72013 Health Equity and Financial Protection Datasheets Middle E ast and North Africa Acknowledgements These datasheets were produced by a task team consisting of Caryn Bredenkamp (Task Team Leader, Health Economist, HDNHE), Adam Wagstaff (Research Manager, DECHD), Leander Buisman (consultant), Leah Prencipe (consultant) and Devon Rohr (consultant, graphic design), under the overall supervision of the Sector Manager, HDNHE, Nicole Klingen. The financial contributions of the Rapid Social Results Trust Fund (RSR-MDTF) and the Trust Fund for Environmentally and Socially Sustainable Development (TFESSD) are gratefully acknowledged. Table of contents Egypt..............................................................................................................5 Jordan...........................................................................................................7 Morocco....................................................................................................... 9 Syrian Arab Republic.................................................................................12 Tunisia..........................................................................................................13 Yemen..........................................................................................................15 Interpretation of Results Measurement of Indicators HealtH equity and Financial Protection dataSHeet Egy pt the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci in HealtH 1995 1a outcoMeS infant mortality rate 120.9 94.0 71.1 53.3 34.3 79.4 -0.231*** under-five mortality rate 170.9 126.0 101.4 68.5 40.4 108.3 -0.253*** Stunting 43.7% 38.3% 34.2% 30.1% 23.6% 34.7% -0.117*** underweight 14.7% 12.9% 9.0% 8.8% 6.5% 10.7% -0.158*** diarrhea 15.8% 15.7% 17 .1% 17.3% 13.7% 16.0% -0.007 acute respiratory infection 21.5% 24.1% 25.0% 24.5% 21.5% 23.3% 0.006 Fever 38.8% 39.3% 41.9% 39.6% 42.5% 40.3% 0.015* 2000 1b infant mortality rate 83.3 70.1 58.2 45.1 31.0 59.3 -0.186*** under-five mortality rate 120.9 97.6 75.2 58.4 41.4 82.4 -0.205*** Stunting 32.4% 27 .0% 24.6% 20.3% 14.9% 24.0% -0.146*** underweight 6.4% 4.4% 4.2% 3.2% 2.4% 4.2% -0.185*** diarrhea 8.7% 7.4% 7.6% 6.6% 5.0% 7.1% -0.089*** acute respiratory infection 11.8% 11.3% 9.2% 8.3% 6.9% 9.5% -0.111*** Fever 19.2% 19.1% 18.0% 18.7% 13.3% 17 .8% -0.051*** 2005 1c infant mortality rate 59.3 46.1 38.1 30.8 23.0 40.5 -0.177*** under-five mortality rate 82.9 70.9 52.9 39.7 29.1 57.0 -0.200*** Stunting 30.4% 25.1% 23.2% 19.2% 19.0% 23.6% -0.104*** underweight 6.2% 6.1% 5.4% 4.8% 5.5% 5.6% -0.040* diarrhea 23.0% 19.5% 17.3% 17.5% 13.9% 18.4% -0.089*** acute respiratory infection 12.0% 10.5% 11.5% 11.8% 9.9% 11.2% -0.015 Fever 23.4% 20.7% 21.2% 21.1% 17.5% 20.9% -0.039*** 2008 1d infant mortality rate 43.0 30.3 28.6 24.9 17.7 29.5 -0.165*** under-five mortality rate 58.8 35.7 37.4 29.0 21.6 37.7 -0.194*** Stunting 30.1% 31.6% 28.6% 31.9% 29.9% 30.4% -0.006 underweight 7.9% 6.8% 6.6% 5.4% 6.3% 6.6% -0.066*** diarrhea 9.8% 8.7% 8.8% 7.7% 7.3% 8.5% -0.049** acute respiratory infection 11.3% 8.4% 8.9% 8.8% 9.1% 9.3% -0.033* Fever 15.8% 11.8% 13.0% 12.6% 13.0% 13.3% -0.026 adult HealtH1a,1b,1c,1d,3 q1 q2 q3 q4 q5 total ci 1995 1a obesity among non-pregnant 6.4% 13.9% 19.5% 27.4% 38.4% 20.8% 0.309*** women 2000 1b obesity among non-pregnant 24.3% 35.5% 43.6% 47.9% 51.7% 41.4% 0.132*** women 2005 1c obesity among non-pregnant 32.7% 40.1% 47.8% 54.7% 58.2% 47.1% 0.116*** women 2008 1d obesity among non-pregnant 30.4% 37.2% 43.5% 44.5% 44.2% 40.1% 0.070*** women 5 riSk FactorS1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci inequalitieS in 2005 1c riSky BeHavior Smoking (women) 0.6% 0.4% 0.5% 0.5% 1.1% 0.6% 0.181** inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interventionS1a,1b,1c,1d,2 utiliZation 1995 1a Full immunization 65.8% 72.8% 81.1% 87.3% 92.5% 79.3% 0.069*** treatment of diarrhea 43.8% 43.1% 44.0% 36.2% 30.0% 40.2% -0.053*** Medical treatment of ari 47 .6% 56.9% 61.5% 70.4% 77.6% 61.7% 0.098*** Skilled antenatal care (4+ visits) 7.1% 11.4% 25.0% 41.3% 72.0% 28.7% 0.439*** Skilled birth attendance 20.3% 30.0% 47.3% 62.3% 87.5% 46.9% 0.289*** 2000 1b Full immunization 92.0% 92.6% 93.4% 95.4% 94.2% 93.5% 0.008** treatment of diarrhea 41.1% 39.7% 34.4% 26.1% 19.7% 33.7% -0.117*** Medical treatment of ari 52.7% 63.5% 66.9% 81.6% 73.8% 66.0% 0.085*** Skilled antenatal care (4+ visits) 13.9% 21.7% 36.4% 51.4% 76.4% 38.6% 0.327*** Skilled birth attendance 31.4% 45.6% 61.7% 76.4% 94.4% 61.2% 0.213*** 2005 1c Full immunization 77.3% 80.4% 84.1% 82.7% 83.2% 81.5% 0.013*** treatment of diarrhea 40.9% 34.4% 33.5% 29.9% 23.4% 33.6% -0.088*** Medical treatment of ari 60.9% 66.9% 64.0% 70.2% 75.9% 67.0% 0.043*** Skilled antenatal care (4+ visits) 31.1% 46.2% 60.8% 77.2% 88.2% 59.5% 0.199*** Skilled birth attendance 50.6% 64.7% 78.8% 87.6% 97.0% 74.8% 0.127*** contraceptive prevalence 65.7% 67.6% 68.3% 69.3% 68.3% 68.0% 0.008** 2008 1d Full immunization 89.2% 89.6% 92.8% 92.4% 94.1% 91.6% 0.013*** treatment of diarrhea 34.7% 32.9% 26.8% 22.5% 23.0% 28.5% -0.089*** Medical treatment of ari 66.4% 66.0% 66.5% 78.3% 75.3% 70.2% 0.032*** Skilled antenatal care (4+ visits) 41.7% 56.3% 65.1% 81.5% 90.7% 66.6% 0.153*** Skilled birth attendance 55.4% 69.8% 83.0% 91.1% 96.9% 78.9% 0.109*** contraceptive prevalence 65.6% 68.0% 68.5% 67.9% 73.6% 68.9% 0.019*** note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. data sources: 1a=1995 egypt demographic and Health Survey, 1b=2000 egypt demographic and Health Survey, cluster Survey, 1c=2005 egypt demographic and Health Survey, 1d=2008 egypt demographic and Health Survey, 2=n/a egypt Multiple indicator, 3=n/a egypt World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - egypt. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: ray Witlin 6 HealtH equity and Financial Protection dataSHeet jordan the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci in HealtH 1990 1a outcoMeS infant mortality rate 51.6 39.9 50.9 32.5 31.7 39.0 -0.040 under-five mortality rate 61.6 48.2 54.4 36.5 34.3 45.2 -0.062* Stunting 28.4% 23.7% 19.2% 15.7% 13.5% 19.6% -0.094*** underweight 7.4% 5.8% 5.1% 4.0% 3.7% 5.1% -0.081** diarrhea 12.4% 8.6% 8.1% 7.4% 7.0% 8.5% -0.050** Fever 18.7% 16.1% 18.2% 15.5% 16.6% 16.9% 0.036** 1997 1b infant mortality rate 37.6 29.5 33.4 28.2 24.8 31.1 -0.074** under-five mortality rate 42.4 35.4 35.9 26.4 27.1 33.8 -0.104** Stunting 19.0% 12.2% 8.1% 6.7% 6.8% 11.1% -0.242*** underweight 6.4% 4.2% 2.8% 3.1% 2.2% 3.9% -0.220*** diarrhea 19.1% 20.8% 15.4% 17.1% 17 .7% 18.1% -0.032* acute respiratory infection 11.2% 11.2% 9.1% 10.4% 9.0% 10.3% -0.039* Fever 20.9% 22.2% 18.4% 19.7% 19.5% 20.3% -0.021 2002 1c infant mortality rate 28.9 27.3 28.0 18.9 19.2 25.3 -0.087** under-five mortality rate 35.6 36.2 38.7 20.6 23.2 31.7 -0.104** Stunting 17 .3% 11.7% 10.3% 9.1% 5.6% 11.8% -0.168*** underweight 5.8% 3.4% 3.1% 3.1% 3.9% 4.0% -0.120** diarrhea 15.7% 13.8% 17.4% 13.8% 11.5% 14.8% -0.024 acute respiratory infection 7.2% 6.5% 6.2% 4.9% 5.5% 6.2% -0.058 Fever 10.3% 9.1% 8.8% 8.7% 5.5% 8.8% -0.059** 2007 1d infant mortality rate 26.9 21.1 12.4 18.3 27.5 21.0 -0.052 under-five mortality rate 33.0 24.2 15.7 13.8 26.9 22.6 -0.131* Stunting 18.8% 15.1% 14.2% 16.3% 10.8% 15.7% -0.075** underweight 9.6% 5.9% 3.5% 4.1% 4.7% 6.0% -0.218*** diarrhea 18.3% 14.7% 17.5% 13.5% 14.4% 16.0% -0.050** acute respiratory infection 7.9% 7.9% 6.5% 9.3% 4.7% 7.4% -0.043 Fever 13.6% 13.9% 14.3% 15.5% 14.8% 14.3% 0.018 adult HealtH1a,1b,1c,1d,3 q1 q2 q3 q4 q5 total ci 1997 1b obesity among non-pregnant 29.3% 28.4% 29.1% 32.5% 26.9% 29.2% 0.004 women 2002 1c obesity among non-pregnant 35.6% 35.5% 40.8% 38.4% 39.3% 37.9% 0.022* women 2007 1d obesity among non-pregnant 30.7% 29.5% 31.5% 36.1% 28.8% 31.3% 0.010 women 7 inequalitieS in riSk FactorS1a,1b,1c,1d,2,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2007 1d Smoking (women) 9.3% 8.9% 10.9% 13.7% 23.5% 13.0% 0.213*** inequalitieS Maternal and cHild HealtH q1 q2 q3 q4 q5 total ci in HealtH care interVentionS1a,1b,1c,1d,2 utiliZation 1990 1a Full immunization 9.9% 17.1% 17.3% 16.8% 14.1% 15.3% 0.092*** treatment of diarrhea 45.5% 42.6% 42.4% 44.8% 32.2% 41.8% -0.007 Skilled antenatal care (4+ visits) 50.7% 61.6% 69.2% 74.5% 78.2% 67.9% 0.099*** Skilled birth attendance 74.0% 83.0% 89.1% 93.1% 94.1% 87.4% 0.052*** 1997 1b Full immunization 21.4% 22.3% 20.5% 18.8% 18.9% 20.6% -0.025 treatment of diarrhea 36.0% 28.6% 29.2% 24.7% 21.6% 28.8% -0.090*** Medical treatment of ari 75.9% 77.1% 74.2% 77.8% 76.4% 76.3% 0.005 Skilled antenatal care (4+ visits) 78.3% 85.6% 89.1% 90.5% 91.3% 86.4% 0.034*** Skilled birth attendance 91.2% 97.5% 98.4% 97.9% 99.3% 96.6% 0.015*** 2002 1c Full immunization 29.4% 29.0% 27.4% 20.3% 33.9% 28.1% -0.008 treatment of diarrhea 27.5% 20.0% 22.2% 21.8% 10.8% 22.0% -0.085* Medical treatment of ari 61.9% 65.0% 76.1% 66.4% 52.9% 65.4% 0.004 Skilled antenatal care (4+ visits) 86.1% 90.3% 91.3% 94.7% 96.5% 91.1% 0.023*** Skilled birth attendance 96.1% 98.7% 99.1% 99.7% 99.2% 98.3% 0.007*** 2007 1d Full immunization 82.2% 86.9% 89.2% 88.5% 89.4% 86.7% 0.019* treatment of diarrhea 26.4% 18.3% 28.5% 20.8% 31.3% 24.9% 0.014 Medical treatment of ari 63.9% 77.6% 83.3% 61.5% 75.3% 71.4% 0.001 Skilled antenatal care (4+ visits) 89.9% 93.9% 95.6% 95.4% 98.4% 94.2% 0.016*** Skilled birth attendance 98.0% 98.8% 99.3% 99.8% 100.0% 99.0% 0.004*** contraceptive prevalence 32.9% 36.9% 39.0% 47.2% 45.0% 40.0% 0.075*** note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. data sources: 1a=1990 Jordan demographic and Health Survey, 1b=1997 Jordan demographic and Health Survey, 1c=2002 Jordan demographic and Health Survey, 1d=2007 Jordan demographic and Health Survey, 2=n/a Multiple indicator cluster Survey, 3=n/a World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - Jordan. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: Francis dobbs 8 HEALTH EquITy AnD FInAnCIAL ProTECTIon DATASHEET MOROCCO The Health Equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. Topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. Data are drawn from the Demographic and Health Surveys (DHS), World Health Surveys (WHS), Multiple Indicator Cluster Surveys (MICS), Living Standards and Measurement Surveys (LSMS), as well as other household surveys where available. The datasheets use a common set of health indicators for all countries. All analyses are conducted using the health modules of the ADePT software. InEquALITIES CHILD HEALTH1a,1b,2,3 q1 q2 q3 q4 q5 Total CI In HEALTH 1992 1a ouTCoMES Infant mortality rate 82.3 72.2 63.2 58.9 33.9 65.2 -0.128*** under-five mortality rate 106.9 91.1 90.9 71.7 45.9 85.4 -0.121*** Stunting 43.3% 33.5% 28.4% 17 .9% 12.3% 29.2% -0.216*** underweight 14.4% 10.1% 6.3% 2.5% 1.9% 7.9% -0.356*** Diarrhea 7.2% 6.3% 7.2% 6.2% 6.0% 6.7% -0.018 Acute respiratory infection 6.3% 5.5% 6.6% 6.3% 4.1% 5.8% -0.032 Fever 28.8% 25.6% 27 .1% 28.4% 25.5% 27 .2% -0.013 2003-04 1b Infant mortality rate 67.4 54.5 37.8 32.8 24.0 45.9 -0.215*** under-five mortality rate 84.9 69.7 51.1 45.2 27.7 59.3 -0.204*** Stunting 34.7% 25.2% 20.0% 15.4% 14.9% 23.1% -0.190*** underweight 16.6% 10.7% 8.0% 7.7% 4.3% 10.0% -0.241*** Diarrhea 7.5% 6.3% 9.1% 6.9% 6.5% 7.3% -0.004 Acute respiratory infection 11.8% 12.5% 12.6% 10.8% 10.5% 11.7% -0.024 Fever 24.4% 27 .6% 30.8% 28.8% 24.2% 27 .2% 0.018 ADuLT HEALTH1a,1b,3 q1 q2 q3 q4 q5 Total CI 1992 1a obesity among non-pregnant 3.4% 5.8% 9.5% 20.7% 22.0% 11.7% 0.366*** women 2003 3 Tuberculosis 20.6% 17.7% 19.3% 17.3% 13.4% 17.7% -0.079*** road traffic accident 0.8% 2.5% 2.0% 2.9% 2.1% 2.1% 0.139** non-road traffic accident 4.1% 2.8% 5.9% 3.8% 2.1% 3.7% -0.060 Angina 7.1% 3.2% 5.6% 3.6% 8.3% 5.6% 0.043 Arthritis 20.7% 17.4% 20.6% 16.3% 19.4% 18.9% -0.006 Asthma 3.6% 3.7% 3.0% 3.3% 3.9% 3.5% -0.009 Depression 2.1% 1.0% 2.6% 5.6% 4.9% 3.2% 0.277*** Diabetes 3.0% 2.3% 4.8% 4.8% 7.5% 4.5% 0.208*** Difficulty with work and 33.1% 23.9% 25.0% 19.6% 24.0% 25.1% -0.083*** household activities Poor self-assessed health 34.9% 25.2% 22.7% 17.8% 20.1% 24.1% -0.134*** status 2003-04 1b obesity among non-pregnant 4.6% 7.0% 10.6% 14.8% 15.6% 10.9% 0.223*** women 9 InEquALITIES In rISk FACTorS1a,1b,2,3 q1 q2 q3 q4 q5 Total CI rISky BEHAvIor 2003 3 Smoking (all) 16.1% 20.5% 19.3% 15.8% 7.8% 15.9% -0.111*** Smoking (women) 0.0% 0.5% 0.1% 1.2% 0.4% 0.4% 0.325* Insufficient intake of fruit and 90.9% 87.7% 84.8% 82.0% 71.4% 83.4% -0.041*** vegetables Insufficient physical activity 16.7% 15.3% 14.9% 11.8% 9.7% 13.7% -0.096*** Drinking 0.5% 0.6% 0.7% 0.7% 1.3% 0.8% 0.211 InEquALITIES MATErnAL AnD CHILD q1 q2 q3 q4 q5 Total CI In HEALTH CArE HEALTH InTErvEnTIonS1a,1b,2 uTILIZATIon 1992 1a Full immunization 53.7% 69.9% 84.8% 92.9% 95.1% 76.0% 0.122*** Treatment of diarrhea 3.3% 3.4% 5.4% 7.5% 2.8% 4.3% 0.113 Medical treatment of ArI 5.3% 10.2% 18.2% 31.3% 40.0% 17 .6% 0.367*** Skilled antenatal care (4+ visits) 0.5% 1.0% 5.2% 14.5% 26.3% 7.8% 0.634*** Skilled birth attendance 4.3% 10.3% 20.1% 40.2% 54.6% 22.5% 0.458*** 2003-04 1b Full immunization 81.7% 85.7% 90.7% 95.2% 98.1% 89.6% 0.039*** Treatment of diarrhea 21.7% 22.0% 34.1% 34.0% 33.2% 28.0% 0.102*** Medical treatment of ArI 19.2% 34.0% 36.6% 53.6% 58.7% 37.8% 0.192*** Skilled antenatal care (4+ visits) 10.9% 19.6% 27.9% 41.2% 61.4% 30.8% 0.323*** Skilled birth attendance 29.2% 50.8% 71.4% 86.6% 95.7% 63.4% 0.227*** Contraceptive prevalence 58.1% 60.3% 57.5% 56.6% 58.7% 58.2% -0.002 ADuLT PrEvEnTIvE CArE2,3 q1 q2 q3 q4 q5 Total CI 2003 3 TB screening 1.0% 2.7% 4.0% 4.0% 3.5% 3.0% 0.173** Cervical cancer screening 11.9% 6.2% 14.0% 6.4% 20.9% 12.6% 0.150* Breast cancer screening 2.2% 0.0% 2.0% 0.6% 4.3% 2.1% 0.235 ADuLT CurATIvE CArE3 q1 q2 q3 q4 q5 Total CI 2003 3 Inpatient or outpatient 41.2% 46.9% 49.6% 61.5% 62.8% 52.4% 0.097*** (12 months) Inpatient (12 months) 3.4% 4.8% 7.7% 5.8% 4.9% 5.3% 0.068 Inpatient (5 years) 12.2% 15.9% 22.9% 16.1% 20.2% 17.4% 0.088*** outpatient (12 months) 37.5% 42.6% 45.3% 58.8% 60.4% 48.8% 0.115*** Threshold share of total household consumption FInAnCIAL CATASTroPHIC ouT-oF- 5% 10% 15% 25% 40% ProTECTIon PoCkET SPEnDIng3 2003 3 Headcount 49.9% 35.7% 24.2% 11.5% 4.2% Concentration index 0.101*** 0.119*** 0.124*** 0.153*** 0.377*** Threshold share of nonfood consumption CATASTroPHIC ouT-oF- 5% 10% 15% 25% 40% PoCkET SPEnDIng3 2003 3 Headcount 60.9% 53.3% 45.5% 33.7% 19.4% Concentration index 0.083*** 0.065*** 0.057*** 0.050** 0.031 10 FInAnCIAL IMPovErISHMEnT3 ProTECTIon Poverty line at uS$1.25 per Consumption Consumption Change % change (ConT.) capita per day including ooP excluding ooP 2003 3 Percentage in poverty 2.2% 3.2% 1.0 pp 46.0% Average shortfall from the $0.01 $0.01 $0.00 21.1% poverty line Average shortfall from the $0.44 $0.36 -$0.07 -17.1% poverty line, among the poor Poverty line at uS$2.00 per Consumption Consumption Change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 8.5% 10.7% 2.2 pp 25.5% Average shortfall from the $0.05 $0.06 $0.01 23.2% poverty line Average shortfall from the $0.58 $0.57 -$0.01 -1.8% poverty line, among the poor note: The Health Equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of Indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, DHS and MICS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q= quintile (where quintile 1 is the poorest) CI= concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using Morocco’s consumer price index. Data sources: 1a=1992 Morocco Demographic and Health Survey, 1b=2003-04 Morocco Demographic and Health Survey, 2=n/a Multiple Indicator Cluster Survey, 3=2003 Morocco World Health Survey. recommended citation: World Bank. 2012. Health Equity and Financial Protection Datasheet - Morocco. Washington, D.C.: World Bank. For more information and the latest versions of the Health Equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: Curt Carnemark, 1994 11 HealtH equity and Financial Protection dataSHeet Sy rian arab repu blic the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1,2,3 q1 q2 q3 q4 q5 total ci in HealtH 2006 2 outcoMeS Stunting 35.5% 26.0% 28.1% 25.2% 25.4% 28.3% -0.061*** underweight 12.7% 10.3% 10.2% 7.2% 9.2% 10.0% -0.080*** diarrhea 9.0% 8.7% 8.5% 8.3% 5.5% 8.2% -0.063*** acute respiratory infection 6.6% 8.7% 9.2% 8.5% 8.6% 8.3% 0.050 inequalitieS Maternal and cHild q1 q2 q3 q4 q5 total ci in HealtH care HealtH interventionS1,2 utiliZation 2006 2 Full immunization 77.4% 94.5% 90.7% 92.0% 94.6% 89.9% 0.030*** treatment of diarrhea 65.0% 67.1% 64.4% 76.4% 72.6% 68.4% 0.033** Medical treatment of ari 84.7% 78.9% 90.1% 87.4% 92.4% 86.4% 0.021** contraceptive prevalence 40.7% 48.9% 54.0% 57.4% 58.4% 52.5% 0.074*** note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. data sources: 1=n/a demographic and Health Survey, 2=2006 Syrian arab republic Multiple indicator cluster Survey, 3=n/a World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - Syrian arab republic. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. 12 HealtH equity and Financial Protection dataSHeet TUNISIA the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1,2,3 q1 q2 q3 q4 q5 total ci in HealtH 2003 3 outcoMeS diarrhea 52.6% 52.7% 38.5% 25.0% 43.0% 42.2% -0.114** acute respiratory infection 22.1% 3.8% 23.0% 19.4% 22.0% 18.3% 0.027 Fever 92.7% 80.3% 79.0% 87.7% 65.1% 82.0% -0.052** adult HealtH1,3 q1 q2 q3 q4 q5 total ci 2003 3 tuberculosis 14.2% 8.1% 9.9% 10.8% 7.9% 10.1% -0.077*** obesity among non-pregnant 4.8% 5.3% 10.5% 6.0% 12.8% 8.2% 0.165*** women road traffic accident 1.7% 2.6% 1.7% 1.4% 1.0% 1.7% -0.124* non-road traffic accident 3.0% 4.1% 4.9% 3.8% 3.8% 4.0% 0.024 angina 2.1% 2.7% 2.3% 1.4% 1.7% 2.0% -0.076 arthritis 25.6% 25.7% 26.2% 24.5% 22.8% 24.9% -0.023 asthma 4.7% 4.3% 3.9% 3.2% 3.6% 3.9% -0.075 depression 3.7% 5.1% 6.3% 5.3% 4.7% 5.0% 0.044 diabetes 2.1% 3.2% 3.8% 5.6% 4.7% 3.9% 0.167*** difficulty with work and 15.7% 11.6% 10.1% 9.5% 6.7% 10.7% -0.152*** household activities Poor self-assessed health 16.5% 8.7% 10.8% 6.8% 3.2% 9.0% -0.248*** status inequalitieS in riSk FactorS1,2,3 q1 q2 q3 q4 q5 total ci riSky BeHaVior 2003 3 Smoking (all) 27.3% 27.3% 28.4% 26.4% 25.1% 26.9% -0.019 Smoking (women) 1.8% 0.7% 1.4% 1.3% 1.5% 1.3% 0.003 insufficient intake of fruit and 96.6% 97.0% 94.7% 93.6% 90.6% 94.5% -0.014*** vegetables insufficient physical activity 17.2% 12.9% 11.0% 8.5% 9.4% 11.8% -0.141*** drinking 1.9% 5.7% 5.6% 5.4% 7.8% 5.3% 0.169*** concurrent partnerships 1.9% 0.2% 0.0% 0.0% 0.0% 0.4% -0.723 inequalitieS adult PreVentiVe care2,3 q1 q2 q3 q4 q5 total ci in HealtH care 2003 3 utiliZation tB screening 2.3% 1.9% 2.4% 2.0% 1.8% 2.1% -0.027 cervical cancer screening 17.5% 18.0% 24.7% 21.2% 28.8% 22.4% 0.095** Breast cancer screening 1.2% 5.6% 9.9% 4.8% 19.0% 8.3% 0.386*** 13 inequalitieS adult curatiVe care3 q1 q2 q3 q4 q5 total ci in HealtH care 2003 3 utiliZation inpatient or outpatient 61.2% 59.0% 65.0% 69.7% 68.6% 64.8% 0.033*** (cont.) (12 months) inpatient (12 months) 7.0% 7.7% 8.6% 8.9% 6.6% 7.8% -0.002 inpatient (5 years) 19.8% 22.2% 24.9% 23.1% 20.0% 22.0% 0.000 outpatient (12 months) 59.1% 56.9% 63.0% 68.2% 68.8% 63.5% 0.041*** threshold share of total household consumption Financial cataStroPHic out-oF- 5% 10% 15% 25% 40% Protection Pocket SPending 2003 3 Headcount 44.8% 33.9% 25.2% 13.9% 6.8% concentration index 0.119*** 0.116*** 0.121*** 0.125*** 0.213*** threshold share of nonfood consumption cataStroPHic out-oF- 5% 10% 15% 25% 40% Pocket SPending 2003 3 Headcount 54.8% 50.1% 45.7% 37.4% 27.5% concentration index 0.072*** 0.060*** 0.047*** 0.015 -0.022 iMPoVeriSHMent Poverty line at uS$1.25 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 12.7% 15.7% 2.9 pp 23.2% average shortfall from the $0.05 $0.07 $0.01 26.4% poverty line average shortfall from the $0.40 $0.41 $0.01 2.6% poverty line, among the poor Poverty line at uS$2.00 per consumption consumption change % change capita per day including ooP excluding ooP 2003 3 Percentage in poverty 27.8% 32.8% 5.0 pp 18.1% average shortfall from the $0.20 $0.25 $0.04 22.0% poverty line average shortfall from the $0.73 $0.75 $0.02 3.3% poverty line, among the poor note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. Poverty lines are at 2005 purchasing power parity, adjusted to current prices using tunisia’s consumer price index. data sources: 1=n/a demographic and Health Survey, 2=n/a Multiple indicator cluster Survey, 3=2003 tunisia World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - tunisia. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: curt carnemark 14 HealtH equity and Financial Protection dataSHeet Y EMEN the Health equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. data are drawn from the demographic and Health Surveys (dHS), World Health Surveys (WHS), Multiple indicator cluster Surveys (MicS), living Standards and Measurement Surveys (lSMS), as well as other household surveys where available. the datasheets use a common set of health indicators for all countries. all analyses are conducted using the health modules of the adePt software. inequalitieS cHild HealtH1,2,3 q1 q2 q3 q4 q5 total ci in HealtH 2006 2 outcoMeS diarrhea 6.1% 5.7% 5.1% 5.7% 3.1% 5.2% -0.084** acute respiratory infection 25.9% 27.3% 19.5% 15.2% 15.8% 21.0% -0.128*** inequalitieS Maternal and cHild q1 q2 q3 q4 q5 total ci in HealtH care HealtH interventionS1,2 utiliZation 2006 2 Full immunization 8.8% 9.4% 16.7% 26.8% 49.8% 20.3% 0.364*** treatment of diarrhea 31.3% 32.8% 31.2% 36.0% 37.1% 33.3% 0.027 Medical treatment of ari 43.6% 52.2% 54.9% 63.9% 59.3% 53.1% 0.088*** contraceptive prevalence 17.5% 19.3% 27.4% 37.7% 45.0% 30.4% 0.199*** among women note: the Health equity and Financial Protection datasheets use a standardized selection of indicators (see Measurement of indicators for full list). When (1) data sources are not available or (2) indicator-specific sample size is less than 250 per quintile for mortality indicators or less than 25 per quintile for all others, indicators are not reported for the country under analysis. For analysis of inequalities using WHS, dHS and MicS, quintile ranking is based on an asset index. For all other analyses, ranking is based on household consumption. q = quintile (where quintile 1 is the poorest) ci = concentration index; ranges between -1 and 1; negative sign indicates that the health outcome takes higher values among the poor * Significant at 10%, **Significant at 5%, ***Significant at 1%. data sources: 1=n/a demographic and Health Survey, 2=2006 yemen Multiple indicator cluster Survey, 3=n/a World Health Survey. recommended citation: World Bank. 2012. Health equity and Financial Protection datasheet - yemen. Washington, d.c.: World Bank. For more information and the latest versions of the Health equity and Financial Protection reports and datasheets, see: www.worldbank.org/povertyandhealth. Photo credit: tomas Sennett 15 I nterpre tatIon of results InequalItIes In health outcomes, rIsky behavIor and health care utIlIzatIon the tables in this section show how health outcomes, risky behaviors and health care utilization vary across asset (wealth) quintiles and periods. the quintiles are based on an asset index constructed using principal components analysis. the tables show the mean values of the indicator for each quintile, as well as for the sample as a whole. also shown are the concentration indices which capture the direction and degree of inequality. a negative value indicates that the variable (e.g. stunting or skilled birth attendance) is more concentrated among the poor, while a positive value indicates that the variable is concentrated among the better off. the larger the index in absolute size, the more inequality there is. the statistical significance of the concentration index is also shown, at 1% (***), 5% (**) and 10% (*) significance levels. For example, if stunting has a concentration index of -0.121***, then stunting is significantly concentrated among the poor. beneFIt-IncIdence analysIs benefit-incidence analysis (bIa) shows whether, and by how much, government health expenditure disproportionately benefits the poor. there are three tables showing, respectively, the distribution of service utilization across consumption quintiles for different types of care, the distribution of user fees, and the distribution of the estimated subsidies. all tables also show the concentration indices which capture the direction and degree of inequality. a negative value indicates that the variable (i.e. utilization, fees or subsidies) is more concentrated among the poor, while a positive value indicates that the variable is concentrated among the better off. the larger the index in absolute size, the greater is the inequality. For example, if the concentration index of subsidies to hospitals is positive, the non-poor benefit more than the poor from government spending on hospital services. the distribution of subsidies depends on the assumptions made to allocate subsidies to households. under the constant unit cost assumption, each unit of utilization is assumed to cost the same and is equal to total costs incurred in delivering this type of service (i.e. subsidies plus user fees) divided by the number of units of utilization. under the constant unit subsidy assumption, the unit subsidy is assumed to be constant, equal to total subsidies for the service in question divided by the number of units of utilization of that service. under the proportional cost assumption, higher fees are indicative of a more costly type of care; specifically, it is assumed that unit costs and fees are proportional to one another. If the concentration index is negative, then the subsidy to the particular level of care is pro-poor and if the concentration index is positive, then the subsidy is pro-rich. the column labeled “share� shows the distribution of the total subsidy across different levels of care. FInancIal protectIon: catastrophIc and ImpoverIshIng expendIture measures of financial protection relate out-of-pocket spending to a threshold. one approach is to classify spending as ‘catastrophic’ if it exceeds a certain fraction of household income or consumption or nonfood consumption. catastrophic payments are defined as health care payments in excess of a predetermined percentage (i.e. 5% to 40%) of their total household spending or nonfood spending. the first line of the first table shows the catastrophic payment “headcount�, i.e. the proportion of households with a health payment budget share greater than the given threshold. For example, if the “headcount� figure given in the last column of the first table is 6%, then 6% of households spend more than 40% of their pre-payment income on health payments. the concentration indices in the second line of each table show whether there is a greater tendency for the better off to have out-of-pocket spending in excess of the payment threshold (in which case it takes on a positive value), or whether the poor are more likely to have out-of-pocket spending exceeding the threshold (in which case it takes on a negative value). another approach is to classify health spending as ‘impoverishing’ if it is sufficiently large to make the household cross the poverty line, i.e. the household would not have been poor had it been able to use for general consumption the money it was forced to spend on health care. the extent of impoverishment due to health care expenditure is measured by comparing the extent of poverty computed using household consumption gross and net of out-of-pocket health spending. the table shows three measures of poverty. the first line of the table shows the percentage of the population living below the poverty line, i.e. the poverty “headcount�. the second line shows the population’s average shortfall from the poverty line, i.e. the “normalized poverty gap�; the normalization is useful when making comparisons across countries with different poverty lines and currency units. Finally, the last line shows the average shortfall from the poverty line, among those who are poor, i.e. the normalized mean positive poverty gap. the last column shows the percentage increase in poverty, the percentage increase in the average shortfall from the poverty line and the percentage increase in the average shortfall from the poverty line among the poor due to out-of-pocket health spending, respectively. progressIvIty oF health FInancIng the table in this section reports whether overall health financing, as well as the individual sources of finance, is regressive (i.e. a poor household contributes a larger share of its resources than a rich one), progressive (i.e. a poor household contributes a smaller share of its resources than a rich one) or proportional. the 1st through 5th columns show the distribution of consumption and different sources of health care financing. the 6th column shows the summary measures of inequality; in the case of consumption, this is the gini coefficient and in the case of other sources of financing it is the concentration index. In the 7th column, the kakwani index (defined as the concentration index less the gini coefficient) takes on a positive value, then payments are more concentrated among the better off than consumption, and is a sign that payments are progressive. If the kakwani index is negative, then payments are regressive. the last column shows the contribution of each financing source to total health care financing (obtained from national health accounts data). For more guIdance on InterpretatIon oF results, see: o’donnell, o., e. van doorslaer, a. Wagstaff and m. lindelow. (2008). analyzing health equity using household survey data: a guide to techniques and their implementation. Washington, d.c.: World bank. Wagstaff, a., m. bilger, z. sajaia and m. lokshin. (2011). health equity and financial protection: streamlined analysis with adept software. Washington, d.c.: World bank. Me asureMent of In dIcators IndIcator MeasureMent data chIld health number of deaths among children under 12 months of age per 1,000 live births (note: mortality Infant mortality rate rate calculated using the true cohort life table approach; the dhs reports use the synthetic cohort dhs life table approach) number of deaths among children under 5 years of age per 1,000 live births (note: mortality rate under-five mortality rate calculated using the true cohort life table approach; the dhs reports use the synthetic cohort life dhs table approach) % of children with a height-for-age z-score <-2 standard deviations from the reference median stunting dhs, MIcs (note: z-score calculated using Who 2006 child Growth standards) % of children with a weight-for-age z-score <-2 standard deviations from the reference median underweight dhs, MIcs (note: z-score calculated using Who 2006 child Growth standards) diarrhea % of children with diarrhea (past two weeks) dhs, MIcs diarrhea % of children with diarrhea (past two weeks; youngest child) Whs acute respiratory infection % of children with an episode of coughing and rapid breathing (past two weeks) dhs, MIcs acute respiratory infection % of children with an episode of coughing and rapid breathing (past two weeks; youngest child) Whs Fever % of children with fever (past two weeks) dhs, MIcs Fever % of children with fever (past two weeks; youngest child) Whs Malaria % of children with an episode of malaria (past year; youngest child) Whs adult health tuberculosis % of adults who reported tuberculosis symptoms (past year) Whs obesity among non-pregnant women % of women aged 15 to 49 with a BMI above 30 dhs obesity among all women % of women aged 18 to 49 with a BMI above 30 Whs road traffic accident % of adults involved in a road traffic accident with bodily injury (past year) Whs % of adults who suffered bodily injury that limited everyday activities, due to a fall, burn, poisoning, non-road traffic accident Whs submersion in water, or by an act of violence (past year) angina % of adults ever diagnosed with angina or angina pectoris Whs arthritis % of adults ever diagnosed with arthritis Whs asthma % of adults ever diagnosed with asthma Whs depression % of adults ever diagnosed with depression Whs diabetes % of adults ever diagnosed with diabetes Whs difficulty with work and household % of adults who have severe or extreme difficulties with work or household activities (past 30 days) Whs activities (note: this indicator was created from an ordinal variable with five categories) % of adults who rate own health as bad or very bad (note: this indicator was created from an Poor self-assessed health status Whs ordinal variable with five categories) hIV Positive Percentage of adults aged 15 to 49 whose blood tests are positive for hIV 1 or hIV 2. dhs rIsk Factors smoking (all) % of adults who smoke any tobacco products such as cigarettes, cigars or pipes Whs smoking (women) % of women aged 15 to 49 who smoke cigarettes, pipe or other tobacco dhs smoking (women) % of women aged 18 to 49 who smoke cigarettes, pipe or other tobacco Whs Insufficient intake of fruit and vegetables % of adults who have insufficient intake of fruit/vegetables (less than 5 servings) Whs Insufficient physical activity % of adults who spend < 150 minutes on walking/ moderate activity/vigorous activity (past week) Whs drinking % of adults who consume ≥5 standard drinks on at least one day (past week) Whs concurrent partnerships % of women aged 15 to 49 who had sexual intercourse with more than one partner (past year) dhs, MIcs concurrent partnerships % of women aged 18 to 49 who had sexual intercourse with more than one partner (past year) Whs % of women aged 15 to 49 who had more than one partner in the past year and used a condom condom usage (more than one partner) dhs, MIcs during last sexual intercourse % of women aged 18 to 49 who had more than one partner in the past year and used a condom condom usage (more than one partner) Whs during last sexual intercourse Mosquito net use by children % of children who slept under an (ever) insecticide treated bed net (Itn) (past night) dhs, MIcs % of pregnant women aged 15 to 49 who slept under an (ever) insecticide treated bed net (Itn) Mosquito net use by pregnant women dhs (past night) Maternal and chIld health InterVentIons % of children aged 12-23 months who received BcG, measles, and three doses of polio and dPt, Full immunization dhs, MIcs either verified by card or by recall of respondent treatment of diarrhea % of children with diarrhea given oral rehydration salts (ors) or home-made solution dhs, MIcs % of children with a cough and rapid breathing who sought medical treatment for acute respiratory Medical treatment of arI dhs, MIcs infection (past 2 weeks) % of mothers aged 15 to 49 who received at least 4 antenatal care visits from any skilled personnel skilled antenatal care (4+ visits) dhs (doctor, nurse/midwife, auxiliary midwife, feldsher, family nurse, trained birth attendant) skilled birth attendance % of mothers aged 15 to 49 that were attended by any skilled personnel at child’s birth dhs contraceptive prevalence % of women aged 15 to 49 who currently use a modern method of contraception dhs, MIcs adult PreVentIVe care tB screening % of adults who were tested for tuberculosis (past year) Whs Voluntary counseling and testing for hIV % of women aged 18 to 49 who were tested for hIV and were told the results of the test Whs,MIcs cervical cancer screening % of women aged 18 to 69 who received a pap smear during last pelvic examination (past 3 years) Whs Breast cancer screening % of women aged 40 to 69 who received a mammogram (past 3 years) Whs adult curatIVe care Inpatient or outpatient (12 months) % of adults who used any inpatient or outpatient health care (past year) Whs Inpatient (12 months) % of adults who used any inpatient health care (past year) Whs Inpatient (5 years) % of adults who used any inpatient health care (past 5 years) Whs % of adults who used any outpatient health care (past year; conditional on having not used any outpatient (12 months) Whs inpatient care past 5 years) note: unless otherwise noted, all children are under the age of 5 and all adults are aged 18 and older About the Health Equity and Financial Protection datasheets The Health Equity and Financial Protection datasheets provide a picture of equity and financial protection in the health sectors of low- and middle-income countries. Topics covered include: inequalities in health outcomes, health behavior and health care utilization; benefit incidence analysis; financial protection; and the progressivity of health care financing. Data are drawn from the Demographic and Health Surveys, World Health Surveys, Multiple Indicator Cluster Surveys, Living Standards and Measurement Surveys, as well as other household surveys, and use a common set of health indicators for all countries in the series. All analyses are conducted using the health modules of the ADePT software. Also available are Health Equity and Financial Protection country reports. The most recent versions of the Health Equity and Financial Protection reports and datasheets can be downloaded at www.worldbank.org/povertyandhealth.