Have health insurance reforms in Tunisia attained their intended objectives?Journal articleKhaled 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?Journal articleMohammad 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.

Appraising financial protection in health: the case of TunisiaJournal articleMohammad Abu-Zaineh, Habiba Ben Romdhane, Bruno Ventelou, Jean-Paul Moatti et Arfa Chokri, International Journal of Health Care Finance and Economics, Volume 13, Issue 1, pp. 73-93, 2013

Despite the remarkable progress in expanding the coverage of social protection mechanisms in health, the Tunisian healthcare system is still largely funded through direct out-of-pocket payments. This paper seeks to assess financial protection in health in the particular policy and epidemiological transition of Tunisia using nationally representative survey data on healthcare expenditure, utilization and morbidity. The extent to which the healthcare system protects people against the financial repercussions of ill-health is assessed using the catastrophic and impoverishing payment approaches. The characteristics associated with the likelihood of vulnerability to catastrophic health expenditure (CHE) are examined using multivariate logistic regression technique. Results revealed that non-negligible proportions of the Tunisian population (ranging from 4.5 % at the conservative 40 % threshold of discretionary nonfood expenditure to 12 % at the 10 % threshold of total expenditure) incurred CHE. In terms of impoverishment, results showed that health expenditure can be held responsible for about 18 % of the rise in the poverty gap. These results appeared to be relatively higher when compared with those obtained for other countries with similar level of development. Nonetheless, although households belonging to richer quintiles reported more illness episodes and received more treatment than the poor households, the latter households were more likely to incur CHE at any threshold. Amongst the correlates of CHE, health insurance coverage was significantly related to CHE regardless of the threshold used. Some implications and policy recommendations, which might also be useful for other similar countries, are advanced to enhance the financial protection capacity of the Tunisian healthcare system.

Gender-Based Analysis of Public Health Sector Services: A Beneficiary-Based StudyMuhammed Abu ZeinahBookMohammad Abu-Zaineh, 2013, MIFTAH publication, 2013

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

Wealth, Health, and the Measurement of Multidimensional Inequality: Evidence from the Middle East and North AfricaBook chapterMohammad Abu-Zaineh et Ramses H. Abul Naga, In: Health and Inequality, Pedro Rosa Dias et Owen O’Donnell (Eds.), 2013-12, Volume 21, Number 21, pp. 421-439, Emerald Group Publishing Limited, 2013

Recent decades have witnessed a rising interest in the measurement of inequality from a multidimensional perspective. This literature has however remained largely theoretical. This chapter presents an empirical application of a recent methodology and in doing so offers practical insights on how multidimensional inequality can be measured over two attributes (wealth and health) in the developing country context. Following Abul Naga and Geoffard (2006), a methodological framework allowing the decomposition of multidimensional inequality into two univariate Atkinson–Kolm–Sen equality indices and a third term measuring the association between the attributes is implemented. The methodology is then illustrated using data from the World Health Surveys 2002–2003. Specifically, this study presents the first comparative analysis on multidimensional inequality for a set of Middle East and North African (MENA) countries. Results reveal that the multidimensional (in-)equality indices tend to mimic the (in-)equality ordering of the wealth distributions as the latter are always less equally distributed than health. An empirical conclusion that emerges is that reducing the correlation between the attributes may help to reduce overall welfare inequality, specifically when socioeconomic inequality in health is pro-poor. The finding that the correlation between attributes has a significant contribution in the quantification of inequality has important policy implications since it reveals that it is not only wealth and health inequalities per se that matter in the measurement of welfare inequality but also the associations between them.

Measuring and decomposing socioeconomic inequality in healthcare delivery: A microsimulation approach with application to the Palestinian conflict-affected fragile settingJournal articleMohammad Abu-Zaineh, Awad Mataria, Jean-Paul Moatti et Bruno Ventelou, Social Science & Medicine, Volume 72, Issue 2, pp. 133-141, 2011

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.

Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality.Journal articleLaurence Lupi-Pégurier, Isabelle Clerc-Urmes, Mohammad Abu-Zaineh, Alain Paraponaris et Bruno Ventelou, Health Policy, Volume 103, Issue 2-3, pp. 160-167, 2011

To examine the relations between density of dental practitioners (DDP) and socio-economic and demographic factors shown to affect access to dental care for the elderly.

Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon.Journal articleSylvie Boyer, Mohammad Abu-Zaineh, Jérôme Blanche, Sandrine Loubiere, Cécile-Renée Bonono, Jean-Paul Moatti et Bruno Ventelou, Health services research, Volume 46, Issue 6pt2, pp. 2029-2056, 2011

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

Individual and Structural Factors Associated With HIV Status Disclosure to Main Partner in Cameroon: ANRS 12-116 EVAL Survey, 2006-2007Journal articleMarie Suzan-Monti, Jérôme Blanche, Paule Bilé, Sinata Koulla-Shiro, Mohammad Abu-Zaineh, Fabienne Marcellin, Sylvie Boyer, Maria Patrizia Carrieri et Bruno Spire, JAIDS Journal of Acquired Immune Deficiency Syndromes, Volume 57, Issue Suppl. 1, pp. s22-s26, 2011

Encouraging HIV-positive people to disclose their serostatus to their main partner is considered as a key component of secondary prevention. The purpose of this study was to identify individual and structural factors associated with HIV serostatus disclosure to one's steady partner in Cameroon, a...

Assessing the causes of inequality in health care in PalestineBook chapterMohammad Abu-Zaineh et Awad Mataria, In: The Palestinian Economy: Theoretical and Practical Challenges, V. Gianni, M. Missaglia et F. Kattan (Eds.), 2010-01, Volume II, pp. 341-394, Pavia University Press, 2010