Progressivity and horizontal equity in health care finance and delivery: What about Africa?
Introduction
In recent years, international debates about foreign aid for development have expressed an increased concern for the health of the poor and for a reduction of inequalities in both health status and access to health care between developed and developing countries on the one hand, and inside developing countries themselves on the other hand [1], [2], [3]. There has been consequently a great deal of interest among economists, decision makers, as well as international organizations, about the relationships between health status of the population, social inequalities, income distribution and macroeconomic growth in developing countries [4], [5], [6]. It is obvious that poverty remains the most important cause of premature death, disease and disability. It is also obvious that, although the so-called law of inverse care can be found in developed countries [7], the most striking examples of its existence today are seen in the developing world: whereas poor people shoulder the greates burden of disease, they receive a smaller share of health care resources than do healthy and better-off people [8]. Finally, it is well-established that the efficiency of government systems – including national health-service systems – has gradually declined over the past decades in most African countries [9]. The need for a pro-poor health reform agenda in low income countries, especially in Africa, is therefore increasingly getting worldwide support [10], [11].
In parallel, new methodological tools have been developed to improve the measurement of equity in health [12], [13], [14]. Unfortunately, the application of these tools has remained focused on health care systems of developed countries. To date there has been very few empirical investigation of the equity characteristics in both health care finance and delivery in African countries [15]. Previous empirical research in African countries has ignored the now well established distinction in the health economics literature between vertical and horizontal equity [16], [17], [18].
Vertical equity in health care finance refers to the extent to which households of unequal ability to pay make appropriately dissimilar payments for health care, whereas horizontal equity in health care utilization concerns the extent to which, on average, persons in equal need of medical treatment receive similar health services regardless of their income and wealth (or of other non-health social and personal characteristics such as gender, race, age, etc.). A rigorous measurment of these two dimensions of equity is a prerequisite to inform the often controversial policy debates about the extent to which reforms aimed at increasing the efficiency of health care systems do not simultaneously increase inequities in access to health care [19], [20], [21].
The household survey “Projet Santé Urbaine (PSU)”, carried out in 1998–1999 in representative samples of the general population of four African capitals with the support of UNICEF and the French Ministry for International Cooperation, gave us the opportunity to investigate both vertical equity in health care finance and horizontal equity in health care delivery. By providing detailed data, which are often not available in African populations, about household consumption, health care seeking behaviors and health care expenditures of members of the household who sought for care, this survey has allowed us to apply the concentration curves and indices approach that has already been used in previous studies about equity in health in developed countries. Our paper also tries to incorporate recent developments in the public finance literature on tax progressivity and extends the scope of progressivity and horizontal equity measurements in health in a number of aspects. Firstly, we report our estimation of these equity indices with their asymptotic standard errors in order to better take into account sampling errors. Secondly, rather than simply comparing the aggregated summary indexes of progressivity and horizontal equity, we use a dominance criterion and perform statistical inferences to measure progressivity or horizontal equity not only at the level of different income ranges but also in the overall distributions. This allows to draw conclusions which go beyond a general summary measure of progressivity and inequity that may be sensitive to the sample structure. Such methodological developments may be specially informative in the context of African systems in which private out of pocket funding accounts for more than half of overall national health expenditures [22], and in which user fees for health services may very differently affect heath care utilization in some specific vulnerable groups of low socio-economic status than in the rest of the population [3], [10], [23].
The remainder of the paper is organized as follows. In Section 2, the methodology to measure progressivity and horizontal equity in both finance and delivery of health care is presented with the stochastic dominance research methodology used. Following, a description of data sources and variables is done in Section 3. The main empirical results are reported in Section 4. The last Section 5 contains some discussion of the limitations of our results and some perspectives for future research on these issues.
Section snippets
Measuring progressivity in financing and horizontal equity in utilization
The progressivity of a health care financing system refers to the extent to which payments for health care rise as a proportion of a person's income when his/her income rises. There are different ways to capture this progressivity, among which are the elasticity of payments with respect to pre-payment income (liability progression), and the elasticity of post-payments income with respect to pre-payment income (residual progression). Another approach, that we adopted in this study, is to
Data and variables specification
The calculation of the equity indices described above requires the availability and the measurement of appropriate information, including household income, the household expenditures for health, illness prevalence and utilization of health services.
Sample description
Table 2 presents detailed data about sample size in each income quintiles. Not surprisingly, size of households tended to decrease with increasing income (column 3 of Table 2). Table 2 also shows (column 4) that the proportion of individuals who declared an episode of illness (or a chronic disease) in the prior month was similar (circa 20.0%) in all four cities. Self-reported morbidity was similar across income quintiles in both Abidjan and Conakry while there was a trend for the two highest
Discussion
This paper has extended to reliable data from a large household survey in four West African capitals the approach based on concentration curves and indices to estimate the progressivity and horizontal inequity of health care financing and delivery systems that had been previously applied to developed countries [12], [13], [14]. To our knowledge, very few studies have adopted a similar approach in other parts of the African continent [41]. The research presented here represents a preliminary
Acknowledgments
The authors would like to thank the United Nation of Children Fund (UNICEF) and the French Ministry of International Cooperation who gave financial support for the household surveys undertaken in the four mentioned capitals. The authors greatly appreciate the comments and suggestions of Jean-Yves Duclos, and are also grateful to participants at two international conference on Poverty yield in 2002 (Oxford) and Equity in Health (Toronto). Comments from anonymous reviewers of Health Policy as
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