Estimating willingness to pay for public health insurance while accounting for protest responses: A further step towards universal health coverage in Tunisia?

INTRODUCTION: Developing countries face major challenges in implementing universal health coverage (UHC): a widespread informal sector, general discontent with rising economic insecurity and inequality and the rollback of state and public welfare. Under such conditions, estimating the demand for a health insurance scheme (HIS) on voluntary basis can be of interest to accelerate the progress of UHC-oriented reforms. However, a major challenge that needs to be addressed in such context is related to protest attitudes that may reflect, inter alia, a null valuation of the expected utility or unexpressed demand. METHODS: We propose to tackle this by applying a contingent valuation survey to a non-healthcare-covered Tunisian sample vis-à-vis joining and paying for a formal HIS. Our design pays particular attention to identifying the nature of the willingness-to-pay (WTP) values obtained, distinguishing genuine null values from protest values. To correct for potential selection issues arising from protest answers, we estimate an ordered-Probit-selection model and compare it with the standard Tobit and Heckman sample selection models. RESULTS: Our results support the presence of self-selection and, by predicting protesters' WTP, allow the "true" sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP. CONCLUSION: The WTP of the poorest non-covered respondents represents about one and a half times the current contributions of the poorest formal sector enrolees, suggesting that voluntary participation in the formal HIS is feasible.

Public-private differentials in health care delivery: the case of cesarean deliveries in Algeria.

Akin to other developing countries, Algeria has witnessed an increasing role of the private health sector in the past two decades. Our study sheds light on the public-private overlap and the phenomenon of physician dual practice in the provision of health care services using the particular case of cesarean deliveries in Algeria. Existing studies have reported that, compared to the public sector, delivering in a private health facility increases the risk of enduring a cesarean section. While confirming this result for the case of Algeria, our study also reveals the existence of public-private differentials in the effect of medical variables on the probability of cesarean delivery. After controlling for selection in both sectors, we show that cesarean deliveries in the private sector tend to be less medically justified compared with those taking place in the public sector, thus, potentially leading to maternal and neonatal health problems. As elsewhere, the contribution of the private health sector to the unmet need for health care in Algeria hinges on an appropriate legal framework that better coordinates the activities of the two sectors and reinforces their complementarity.

Who bears the burden of universal health coverage? An assessment of alternative financing policies using an overlapping-generations general equilibrium model.

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.

Health differentials between citizens and immigrants in Europe: A heterogeneous convergence.

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.

Youth wellbeing through the lens of the Senian capability approach: insights from the occupied Palestinian territory: a cross-sectional study.

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).

Can a Circular Payment Card Format Effectively Elicit Preferences? Evidence From a Survey on a Mandatory Health Insurance Scheme in Tunisia.

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.

Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region.

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.

How do supply-side factors influence informal payments for healthcare? The case of HIV patients in Cameroon.

Direct out-of-pocket payments for healthcare continue to be a major source of health financing in low-income and middle-income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed healthcare 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-effect 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 the following: (i) human resource 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 healthcare facilities is found to play a role: informal payments appear to be significantly lower in private non-profit facilities compared with those belonging to public sector. Our findings allude to some policy recommendations that can help reduce the incidence of informal payments.

To count or not to count deaths: reranking effects in health distribution evaluation.

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.

Have health insurance reforms in Tunisia attained their intended objectives?

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".

Fairness in healthcare finance and delivery: what about Tunisia?

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 Tunisia.

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.

Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon.

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 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics. PRINCIPAL FINDINGS: Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE. CONCLUSION: The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.

Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality.

OBJECTIVES: 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. METHODS: Data are taken from a cross-sectional survey - 2008 Disability Healthcare - Household section Survey (HSM). HSM is a representative random sample of French people living in their own domiciles. Our study focuses on the 9233 individuals aged 60 years and above. Multilevel models are employed to disentangle the relations between the determinants of dental care utilisation and DDP. Statistical analyses are conducted using SAS 9.2 and HLM 6. RESULTS: Low-income and lack of complementary health insurance are associated with higher odds of not having visited a dentist, revealing a high unequal access to dental care. By using multilevel modelling, DDP appears to be a significant factor to access to dental services. When considering the intricate relations between income gradient and DDP, the latter lessens the income-related inequality to access dental services. CONCLUSION: DDP seems favouring a more equitable access to dental care, mitigating under-caring of the poorest. This point is to be added in the debate about density of healthcare suppliers.

Individual and structural factors associated with HIV status disclosure to main partner in Cameroon: ANRS 12-116 EVAL survey, 2006-2007.

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 country which has implemented a large program for access to antiretroviral therapy. We used data from the cross-sectional, nationally representative survey, ANRS 12-116 EVAL (Evaluation du programme camerounais d'accès aux traitements antirétroviraux--Impact sur la prise en charge et les conditions de vie de la population infectée par le VIH), conducted between 2006 and 2007 among HIV-infected outpatients attending health care facilities. Among the 1673 HIV-positive individuals reporting a steady partner at the time of the survey (61% women), 85.4% (n = 1429) had disclosed their serostatus to them; 77% of the respondents were receiving antiretroviral therapy. Multivariate analysis based on multilevel modeling approaches showed that the following individual factors were associated with disclosure: living with one's steady partner, living with children, reporting systematic condom use or sexual abstinence with one's steady partner, being a woman who is not the head of the household, and finally having HIV-infected people among friends or relatives and not living below the poverty line. Structural factors associated with disclosure were as follows: attending national health facilities in the country's capital cities Yaoundé or Douala and having access to psychosocial or economical support interventions. These results strengthen the argument for the introduction or development of psychosocial interventions at all levels of organization in Cameroonian hospitals as an important component of public health policies for those living with HIV.

Measuring and decomposing socioeconomic inequality in healthcare delivery: A microsimulation approach with application to the Palestinian conflict-affected fragile setting.

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.

Catastrophic healthcare payments and impoverishment in the occupied Palestinian territory.

BACKGROUND: Financial protection from the risks of ill health has globally recognized importance as a principal performance goal of any health system. This type of financial protection involves minimizing catastrophic payments for healthcare and their associated impoverishing effects. Realization of this performance goal is heavily influenced by factors related to the overall policy environment and sociopolitical context in each country. OBJECTIVES: To examine the incidence and intensity of catastrophic and impoverishing healthcare payments borne by Palestinian households between 1998 and 2007. The incidence and intensity of these effects are examined within the historically unique policy and socioeconomic context of the occupied Palestinian territory. METHODS: A healthcare payment was considered catastrophic if it exceeded 10% of household resources, or 40% of resources net of food expenditures. The impoverishing effect of healthcare was examined by comparing poverty incidence and intensity before and after healthcare payments. The data source was a series of annual expenditure and consumption surveys covering 1998 and 2004-7, and including representative samples of Palestinian households (n = 1231-3098, per year). Total household expenditure was used as a proxy for household level of resources; and the sum of household expenses on a comprehensive list of medical goods and services was used to estimate healthcare payments. RESULTS: While only around 1% of the surveyed households spent ≥40% of their total household expenditures (net of food expenses) on healthcare in 1998, the percentage was almost doubled in 2007. In terms of impoverishing effect, while 11.8% of surveyed households fell into deep poverty in 1998 due to healthcare payments, 12.5% of households entered deep poverty for the same reason in 2006. Over the same period, the monthly amount by which poor households failed to reach the deep poverty line due to healthcare payments increased from $US9.4 to $US12.9. CONCLUSIONS: The inability of the Palestinian healthcare system to protect against the financial risks of ill health could be attributed to the prevailing sociopolitical conditions of the occupied Palestinian territory, and to some intrinsic system characteristics. It is recommended that pro-poor financing schemes be pursued to mitigate the negative impact of the recurrent health shocks affecting Palestinian households.

Equity in health care finance in Palestine: the triple effects revealed.

This paper presents an application of the Urban and Lambert "upgraded-AJL Decomposition" approach that was designed to deal with the problem of close-income equals in equity analysis, and as applied to the area of health care finance. Contrary to most previous studies, vertical and horizontal inequities and the triple effects of inter-groups, intra-group and entire-group reranking of various financing schemes are estimated, with statistical significance calculated using the bootstrap method. Application is made on the three financing schemes present in the case of the Occupied Palestinian Territory. Results demonstrate the relative importance of the three forms of reranking in determining overall inequality. The paper offers policy recommendations to limit the existing inequalities in the system and to enhance the capacity of the governmental insurance scheme.

Equity in health care financing in Palestine: the value-added of the disaggregate approach.

This paper analyzes the redistributive effect and progressivity associated with the current health care financing schemes in the Occupied Palestinian Territory, using data from the first Palestinian Household Health Expenditure Survey conducted in 2004. The paper goes beyond the commonly used "aggregate summary index approach" to apply a more detailed "disaggregate approach". Such an approach is borrowed from the general economic literature on taxation, and examines redistributive and vertical effects over specific parts of the income distribution, using the dominance criterion. In addition, the paper employs a bootstrap method to test for the statistical significance of the inequality measures. While both the aggregate and disaggregate approaches confirm the pro-rich and regressive character of out-of-pocket payments, the aggregate approach does not ascertain the potential progressive feature of any of the available insurance schemes. The disaggregate approach, however, significantly reveals a progressive aspect, for over half of the population, of the government health insurance scheme, and demonstrates that the regressivity of the out-of-pocket payments is most pronounced among the worst-off classes of the population. Recommendations are advanced to improve the performance of the government insurance schemes to enhance its capacity in limiting inequalities in health care financing in the Occupied Palestinian Territory.