Abu-Zaineh

Publications

The importance of health for income inequality in the occupied Palestinian territory: a decomposition analysis and cross-sectional studyMohammad Abu-Zaineh, Maame Esi Woode et Mârwan-al-Qays Bousmah, The Lancet, Volume 391, Issue Supplement 1, pp. S23, 2018

Background:
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.

Methods:
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.

Findings:
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.

Interpretation:
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.

Youth wellbeing through the lens of the Senian capability approach: insights from the occupied Palestinian territory: a cross-sectional studyMohammad Abu-Zaineh, Maame Esi Woode et Rita Giacaman, The Lancet, Volume 391, Issue Supplement 2, pp. S53, 2018

Background:
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.

Methods:
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.

Findings:
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).

Interpretation:
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.

Funding:
Investissements d’Avenir French Government programme, managed by the French National Research Agency (ANR).

Investigating the Dimensions of Youth Wellbeing: An Exploratory Structural Equation Modelling Approach Applied to PalestineMohammad Abu-Zaineh et Maame Esi Woode, Child Indicators Research, Volume 11, Issue 1, pp. 57-78, 2018

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.

Can a Circular Payment Card Format Effectively Elicit Preferences? Evidence From a Survey on a Mandatory Health Insurance Scheme in TunisiaOlivier Chanel, Khaled Makhloufi et Mohammad Abu-Zaineh, Applied Health Economics and Health Policy, Volume 15, Issue 3, pp. 385-398, 2017

Background:
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.

Methods:
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.

Conclusion:
Overall, our results are encouraging and suggest CPC could be an effective alternative format to elicit ‘true’ WTP.

How do supply-side factors influence informal payments for healthcare? The case of HIV patients in CameroonHyacinthe T. Kankeu, Sylvie Boyer, Raoul A. Fodjo Toukam et Mohammad Abu-Zaineh, International Journal of Health Planning and Management, Volume 31, Issue 1, pp. 41-57, 2016

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.

Potential market size and impact of hepatitis C treatment in low- and middle-income countriesMaame Esi Woode, Mohammad Abu-Zaineh, J. Perriens, F. Renaud, S. Wiktor et Jean-Paul Moatti, Journal of Viral Hepatitis, Volume 23, Issue 7, pp. 522-534, 2016

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.

Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA regionMârwan-al-Qays Bousmah, Bruno Ventelou et Mohammad Abu-Zaineh, Health Policy, Volume 120, Issue 8, pp. 928-935, 2016

Evidence suggests that the effect of health expenditure on health outcomes is highly context-specific and may be driven by other factors. We construct a panel dataset of 18 countries from the Middle East and North Africa region for the period 1995–2012. Panel data models are used to estimate the macro-level determinants of health outcomes. The core finding of the paper is that increasing health expenditure leads to health outcomes improvements only to the extent that the quality of institutions within a country is sufficiently high. The sensitivity of the results is assessed using various measures of health outcomes as well as institutional variables. Overall, it appears that increasing health care expenditure in the MENA region is a necessary but not sufficient condition for health outcomes improvements.

To Count or Not to Count Deaths: Reranking Effects in Health Distribution EvaluationYves Arrighi, Mohammad Abu-Zaineh et Bruno Ventelou, Health Economics, Volume 24, Issue 2, pp. 193-205, 2015

Populations' structures and sizes can be a result of healthcare policy decisions. We use a two‐period theoretical framework and a dynamic microsimulation model to examine the consequences of this assertion on the appraisal of alternative health policy options. Results show that standard welfare‐in‐health measures are sensitive to changes in populations' sizes, in that taking into account the (virtual) existence of the dead can alter the ranking of policy options. Disregarding differences in the survivals induced by alternative policies can bias programmes' ranking in favour of less live‐saving policies. The paper alerts on the risk of policy misranking by the use of ex‐post cross‐sectional analyses, neglecting deaths occurring in the past as well as counterfactual deaths in alternative policy scenarios. Copyright © 2013 John Wiley & Sons, Ltd.

Have health insurance reforms in Tunisia attained their intended objectives?Khaled Makhloufi, Bruno Ventelou et Mohammad Abu-Zaineh, International Journal of Health Economics and Management, Volume 15, Issue 1, pp. 29-51, 2015

A growing number of developing countries are currently promoting health system reforms with the aim of attaining ‘ universal health coverage’ (UHC). In Tunisia, several reforms have been undertaken over the last two decades to attain UHC with the goals of ensuring financial protection in health and enhancing access to healthcare. The first of these goals has recently been addressed in a companion paper by Abu-Zaineh et al. (Int J Health Care Financ Econ 13(1):73–93, 2013). The present paper seeks to assess whether these reforms have in fact enhanced access to healthcare. The average treatment effects of two insurance schemes, formal-mandatory (MHI) and state-subsidized (MAS) insurance, on the utilization of outpatient and inpatient healthcare are estimated using propensity score matching. Results support the hypothesis that both schemes (MHI and MAS) increase the utilization of healthcare. However, significant variations in the average effect of these schemes are observed across services and areas. For all the matching methods used and compared with those the excluded from cover, the increase in outpatient and inpatient services for the MHI enrollees was at least 19 and 26 %, respectively, in urban areas, while for MAS beneficiaries this increase was even more pronounced (28 and 75 % in the urban areas compared with 27 and 46 % in the rural areas for outpatient and inpatient services, respectively). One important conclusion that emerges is that the current health insurance schemes, despite improving accessibility to healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for all services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”. Copyright Springer Science+Business Media New York 2015

Fairness in healthcare finance and delivery: what about Tunisia?Mohammad Abu-Zaineh, Chokri Arfa, Bruno Ventelou, Habiba Ben Romdhane et Jean-Paul Moatti, Health Policy and Planning, Volume 29, Issue 4, pp. 433-442, 2014

Anecdotal evidence on hidden inequity in health care in North African countries abounds. Yet firm empirical evidence has been harder to come by. This article fills the gap. It presents the first analysis of equity in the healthcare system using the particular case of Tunisia. Analyses are based on an unusually rich source of data taken from the Tunisian HealthCare Utilization and Morbidity Survey. Payments for health care are derived from the total amount of healthcare spending which was incurred by households over the last year. Utilization of health care is measured by the number of physical units of two types of services: outpatient and inpatient. The measurement of need for health care is apprehended through a rich set of ill-health indicators and demographics. Findings are presented and compared at both the aggregate level, using the general summary index approach, and the disaggregate level, using the distribution-free stochastic dominance approach. The overall picture is that direct out-of-pocket payments, which constitute a sizeable share in the current financing mix, emerge to be a progressive means of financing health care overall. Interestingly, however, when statistical testing is applied at the disaggregate level progressivity is retained over the top half of the distribution. Further analyses of the distributions of need for—and utilization of—two types of health care—outpatient and inpatient—reveal that the observed progressivity is rather an outcome of the heavy use, but not need, for health care at the higher income levels. Several policy relevant factors are discussed, and some recommendations are advanced for future reforms of the health care in Tunisia.

Health differentials between citizens and immigrants in Europe: A heterogeneous convergenceMârwan-al-Qays Bousmah, Jean-Baptiste Simon Combes et Mohammad Abu-Zaineh, Health Policy, Forthcoming

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.