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.

Sponsored by the United Nations Entity for Gender Equality and the Empowerment
of Women &
published by MIFTAH
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Initiative for the promotion of Global Dialogue and Democracy, Ramallah,
Palestine.

Socioeconomic-related inequalities in healthcare delivery have been extensively studied in developed countries, using standard linear models of decomposition. This paper seeks to assess equity in healthcare delivery in the particular context of the occupied Palestinian territory: the West Bank and the Gaza Strip, using a new method of decomposition based on microsimulations. Besides avoiding the 'unavoidable price' of linearity restriction that is imposed by the standard methods of decomposition, the microsimulation-based decomposition enables to circumvent the potentially contentious role of heterogeneity in behaviours and to better disentangle the various sources driving inequality in healthcare utilisation. Results suggest that the worse-off do have a disproportinately greater need for all levels of care. However with the exception of primary-level, utilisation of all levels of care appears to be significantly higher for the better-off. The microsimulation method has made it possible to identify the contributions of factors driving such pro-rich patterns. While much of the inequality in utilisation appears to be caused by the prevailing socioeconomic inequalities, detailed analysis attributes a non-trivial part (circa 30% of inequalities) to heterogeneity in healthcare-seeking behaviours across socioeconomic groups of the population. Several policy recommendations for improving equity in healthcare delivery in the occupied Palestinian territory are proposed.

OBJECTIVE: Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS