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Publications

Attainment of universal health coverage in the occupied Palestinian territory assessed by a general equilibrium approach: is informality an irreversible hurdle for universality?Journal articleMohammad Abu-Zaineh and Sameera Awawda, The Lancet, Volume 399, pp. S24, 2022

Background:
Achieving universal health coverage (UHC) has recently received attention in response to calls from international organisations to expand health coverage to hard-to-reach segments of the population (eg, informal workers, and unemployed and poor people). Despite the strong commitment to achieving UHC, its implementation continues to spark vigorous debate among policy makers, scholars, and the international health community. Much of the recent debate has focused on the macro-fiscal challenges that many developing countries face in implementing and sustaining UHC-oriented reforms, and there has also been debate in relation to challenges of the micro-behavioural sphere (at the level of the individual). Some of these challenges pertain to the structure of the labour market in developing countries, which is characterised by the large size of non-contributory segments of the population, mainly informal workers and unemployed individuals. This raises the important policy questions of the feasibility of expanding health coverage to the informal sector and the unemployed on a contributory basis.
Methods:
We assessed the feasibility of UHC using a dynamic general equilibrium approach while accounting for heterogeneity across households in terms of their employment and socioeconomic status. The model was calibrated using the Palestinian Expenditures and Consumption Survey (PECS, 2011), and the Social Accounting Matrix (SAM, 2011). We assessed alternative health insurance designs proposed to target the informal workers. Fiscal sustainability of the reforms was examined using the debt-to-GDP ratio and the microeconomic impact was assessed using the concept of consumption equivalent variation (CEV), defined as the amount of additional consumption a household would give up to move from the pre-insurance to the post-insurance level of welfare. A positive CEV value indicates that individuals are willing to pay for the health insurance. The higher the CEV value, the higher the gains of health insurance.
Findings:
A simultaneous expansion of UHC coverage of the population and health-care costs would enhance welfare for all households. However, such an expansion would reduce government expenditure that is allocated to other sectors; for example, it was estimated that the reduction would have been approximately 10% in 2020. To finance this UHC-driven debt, we examined the impact of a tax-financed UHC-oriented reform and a low-premium, low-coverage government-sponsored health insurance that targets informal workers. Although both policies would generate additional revenues to serve the UHC debt, government-sponsored health insurance targeting informal workers seems to be more feasible in terms of its impact on household welfare. That is, the informal workers would be better off under the government-sponsored health insurance scheme.
Interpretation:
In the absence of precise information on the ability to pay of informal workers, which in some cases might be comparable to that of formal workers, it is reasonable for the government to charge better-off informal workers rather than naively exempting them. The findings corroborate previous evidence suggesting that informal workers are willing to join health insurance schemes that charge them lower premiums for a slightly less generous benefit package than the health insurance schemes of formal workers. This health insurance might be deemed equitable in terms of the degree of financial protection that informal workers can obtain compared with the scenario in which they are left to bear high out-of-pocket health-care costs.

Vers une couverture sanitaire universelle au Sénégal : quelles sont les meilleures stratégies de financement ?Journal articleSameera Awawda, Mohammad Abu-Zaineh and Bruno Ventelou, Revue internationale des études du développement, Volume 247, Issue 3, pp. 37-60, 2021

Cette étude a pour objectif d’évaluer différents modes de financement de la couverture santé universelle au Sénégal. La méthode utilisée, la micro-simulation, permet d’examiner l’impact de différents scenarii sur les consommations des ménages ainsi que sur les dépenses publiques. Les résultats montrent que la généralisation d’une assurance-maladie à l’ensemble de la population, associée à une réduction des coûts directs des soins, augmenterait les consommations de soins des Sénégalais, améliorant donc leur accès aux services de santé. Néanmoins, une telle généralisation serait coûteuse pour les finances publiques. Pour limiter les coûts supportés par le gouvernement, l’augmentation du taux d’imposition sur la consommation et de la prime de contribution à l’assurance-maladie serait utile et permettrait de ramener les finances publiques à l’équilibre.

La couverture sanitaire universelle au SAHEL : Le cas du Mali et du TchadJournal articleSameera Awawda, Mohammad Abu-Zaineh and Bruno Ventelou, UnisSahel - Couverture Universelle en Santé au Sahel, 2021

Cette étude vise à évaluer la faisabilité et l’impact macro-économique de l’extension de la couverture sanitaire à l’ensemble de la population en vue de l’atteinte de la couverture universelle (CSU) au Mali et au Tchad. Nous utilisons une approche méthodologique par micro-simulation pour examiner l’impact d’un scénario de CSU sur les dépenses de santé des ménages ainsi que les recettes et les dépenses publiques. Etant donné les différents taux actuels de couverture de la population, les résultats montrent que l’atteinte de l'objectif coûterait aux gouvernements du Mali et du Tchad 17 182 et 44 415 millions de FCFA, respectivement. L’atteinte de la CSU pourrait augmenter l’accès aux soins des ménages, mais aussi le fardeau budgétaire du gouvernement ; il faudrait donc disposer de bonnes stratégies de financement public. L’étude évalue donc en parallèle les bénéfices à attendre d’une hausse de la prime d’assurance maladie.

Assessing the Health and Economic Impact of the COVID-19 Pandemic in PalestineReportMohammad Abu-Zaineh and Sameera Awawda, pp. 30, 2021
Who bears the burden of universal health coverage? An assessment of alternative financing policies using an overlapping-generations general equilibrium modelJournal articleMohammad Abu-Zaineh, Sameera Awawda and Bruno Ventelou, Health Policy and Planning, Volume 35, Issue 7, pp. 867-877, 2020

In their quest for universal health coverage (UHC), many developing countries use alternative financing strategies including general revenues to expand health coverage to the whole population. Unless a policy adjustment is undertaken, future generations may foot the bill of the UHC. This raises the important policy questions of who bears the burden of UHC and whether the UHC-fiscal stance is sustainable in the long term. These two questions are addressed using an overlapping generations model within a general equilibrium (OLG-CGE) framework applied to Palestine. We assess and compare alternative ways of financing the UHC-ridden deficit (viz. deferred-debt, current and phased-manner finance) and their implications on fiscal sustainability and intergenerational inequalities. The policy instruments examined include direct labour-income tax and indirect consumption taxes as well as health insurance contributions. Results show that in the absence of any policy adjustment, the implementation of UHC would explode the fiscal deficit and debt-GDP ratio. This indicates that the UHC-fiscal stance is rather unsustainable in the long term, thus, calling for a policy adjustment to service the UHC debt. Among the policies we examined, a current rather than deferred-debt finance through consumption taxation emerged to be preferred over other policies in terms of its implications for both fiscal sustainability and intergenerational inequality.

Vers une couverture sanitaire universelle au Sénégal : quelles sont les meilleures stratégies de financement ?Journal articleSameera Awawda, Mohammad Abu-Zaineh and Bruno Ventelou, UnisSahel - Couverture Universelle en Santé au Sahel, pp. 4, 2020

Cette étude a pour objectif d’évaluer différents modes de financement de la couverture santé universelle au Sénégal. La méthode utilisée, la micro-simulation, permet d’examiner l’impact de différents scenarii sur les consommations des ménages ainsi que sur les dépenses publiques. Les résultats montrent que la généralisation d’une assurance-maladie à l’ensemble de la population, associée à une réduction des coûts directs des soins, augmenterait les consommations de soins des Sénégalais, améliorant donc leur accès aux services de santé. Néanmoins, une telle généralisation serait coûteuse pour les finances publiques. Pour limiter les coûts supportés par le gouvernement, l’augmentation du taux d’imposition sur la consommation et de la prime de contribution à l’assurance-maladie serait utile et permettrait de ramener les finances publiques à l’équilibre.

The quest to expand the coverage of public health insurance in the occupied Palestinian territory: an assessment of feasibility and sustainability using a simulation modelling frameworkJournal articleSameera Awawda, Mohammad Abu-Zaineh and Bruno Ventelou, The Lancet, Volume 393, pp. S17, 2019

Background:
In their quest for universal health coverage (UHC), many developing countries explore alternative financing strategies to address the potential budgetary impact of health coverage expansion (for example, deferred debt versus current finance through taxation or premiums). Given the limited fiscal space, these policies may have different implications for fiscal sustainability and may worsen intergenerational inequality.

Methods:
We assessed the impact of UHC on fiscal sustainability and intergenerational inequality using an overlapping generations model within a general equilibrium framework, which we calibrate using data from the Palestinian Expenditures and Consumption Survey (PECS-2011) and the Social Accounting Matrix (SAM-2011). Fiscal sustainability is assessed using a prudent debt–GDP level of 39%. Intergenerational inequality induced by different policies is assessed by comparing the relative incremental burden (RIB) borne by each generation following the policy adjustment.

Findings:
In the absence of any policy adjustment, an ad hoc expansion of health coverage would increase the debt–GDP level to 15% above the prudent level. This indicates that the UHC fiscal stance may be financially unsustainable in the long run, therefore calling for a policy adjustment. Among the policies we examined, UHC finance through the increase of premiums (whether current or deferred) seems to be unsustainable and may further widen intergenerational inequality (RIB∈[3,6]). By contrast, current finance through indirect taxes helps to restore a prudent debt–GDP level and seems to be associated with a lower level of intergenerational inequality than deferred-debt finance through direct taxation (RIB of 1·25 and 5, respectively).

Interpretation:
Among the policy options assessed, the current indirect taxation emerged as the best policy option in terms of its impact on both fiscal sustainability and intergenerational inequalities. However, from a policy perspective, the capacity of governments to raise additional revenues might be constrained in the short-term. Under such circumstances, deferred-debt finance may be preferred—a situation in which policy makers may have to trade fiscal sustainability against intergenerational inequality.

Funding:
The A*MIDEX project (number ANR-11-IDEX-0001-02) funded by the French Government programme Investissements d'avenir, managed by the French National Research Agency (ANR).

Contributors:
SA prepared the data, conceived the framework for the study and carried out data analysis. MA-Z developed the framework for the study, carried out data analysis and wrote the Interpretation section. BV developed the framework for the study. All authors have seen and approved the final version of the Abstract for publication.