Progressivity and horizontal equity in health care finance and delivery: what about Africa?

This paper applies concentration curves and indices, that have been previously used to analyze progressivity in health care finance and horizontal equity in health care delivery in developed countries, to a 1998-1999 household survey about health care expenditures and utilization carried out in four francophone West African capitals (Abidjan, Bamako, Conakry and Dakar). The paper also uses statistical inference for testing stochastic dominance relationship between curves, a technique already applied in the literature about equity in taxation, as the criterion for making rigorous inequality comparisons. In all four capitals, the results strongly suggest a regressive pattern of payments for health care, with lower income groups bearing an higher burden of health expenditures as a proportion of their income than do the higher income segments of the population. As soon as dominance between concentrations curves is statistically tested, results appear less conclusive, notably for the groups of population affected by severe morbidity, on the issue of horizontal inequity in health care delivery, which requires that persons with similar medical need be treated equally. Some recommendations are made for the use of equity measurements in access to care for future evaluations of the impact of health care reforms in Africa.