Tackling Inequalities in Health and Access to Health Care in African and Middle-Eastern Countries: Challenges of Measurement and Explanation – INEGSANTE

Our project has started with the establishment of a multidisciplinary network gathering researchers from both developing and developed countries. In accordance with the initail plan, an analytical overview of the state of arte on the measurement of health inequalities was performed. This helped to conceptualize the appropriate theoretical framework for our empirical analysis and to develop methodological tools. We opted for non-linear decomposition methods and microsimulation techniques. Two sources of databases were used: i) international sources including demographic and health surveys (DHS) managed by USAID and World Health Surveys (WHS) managed by the WHO, and ii) national surveys such as those on morbidity and healthcare utilization (eg., Tunisia, Morocco, Palestine – PAPFAM project managed by the Arab League). Contextualization of analysis and interpretation of results were facilitated by the active participation of researchers from the east meditteranean region. In addition, the impact on international debates were facilitated by the role of some of the involved researchers as experts for various international organizations (e.g., WHO).

The methodological developments allowed to examine health inequalities dynamically in the context of sub-Saharan Africa. Results showed that disregarding the population differential induced by different healthcare policies can bias programs’ ranking in favor of less live-saving policies. Our project has also explored a methodological framework that allowed the decomposition of multidimensional inequality into univariate Atkinson-Kolm-Sen equality indices and a term measuring the association between the attributes with appliction to five Middle-Eastern and North African countries.

With the project INEGNANTE approaching its end (in September 2014) and having achieved its goals, a new research project building on what has been learnt has been elaborated and accepted.

The project has resulted in seven artciles (of which five were published in highly-ranked peer-reviewed journals, one is accepted and another is submitted). The articles reported the methods and results produced by the teams involved in this projet on the measurement of dynamic health inequality in the context of in Sub-Saharan Africa; the multidimensional inequality in five countries in the Middle-East and North Africa, and equity in healthcare in the case of Tunisia and Palestine.

The 2009 landmark report from the WHO Commission on “social determinants of health” has reemphasized the universally observed inequalities in morbidity and premature mortality to the detriment of socio-economic groups at the lowest level of the social gradient. In developing countries, following the so-called 1987 “Bamako Initiative” introducing cost-recovery policies and user-fees at the point of delivery of public health care, the equity debate has been rather focused on the social distribution of both health care financing and access to health care. Recent research, including that carried out in Palestine and in four African capitals by some of the teams participating in this project (INSERM/IRD/University Aix-Marseille II UMR SE4S and GREQAM/IDEP), has however shown that aggregate summary measures of vertical and horizontal inequality (such as concentration indices derived from the general class of Gini-type and rank-based measures), which have been widely used in the health economics literature dealing with developed countries, may not be fully appropriate in the context of developing countries where out-of-pocket payments at the point of health care consumption represent a greater share of total expenditures (often >50% in low-income countries).

The INEGSANTE research project is directly related to themes 4 (Catastrophe, risks, vulnerabilities) and 1 (Demographic dynamics and future of societies in developing countries) of the call for proposals “les Suds Aujourd’hui II”. It proposes to improve the scientific debate about equity in health care expenditures and in access to health care in developing countries in three related ways:

-To transfer to this field recent methodological advances in the measurement of inequality from the tax and public economics literature (notably using new non-linear estimation methods of decomposition and microsimulation techniques that are more appropriate for disentangling the respective roles of individual behaviours and preferences and of characteristics of health care delivery systems and financing schemes in the analysis of equity).
-To re-examine the relationship between income and health care inequalities (notably with an attempt to operationalise in this field Sen’s concepts of “adaptive preferences and capability deprivation” and through measuring ex post re-ranking effects of health care expenditures on income distribution ).
-To perform econometric analysis applying, for the first time, these approaches to national household surveys including detailed data on health care expenditures and consumption in a large sample of 12 African and Middle-Eastern low-income (Burkina-Faso, Senegal, Zambia), lower middle-income (Cameroon, Côte d’Ivoire, Egypt, Jordan, Morocco, Palestine, Tunisia) and upper middle-income (Lebanon, South Africa) countries.

Contextualization of analysis and interpretation of data will be facilitated by the active participation of researchers from the EMRO region of the WHO and from the Universities of Birzeit, Cape Town and Tunis). In addition to scientific valorisation of the results, impact on international debates and on policy-makers will be facilitated by the role of some of the involved researchers as experts for various international organizations (World Bank, ILO, Global Fund, WHO, etc.).