The Palestinian Economy. Theoretical and Practical Challenges

Proceedings “The Palestinian Economy: Theoretical and Practical Challenges” 343
1. Introduction
Although huge literature has been accumulating over the last two decades to assess
inequalities in access to – and utilisation of – health care services in the context of
developed countries (Wagstaff, Van Doorslaer et al. 1991; van Doorslaer, Wagstaff et al.
1992; van Doorslaer, Wagstaff et al. 2000; Waters 2000; Wagstaff, van Doorslaer et al.
2003; van Doorslaer and Masseria 2004; Wilkinson and Pickett 2006), little efforts were
devoted to assess inequalities in health care delivery in the context of developing
countries. In addition, the very few studies (e.g., Baker and Gaag 1993; Pannarunthai and
Mills 1997; Cissé, Luchini et al. 2007) that attempted to incorporate this endeavour have
resorted to a “classical” approach that serves, at its best, to provide aggregate
“descriptive” results on the degree of inequalities prevailing in a given distribution, with
no attempts being made to unveil the latent factors that may possibly contribute to these
inequalities. Furthermore, while the available literature offers a variety of tools and
methods for assessing inequalities in health care delivery (e.g., van Doorslaer, Wagstaff
et al. 1992; Wagstaff and van Doorslaer 2000b; Waters 2000; Gravelle 2003; Huber
2006; van Doorslaer, Masseria et al. 2006), the variability of available approaches, the
inconsistency of presented results, and the controversial policy debates characterising this
field of research, all call for more attention to identifying and endorsing the appropriate
approach for studying inequalities in health care delivery.
Undeniably, the variability in the approaches used may be due, in large part, to the
diverse dimensions chosen to appraise inequalities, the specific indicators used to
apprehend these dimensions, and the different theories of “distributive and social justice”
underpinning the adopted approach (Gauthier 1983; Mooney 1987; Le Grand 1991;
Culyer and Wagstaff 1993; Gerdtham, Johannesson et al. 1999; Macinko and Starfield
2002). Indeed, considerable disagreement exists among economists (cf. Wagstaff and van
Doorslaer 2000a, for a review) on how inequalities in health care utilisation can be
identified, measured and valued, something which resulted in an ample amount of
theoretical and empirical literature – originated for most part from developed countries –
however, with few consistent findings. These findings suggest possible pathways by
which inequality in health care use might be generated and perpetuated (Macinko and
Starfield 2002). The extent of inequalities in access to – and utilisation of – health care
services has shown to differ according to the measurement of need (e.g., subjective selfreported
vs. objective indicators of ill-health), the types of health care services (e.g.,
medical specialists vs. general practionners), and due to the inclusion or not of potential