, Hashemi SY, Mousavi A, Khodabakhshzadeh S. Effects of Air Pollution on Public and Private Health Expenditures in Iran: A Time Series Study (1972-2014). J Prev Med Public Health. 2018;51(3):140-7. doi: 10.3961/jpmph.17.153.
7. Zaidi S, Saidi K. Environmental pollution, health expenditure and economic growth in the Sub- Saharan Africa countries: Panel ARDL approach. Sustainable cities and society. 2018;41:833-40. doi: 10.1016/j.scs.2018.04.034.
8. Narayan PK, Narayan S. Does environmental quality influence health expenditures? Empirical evidence from a panel of selected OECD countries. Ecological economics. 2008;65(2):367- 74. doi: 10.1016/j.ecolecon.2007.07.005.
9. Blazquez-Fernandez C, Cantarero-Prieto D, Pascual-Saez M. On the nexus of air pollution and health expenditures: new empirical evidence. Gac Sanit. 2019;33(4):389-94. doi: 10.1016/j. gaceta.2018.01.006.
10. Khoshnevis Yazdi S, Khanalizadeh B. Air pollution, economic growth and health care expenditure. Economic research Ekonomska istraživanja. 2017;30(1):1181-90. doi: 10.1080/1331677X.2017.1314823
11. Nafngiyana U, Rahayu SP, editors. Generalized Method of Moment Application in Simultaneous Dynamic Panel Data Equations for Economic Growth, CO2 Emissions, and Health Expenditures Modelling. IOP Conference Series:
Materials Science and Engineering; 2019. doi: 10.1088/1757-899X/546/5/052045.
12. Yale Center for Environmental Law and Policy [Internet]. Environmental performance index. New Haven: Yale Center for Environmental Law and Policy. [cited 2020 March 22]. Available from:
13. The world bank [Internet]. World Bank Open Data. Washington: World Bank; c2020 Availablefrom:
14. Shahraki M, Ghaderi S. The Impact of Economic Growth and Environmental Quality on Health Expenditures in Iran; Aggregate in Autoregressive Distributed Lag Model. Health Research Journal. 2020;5(4):224-34. doi: 10.29252/hrjbaq.5.4.224.
15. Shahraki M, Ghaderi S. Investigating the Factors Affecting Hospital Expenditures of Iranian Urban Households: Emphasis on Maternal Education. Journal of Health Management & Informatics. 2020;7(2):76-83.
16. Shahraki M, Ghaderi S. The impact of children’s entry to labor market on health expenditures of urban household. Journal of Research and Health. 2019;9(5):428-36. doi: 10.29252/jrh.9.5.428.
17. Jebeli SSH, Hadian M, Souresrafil A. Studyof health resource and health outcomes: Organization of economic corporation and development panel data analysis. Journal of Education and Health Promotion. 2019;8:70.
18. Shahraki M, Ghaderi S. Effect of Health Resources on Health Status in Iran. Hakim. 2020;23(1):122-9. Persian.
19. Amiri A, Ventelou B. Granger causality between total expenditure on health and GDP in OECD: Evidence from the Toda Yamamoto approach. Economics Letters. 2012;116(3):541-4. doi: 10.1016/j.econlet.2012.04.040.
20. Linden M, Ray D. Life expectancy effects of public and private health expenditures in OECD countries 1970–2012: Panel time series approach. Economic Analysis and Policy. 2017;56:101-13. doi: 10.1016/j.eap.2017.06.005.
21. Lee S-D, Lee J, Jun C-H. Causality analysis for public and private expenditures on health using panel Granger-causality test. Industrial Engineering & Management Systems. 2015;14(1):104-10. doi: 10.7232/iems.2015.14.1.104.
22. Shahraki M, Ghaderi S. Investigating the causal relationship between public health expenditure and health status; Panel vector auto-regression model. Health Research Journal. 2019;4(4):220-6. doi: 10.29252/hrjbaq.4.4.220.
23. Bidirici M, Bohur E. Design and economic growth: Panel cointegration and causality analysis. Procedia-Social and Behavioral Sciences. 2015;210:193-202. doi: 10.1016/j. sbspro.2015.11.359. 
24. Stock JH, Watson MW. A simple estimator of cointegrating vectors in higher order integrated systems. Econometrica: Journal of the Econometric Society. 1993:783-820. doi: 10.2307/2951763.
25. Charfeddine L. The impact of energy consumption and economic development on ecological footprint and CO2 emissions: evidence from a Markov switching equilibrium correction model. Energy Economics. 2017;65:355-74. doi: 10.1016/j.eneco.2017.05.009.
26. Chojnicki X, Moullan Y. Is there a ‘pig cycle’ in the labour supply of doctors? How training and immigration policies respond to physician shortages. Soc Sci Med. 2018;200:227-37. doi: 10.1016/j.socscimed.2018.01.038.
27. Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030. Hum Resour Health. 2017;15(1):11. doi: 10.1186/s12960-017-0187-2.
28. Or Z, Wang J, Jamison D. International differences in the impact of doctors on health: a multilevel analysis of OECD countries. J Health Econ. 2005;24(3):531-60. doi: 10.1016/j. jhealeco.2004.09.003.
29. Liebert H, Mäder B. Marginal effects of physician coverage on infant and disease mortality. HEDG, c/o Department of Economics, University of York. 2016. doi: 10.1787/health_glance_ap-2016-6-en.