Hostname: page-component-cb9f654ff-plnhv Total loading time: 0.001 Render date: 2025-08-01T18:04:05.528Z Has data issue: false hasContentIssue false
  • English
  • Français

Income and the use of health care: an empirical study of Egypt and Lebanon

Published online by Cambridge University Press:  01 October 2009

HEBA ELGAZZAR
HEBA ELGAZZAR*
Affiliation:
Personal Social Services Research Unit, The London School of Economics and Political Science, UK
*
*Correspondence to: Email: h.a.elgazzar@lse.ac.uk
Get access Rights & Permissions [Opens in a new window]

Abstract

In middle-income Arab countries such as Egypt and Lebanon, income-associated equity in health care remains an elusive policy objective in part due to a relatively high reliance on out-of-pocket payments in financing care. This article examines the effect of income on the use of outpatient and inpatient health care services in Egypt and Lebanon using econometric analysis of cross-sectional data from the World Health Organization. In light of noticeable differences in income and public financing arrangements, these two countries serve as interesting case studies. Multivariate regression results suggest that Egyptian respondents were more likely to use health services than their Lebanese counterparts, holding all else constant, and that this effect was particularly evident for outpatient care. A higher income and insurance increased the likelihood of outpatient use more so than inpatient use, with these effects more pronounced in Lebanon. Overall, lower-income groups tended to report having worse health levels and paying more out-of-pocket on health care as a share of income than did higher-income groups. At the same time, these socioeconomic disparities in health appeared to be greater in Lebanon than in Egypt. Economic barriers to the use of health services are discussed within the context of health financing policy reforms aimed at improving equity in access to care in countries such as Egypt and Lebanon.

Information

Type
Articles
Information
Health Economics, Policy and Law , Volume 4 , Issue 4 , October 2009 , pp. 445 - 478
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Abd El Fattah, H., Saleh, I.Ezzat, E.et al. (1997), ‘The health insurance organization of Egypt: an analytical review and strategy for reform’, Technical report no. 43, Partnerships for Health Reform Project, Abt Associates Inc., Bethesda, MD.Google Scholar
Adeyi, O., Smith, O. and Robles, S. (2007), ‘Public policy and the challenge of chronic noncommunicable diseases’, Human Development Network, The World Bank, Washington, DC.CrossRefGoogle Scholar
Adib, S.M. (2004), ‘From the biomedical model to the Islamic alternative: a brief overview of medical practices in the contemporary Arab world’, Social Science and Medicine, 58: 697–702.CrossRefGoogle Scholar
Akala, A.F. and El-Saharty, F. (2006), ‘Public health challenges in the Middle East and North Africa’, The Lancet, 367: 961–964.CrossRefGoogle ScholarPubMed
Amemiya, T. (1985), Advanced Econometrics, Oxford: Basil Blackwell, pp. 267–359.Google Scholar
Ammar, W. (2003), ‘Health system and reform in Lebanon’, Regional Office for the Eastern Mediterranean, World Health Organization, Cairo and Entreprise Universitaire d'Etudes et de Publications, Beirut.Google Scholar
Anderson, R. (1975), ‘Introduction’, in Anderson, R. and Kravits, J. (eds.), Equity in Health Services, Cambridge: Ballinger Publishing Company.Google Scholar
Anderson, R. and Benham, L. (1970), ‘Factors affecting the relationship between family income and medical care consumption’, in Klarman, H. (ed.), Empirical Studies in Health Economics, Baltimore: Johns Hopkins Press.Google Scholar
Andersen, R. and Newman, J.F. (1973), ‘Societal and individual determinants of medical care utilization in the United States’, The Milbank Memorial Fund Quarterly: Health and Society, 51(1): 95–124.CrossRefGoogle ScholarPubMed
Arrow, K. (1963), ‘Uncertainty and the welfare economics of medical care’, The American Economic Review, 53(5): 941–973.Google Scholar
Bago d'Uva, T., van Doorslaer, E.K.A.Lindeboom, M. and O'Donnell, O. (2008), ‘Does reporting heterogeneity bias the measurement of health disparities?’, Health Economics, 17(3): 351–375.CrossRefGoogle ScholarPubMed
Barnett, J.R. (1984), ‘Equity, access and resource allocation: planning hospital services in New Zealand’, Social Science and Medicine, 9(11): 981–989.CrossRefGoogle Scholar
Barr, N.A. (2004), Economics of the Welfare State, Oxford: Oxford University Press.Google Scholar
Bloom, G. (2001), ‘Equity in health in unequal societies: meeting health needs in contexts of social change’, Health Policy, 57: 205–224CrossRefGoogle ScholarPubMed
Boutayeb, A. and Serghini, C. (2006), ‘Health indicators and human development in the Arab region’, International Journal of Health Geographics, 5: 61. Available from: http://www.ij-healthgeographics.com/content/5/1/61 [Accessed 21 January 2007]CrossRefGoogle ScholarPubMed
Chernichovsky, D. (1995), ‘What can developing economies learn from health system reforms of developed economies?’, Health Policy 32: 79–91.CrossRefGoogle Scholar
Cockerham, W.C. (2001), ‘Medical sociology and sociological theory’, in Cockerham, W.C. (ed.), The Blackwell Companion to Medical Sociology, Malden: Blackwell Publishers Inc.CrossRefGoogle Scholar
Constitution of the Arab Republic of Egypt (1923/1952), ‘Cairo: People's Assembly’. Available from: http://www.misr.gov.eg [Accessed 7 August 2007]Google Scholar
Culyer, A.J. (1976), Need and the National Health Service, London: Martin Robertson & Co.Google Scholar
Deaton, A. (1997), The Analysis of Household Surveys, Baltimore: Johns Hopkins University Press.CrossRefGoogle Scholar
Deaton, A. (2002), ‘Policy implications of the gradient of health and wealth: an economist asks, would redistributing income improve population health?’, Health Affairs, 21(2): 13–30.CrossRefGoogle Scholar
Deaton, A. and Zaidi, S. (2002), ‘Guidelines for constructing consumption aggregates’, LSMS Working Paper 135, The World Bank, Washington DC.Google Scholar
Dougherty, C. (2007), Introduction to Econometrics, 3rd edn, Oxford: Oxford University Press, pp. 291–321.Google Scholar
Ekman, B. (2007), ‘The impact of health insurance on outpatient utilization and expenditure: evidence from one middle-income country using national household survey data’, Health Research Policy and Systems, 5: 6. Available from http://www.health-policy-systems.com [Accessed 1 August 2007]CrossRefGoogle ScholarPubMed
Ellis, R.P., McInnes, D.K. and Stephenson, E.H. (1994), ‘Inpatient and outpatient health care demand in Cairo, Egypt’, Health Economics, 3(3): 183–200.CrossRefGoogle ScholarPubMed
El-Zanaty, F. and Way, A. (2006), Egypt Demographic and Health Survey 2005, Cairo: Ministry of Health and Population, National Population Council, El-Zanaty and Associates, and ORC Macro.Google Scholar
Ensor, T. and Ronoh, J. (2005), ‘Effective financing of maternal health services: a review of the literature’, Health Policy, 75: 49–58.CrossRefGoogle ScholarPubMed
Equitap (2002), Equity in Asia-Pacific Health Systems: Empirical guidelines 1, Rotterdam: Erasmus University, and Colombo: Institute of Policy Studies.Google Scholar
Fabbri, D., Monfardini, C. and Radice, R. (2004), ‘Testing exogeneity in the bivariate probit model: Monte Carlo evidence and an application to health economics’, working paper no. 514, Department of Economics, University of Bologna, Bologna.Google Scholar
Ferguson, B.D., Tandon, A.Gakidou, E. and Murray, C.J. (2003), ‘Estimating permanent income using indicator variables’, in Murray, C.J. and Evans, D.B.(eds.), Health Systems Performance Assessment: Debates, Methods and Empiricism, Geneva: World Health Organization.Google Scholar
Gallagher, E. (2001), ‘Health, health care, and medical education in the Arab world’, in Cockerham, W.C. (ed.), The Blackwell Companion to Medical Sociology, Malden: Blackwell Publishers.Google Scholar
Gertler, P., Locay, L. and Sanderson, W. (1987), ‘Are user fees regressive? The welfare implications of health care financing proposals in Peru’, Journal of Econometrics, 36: 67–88.CrossRefGoogle Scholar
Goodin, R. (1988), ‘Reasons for welfare: economic, sociological, and political – but ultimately moral’, in Moon, D.J. (ed.), Responsibility, Rights, and Welfare: The Theory of the Welfare State, Boulder, CO and London: Westview Press.Google Scholar
Grogan, C.M. (1995), ‘Urban economic reform and access to health care coverage in the People's Republic of China’, Social Science and Medicine, 41(8): 1073–1084.CrossRefGoogle ScholarPubMed
Grossman, M. (1972), ‘The demand for health: a theoretical and empirical investigation’, Occasional paper 119, National Bureau of Economic Research, New York.Google Scholar
Gulliford, M.et al. (2002), ‘What does “access to health care” mean?’, Journal of Health Services Research and Policy, 7(3): 186–188.CrossRefGoogle Scholar
Horton, N.J. and Kleinman, K.P. (2007), ‘Much ado about nothing: a comparison of missing data methods and software to fit incomplete data regression models’, The American Statistician, 61(1): 79–90.CrossRefGoogle ScholarPubMed
Jabbour, S., El-Zein, A.Nuwayhid, I. and Giacaman, R. (2006), ‘Can action on health achieve political and social reform?’, British Medical Journal, 333(7573): 837–839.CrossRefGoogle ScholarPubMed
Jones, A.M. (2007), Applied Econometrics for Health Economists: A Practical Guide, 2nd edn, Oxford: Radcliffe Medical Publishing.CrossRefGoogle Scholar
Jones, A.M., Koolman, X. and van Doorslaer, E. (2004), ‘The impact of supplementary private health insurance on the use of specialists in European countries’, ECuity III working paper no. 21, Erasmus University, Rotterdam.Google Scholar
Jones, A.M., Rice, N.Bago d'Uva, T. and Balia, S. (2007), ‘Bias in self-reported health’, in Jones, A.M.Rice, N.Bago d'Uva, T. and Balia, S. (eds.), Applied Health Economics, London and New York: Routledge.CrossRefGoogle Scholar
Jowett, M., Contoyannisb, P. and Vinh, N.D. (2003), ‘The impact of public voluntary health insurance on private health expenditures in Vietnam’, Social Science and Medicine, 56: 333–342CrossRefGoogle ScholarPubMed
Jurjus, A.R. (1995), Health Financing in Lebanon: Cost and Insurance Coverage, Beirut: Ministry of Public Health.Google Scholar
Karshenas, M. and Moghadam, V. M.(eds) (2005), Social Policy in the Middle East: Economic, Political and Gender Dynamics, Basingstoke: Palgrave Macmillan.Google Scholar
Keeler, E.B. (1992), ‘Effects of cost sharing on use of medical care and health’, Journal of Medical Practice Management, 8: 317–321.Google Scholar
King, G., Murray, C.J.Salomon, J.A. and Tandon, A. (2003) ‘Enhancing the validity and cross cultural comparability of measurement in survey research’, American Political Science Review, 98(1): 191–207.CrossRefGoogle Scholar
Klavus, J. and Häkkinen, U. (1996) ‘Health care and income distribution in Finland’, Health Policy, 38(1): 31–43.CrossRefGoogle ScholarPubMed
Klein, R. and Millar, J. (1995), ‘Do-it-yourself social policy: searching for a new paradigm?’, Social Policy and Administration, 29(4): 303–316.CrossRefGoogle Scholar
Knapp, M., Funk, M.Curran, C.Prince, M.Grigg, M. and McDaid, D. (2006), ‘Economic barriers to better mental health practice and policy’, Health Policy and Planning, 21(3): 157–170.CrossRefGoogle ScholarPubMed
Kutzin, J. (2001), ‘A descriptive framework for country-level analysis of health care financing arrangements’, Health Policy, 56: 171–204.CrossRefGoogle ScholarPubMed
Le Grand, J. (1991), ‘Quasi-markets and social policy’, The Economic Journal, 101: 1256–1267.CrossRefGoogle Scholar
Le Grand, J., Robinson, R. and Propper, C. (1984), The Economics of Social Problems, London: Macmillan.CrossRefGoogle Scholar
Lerberghe, W.V., Ammar, W.El Rashidi, R.et al. (1997), ‘Reform follows failure: I. unregulated private care in Lebanon’, Health Policy and Planning, 12(4): 296–311.CrossRefGoogle ScholarPubMed
Litvack, J.I. and Bodart, C. (1993), ‘User fees plus quality equals improved access to health care: results of a field experiment in Cameroon’, Social Science and Medicine, 37(3): 369–383.CrossRefGoogle ScholarPubMed
Lu, J.F., Leung, G.M.Kwon, S.Tin, K.Y.Van Doorslaer, E. and O'Donnell, O. (2007), ‘Horizontal equity in health care utilization evidence from three high-income Asian economies’, Social Science and Medicine, 64(1): 199–212.CrossRefGoogle ScholarPubMed
Maddala, G.S. (1983), Limited-Dependent and Qualitative Variables in Econometrics, Cambridge: Cambridge University Press, pp. 22–32, 94–147.CrossRefGoogle Scholar
Marmot, M. (2005), ‘Social determinants of health inequalities’, Lancet 365(9464): 1099–104.CrossRefGoogle ScholarPubMed
Maziak, W. (2006), ‘Health in the Middle East’, British Medical Journal, 333(7573): 815–816.CrossRefGoogle ScholarPubMed
Muennig, P., Franks, P.Haomiao, J.Lubetkin, E. and Gold, M. (2005) ‘The income-associated burden of disease in the United States’, Social Science and Medicine, 61: 2018–2026.CrossRefGoogle ScholarPubMed
Mushkin, S.J. (1962), ‘Health as an investment’, Journal of Political Economy, 70(5): 129–157.CrossRefGoogle Scholar
Nandakumar, A.K., Nada, K.Ibrahim, A.et al. (1999), ‘Health Expenditure Review: Alexandria, Egypt, Technical report no. 35, Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc.Google Scholar
Nord, E. (2002), ‘Measures of goal attainment and performance in the World Health Report 2000: a brief, critical consumer guide’, Health Policy, 59: 183–191.CrossRefGoogle ScholarPubMed
O'Donnell, O., van Doorslaer, E.Rannan-Eliya, R.et al. (2007), ‘The incidence of public spending on health care: comparative evidence from Asia’, World Bank Economic Review, Washington, DC: The World Bank.Google Scholar
Palmer, N., Mueller, D.H.Gilson, L.Mills, A. and Haines, A. (2004), ‘Health financing to promote access in low income settings – how much do we know?’, Lancet, 364(9442): 1365–1370.CrossRefGoogle ScholarPubMed
Phelps, C.E. (1975), ‘Effects of insurance on demand for medical care’, in Anderson, R.Kravits, J. and Anderson, W. (eds.), Equity in Health Services: Empirical Analyses in Social Policy, Cambridge: Ballinger Publishing.Google Scholar
Rannan-Eliya, R.P., Blanco-Vidal, C. and Nandakumar, A.K. (1999), ‘The distribution of health care resources in Egypt: implications for equity’, Data for Decision Making Project, Harvard School of Public Health, Boston.Google Scholar
Roy, K. and Howard, D.H. (2007), ‘Equity in out-of-pocket payments for hospital care: evidence from India’, Health Policy, 80: 297–307.CrossRefGoogle ScholarPubMed
Salem, M.A. (2002), Policy Research In Egypt's Health Sector Reform, Geneva: The Alliance for Health Policy, World Health Organization.Google Scholar
Schenker, N., Raghunathan, T.E.Chiu, P.-L.et al. (2006), ‘Multiple imputation of missing income data in the National Health Interview Survey’, Journal of the American Statistical Association, 101(475): 924–933.CrossRefGoogle Scholar
Sen, A. (2001), Development as Freedom, Oxford: Oxford University Press.Google Scholar
Titmuss, R.M. (1956/2000), ‘The social division of welfare: some reflections on the search for equity’, in Goodin, R.E. and Mitchell, D. (eds.), The Foundations of the Welfare State, Vol. I, Cheltenham: Edward Elgar Publishing.Google Scholar
United Nations Development Program (UNDP) (2005), ‘Egypt human development report’, United Nations Development Program, New York and the Institute of National Planning, Egypt.Google Scholar
United Nations Statistics Division (2007), ‘Common Database (UNCDB), International Labour Organization estimates for consumer price index (CPI)’, New York: United Nations Statistics Division. Available from http://unstats.un.org [Accessed 22 September 2007]Google Scholar
Üstün, T.B., Chatterji, S.Villanueva, M.Benib, L.Celik, C.Sadana, R.Valentine, N.B.Ortiz, J.P.Tandon, A.Salomon, J.Yang, C.Xie, X.J.Ozaltin, E.Mather, C.D. and Murray, C.J.L. (2003), ‘WHO multi-country survey study on health and responsiveness 2001–2’, in Murray, C.J.L. and Evans, D.B.(eds.), Health Systems Performance Assessment: Debates, Methods and Empiricism, Geneva: World Health Organization.Google Scholar
Van de Ven, W.P. and Van der Gaag, J. (1982), ‘Health as an unobservable: a MIMIC-model of demand for health care’, Journal of Health Economics, 1: 157–183.CrossRefGoogle ScholarPubMed
Van Doorslaer, E. and Wagstaff, A. (1992), ‘Equity in the delivery of health care: some international comparisons’, Journal of Health Economics, 11: 389–411.CrossRefGoogle ScholarPubMed
Van Doorslaer, E., Masseria, C.and the OECD Health Equity Research Group Members (2004), ‘Income-related inequality in the use of medical care in 21 OECD countries’, OECD Health working paper no. 14, Organisation for Economic Cooperation and Development, Paris.Google Scholar
Van Doorslaer, E., O'Donnell, O.Rannan-Eliya, R.P.et al. (2006), ‘Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data’, Lancet, 368(9544): 1357–1364.CrossRefGoogle ScholarPubMed
Van Doorslaer, E., O'Donnell, O.Rannan-Eliya, R.P.et al. (2007), ‘Catastrophic payments for health care in Asia’, Health Economics, 16(11): 1159–1184.CrossRefGoogle ScholarPubMed
Van Doorslaer, E.K. (1987), Health, Knowledge and the Demand for Medical Care f Assen: Van Gorcum.Google Scholar
Wagstaff, A. and van Doorslaer, E. (2001), ‘Paying for health care: quantifying fairness, catastrophe, and impoverishment, with applications to Vietnam 1993–98’, Policy Research Working Paper No. 2715. Washington DC: The World Bank.CrossRefGoogle Scholar
Wagstaff, A., van Doorslaer, E.O'Donnell, O. and Lindelow, M. (2003), Quantitative Techniques for Health Equity Analysis: A Series of 20 Technical Notes, Washington, DC: The World Bank.Google Scholar
Walker, G.K. (1986), ‘Reforming Medicare: the limited framework of political discourse on equity and economy’, Social Science and Medicine, 13(12): 1237–1250.CrossRefGoogle Scholar
Ware, J.E., Rogers, W.H.Davies, A.R.et al. (1986), ‘Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care’, Lancet, 327(8488): 1017–1022.CrossRefGoogle Scholar
Waters, H.R. (1999), ‘Measuring the impact of health insurance with a correction for selection bias – a case study of Ecuador’, Health Economics, 8: 473–4833.0.CO;2-C>CrossRefGoogle ScholarPubMed
Weber, M. (1978), ‘Class and status’, in Roth, G. and Wittich, C. (eds.), Economy and Society: An Outline of Interpretive Sociology, Vol. II, Berkeley: University of California Press.Google Scholar
Williams, A. (1978/1991), ‘Need – an economic exegesis’, in Culyer, A.J. (ed.), The Economics of Health, Vol. I, Aldershot: Edward Elgar Publishing.Google Scholar
Winship, C. and Morgan, S.L. (1999), ‘The estimation of causal effects from observational data’, Annual Review of Sociology, 25: 659–706.CrossRefGoogle Scholar
Wolfe, B.L. and Behrman, B.R. (1984), ‘Determinants of women's health status and health-care utilization in a developing country: a latent variable approach’, The Review of Economics and Statistics, 66(4): 696–703.CrossRefGoogle Scholar
World Bank (2001), World Development Indicators, Washington, DC: The World Bank Group. Available from: http://www.worldbank.org [Accessed 27 July 2007].Google Scholar
World Bank (2005), Country Assistance Strategy for the Republic of Lebanon, International Bank for Reconstruction and Development, report no. 34463-LB, Washington, DC: The World Bank.Google Scholar
World Bank (2008), World Development Indicators, Washington, DC: The World Bank Group. Available from: http://www.worldbank.org [Accessed 27 July 2008].Google Scholar
World Health Organization (2002), ‘Towards a common language for functioning, disability and health: ICF, the International Classification of Functioning, Disability and Health’, World Health Organization, Geneva. Available from: http://www3.who.int/icf/beginners/bg.pdf [Accessed 13 March 2007]Google Scholar
World Health Organization (2005), ‘Action on the social determinants of health: learning from previous experiences’, World Health Organization, Geneva. Available from: http://www.who.int/social_determinants [Accessed 15 May 2007]Google Scholar
World Health Organization (2006a), ‘Health system profile: Egypt’, Regional Office for the Eastern Mediterranean, Cairo, World Health Organization.Google Scholar
World Health Organization (2006b), ‘Health system profile: Lebanon’, Regional Office for the Eastern Mediterranean, Cairo, World Health Organization.Google Scholar
Zimmer, Z., Natividad, J., Lin, H.-S., and Chayovan, N. (2000), ‘A cross-national examination of the determinants of self-assessed health’, Journal of Health and Social Behaviour, 41: 465–481.CrossRefGoogle ScholarPubMed
Ministry of Finance, Egypt (2007), ‘State Budget for the Fiscal Year 2007/2008 by Functional Classification, Cairo: Arab Republic of Egypt. Available from: http://www.mof.gov.eg [Accessed 22 July 2008]Google Scholar
Ministry of Health and Population, Egypt (2007), Supply of Human Resources in Health as of 1/1/2006, in ‘Statistical Information for the Ministry of Health and Population’, Cairo: Arab Republic of Egypt. Available from: http://www.mohp.gov.eg [Accessed 22 July 2008]Google Scholar
Ministry of Public Health, Lebanon (2007). Public services and support: outreach and gaps. Beirut: Ministry of Finance, Republic of Lebanon.Google Scholar
Ministry of Public Health, Lebanon (2007). Annual report. Beirul: Ministry of Public Health, Republic of Lebanon.Google Scholar