AMU - AMSE
5-9 Boulevard Maurice Bourdet, CS 50498
13205 Marseille Cedex 1
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.
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.
The literature on immigration and health has provided mixed evidence on the health differentials between immigrants and citizens, while a growing body of evidence alludes to the unhealthy assimilation of immigrants. Relying on five different health measures, the present paper investigates the heterogeneity in health patterns between immigrants and citizens, and also between immigrants depending on their country of origin. We use panel data on more than 100,000 older adults living in nineteen European countries. Our panel data methodology allows for unobserved heterogeneity. We document the existence of a healthy immigrant effect, of an unhealthy convergence, and of a reversal of the health differentials between citizens and immigrants over time. We are able to estimate the time threshold after which immigrants’ health becomes worse than that of citizens. We further document some heterogeneity in the convergence of health differentials between immigrants and citizens in Europe. Namely, the unhealthy convergence is more pronounced in terms of chronic conditions for immigrants from low-HDI countries, and in terms of self-assessed health and body-mass index for immigrants from medium- and high-HDI countries.
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.
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.
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).
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.
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).
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.
The contribution of income inequality to health inequality has been widely examined in developed countries. However, little evidence exists on the effect of health on income inequality in resource-constrained settings. Findings from previous studies have indicated several mechanisms through which health affects income inequality, with the labour market being an important channel. Given the different levels of development, there are reasons to believe that health might represent a greater constraint on earnings in low-income settings. The aim of this study was to examine the relation between income and health in the West Bank and Gaza Strip.
Data were extracted from the 2004 Household Health Expenditure Survey, which covered 4014 households. We applied a Shapley value approach to assess the contribution of health to income inequality. The analysis involved estimating and decomposing the relative Gini index. The contribution of each variable to income inequality was then computed as the average marginal effect, holding all other covariates at the mean.
Results indicated clear age-specific health-income gradients. This is particularly apparent in the working-age population. Results also indicated that chronically ill people live in households witht low income. The regression analyses showed a negative effect of the proportion of adults in the household with chronic illness on income. The lack of education and employment appear to have the highest negative effect on income. The decomposition analyses revealed that ill health contributes to income inequality, whereas such an effect is reduced when we controlled for employment status.
Our results suggested the presence of a ubiquitous relation between health and income. The contribution of health to income inequality depends on how it is distributed. Evidence supports a significant effect of ill health on income, which mainly operates through employment. Additionally, variation in exposure to health risks is a potentially important mechanism through which health might generate income inequality.
Interest in the Senian capability framework as an alternative approach to wellbeing measurement has increased in recent decades. The aim of this study was to look at the extent to which an individual's capability to achieve wellbeing in one dimension is associated with his or her attempt to achieve wellbeing in another dimension in a fragile setting affected by conflict.
Capability is defined as the ability to achieve health, knowledge, and wealth and is measured as latent variables using a structural equation model. Health capability is identified by self-assessed health, mental health, lifestyle, and knowledge of sexually transmitted diseases. Knowledge capability is captured using school attendance, completion of compulsory education, and media access. Wealth capability is identified using indicators on utilities, asset ownership, and housing conditions. Estimation results are used to derive normalised capability scores with values close to 1 indicating high capabilities. A nationally representative sample of 4329 youth aged 15–29 years was drawn from the 2010 Palestinian Family Survey.
Interpretations are made in terms of standardised units, which measure the change in the explained variable due to a standard deviation's change in the explanatory variable. Achieving good health is associated with knowledge capability (0·125; p=0·098) and vice versa (0·462; p=0·004). Health capability is positively associated with wealth capability (0·109; p=0·021); however, the reverse is not the case (–0·753; p=0·021). Men are more likely than women to have higher health knowledge and living conditions capabilities but lower knowledge capabilities. Results suggest the importance of some exogenous factors in the conversion of capabilities into achievements (eg, location of residence). With the exception of health, the data show higher capabilities in Areas A and B of the West Bank than in Area C and the Gaza Strip (mean 0·71 and 0·69 vs 0·60 and 0·61 vs 0·57 and 0·68 for wealth and knowledge, respectively).
Although achieving good health appears to entail knowledge capabilities, the wealth-health association is blurred by the effect of exogenous factors (eg, health-care access). Capability deprivation in the local context seems to derive from geographical barriers, as is captured by the contribution of location of residence. This reflects the effect of geopolitical segregation that restricts the movement of people.
Investissements d’Avenir French Government programme, managed by the French National Research Agency (ANR).
This paper illustrates the “Sen-Nussbaum-type” capability approach to the measurement of youth wellbeing using the newly developed Exploratory Structural Equation Modelling (ESEM). It offers insights into how the capability to achieve wellbeing can be measured in a conflict-affected and resource-constrained setting. The methodology is applied to nationally representative data taken from the Palestinian Family Survey. The population of interest is youth aged 15 to 29. Three capability dimensions are identified: health awareness, knowledge and living conditions. Results show an interrelation between capability dimensions. It is especially important to note the effect of knowledge capabilities on both health awareness and living conditions indicators. Results also confirm the importance of some (exogenous) factors such as the education of the household head in the conversion of capabilities into achievements. Capabilities are shown to be highest in the West Bank for both knowledge and living conditions compared to the Gaza Strip.
The choice of elicitation format is a crucial but tricky aspect of stated preferences surveys. It affects not only the quantity and quality of the information collected on respondents’ willingness to pay (WTP) but also the potential errors/biases that prevent their true WTP from being observed. Objectives We propose a new elicitation mechanism, the circular payment card (CPC), and show that it helps overcome the drawbacks of the standard payment card (PC) format. It uses a visual pie chart representation without start or end points: respondents spin the circular card in any direction until they find the section that best matches their true WTP.
We performed a contingent valuation survey regarding a mandatory health insurance scheme in Tunisia, a middle-income country. Respondents were randomly allocated into one of three subgroups and their WTP was elicited using one of three formats: open-ended (OE), standard PC and the new CPC. We compared the elicited WTP. Results We found significant differences in unconditional and conditional analyses. Our empirical results consistently indicated that the OE and standard PC formats led to significantly lower WTP than the CPC format.
Overall, our results are encouraging and suggest CPC could be an effective alternative format to elicit ‘true’ WTP.
Direct out-of-pocket payments for health care continue to be a major source of health financing in low- and middle-income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed health care services. Remarkably, however, little is known about the extent to which these payments are exercised and their determinants in the context of Sub-Saharan Africa. This study attempts therefore to shed light on the role of supply-side factors in the occurrence of informal payments while accounting for the demand-side factors. The study relies on data taken from a nationally representative survey conducted among people living with HIV/AIDS in Cameroon. A multilevel mixed-effects logistic model is employed to identify the factors associated with the incidence of informal payments. Results reveal that circa 3.05% of the surveyed patients incurred informal payments for the consultations made on the day of the survey. The amount paid informally represents up to four times the official tariff. Factors related to: (i) human resources management of the health facilities (e.g., task shifting); (ii) health professionals’ perceptions vis-à-vis the remunerations of HIV-care provision and (iii) reception of patients (e.g., waiting time) significantly influence the probability of incurring informal payments. Also of note, the type of health care facilities is found to play a role: informal payments appear to be significantly lower in private non-profit facilities compared to those belonging to public sector. Our findings allude to some policy recommendations than can help reduce the incidence of informal payments.
The introduction of direct-acting antiviral agents (DAAs) has made hepatitis C infection curable in the vast majority of cases and the elimination of the infection possible. Although initially too costly for large-scale use, recent reductions in DAA prices in some low-and middle-income countries (LaMICs) has improved the prospect of many people having access to these drugs/medications in the future. This article assesses the pricing and financing conditions under which the uptake of DAAs can increase to the point where the elimination of the disease in LaMICs is feasible. A Markov simulation model is used to study the dynamics of the infection with the introduction of treatment over a 10-year period. The impact on HCV-related mortality and HCV incidence is assessed under different financing scenarios assuming that the cost of the drugs is completely paid for out-of-pocket or reduced through either subsidy or drug price decreases. It is also assessed under different diagnostic and service delivery capacity scenarios separately for low-income (LIC), lower-middle-income (LMIC) and upper-middle-income countries (UMIC). Monte Carlo simulations are used for sensitivity analyses. At a price of US$ 1680 per 12-week treatment duration (based on negotiated Egyptian prices for an all oral two-DAA regimen), most of the people infected in LICs and LMICs would have limited access to treatment without subsidy or significant drug price decreases. However, people in UMICs would be able to access it even in the absence of a subsidy. For HCV treatment to have a significant impact on mortality and incidence, a significant scaling-up of diagnostic and service delivery capacity for HCV infection is needed.