Abstract
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.
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Notes
Demand-side factors include the role of social network (Leone, Padmadas, & Matthews, 2008) or the fear of vaginal delivery (Fritel, 2015), while supply-side factors are mainly related to financial motives (Cavalieri, Guccio, Lisi, & Pignataro, 2014; Gruber, Kim, & Mayzlin, 1999; Gruber & Owings, 1996; Johnson & Rehavi, 2016; McGuire & Pauly, 1991; Milcent & Rochut, 2009; Triunfo & Rossi, 2009).
This may be explained by the fact that the majority of clinics are located in the main urban centers. In 2015, 34.5% of medical and surgical clinics were concentrated in the cities of Algiers and Oran (MSPRH, 2017). Also, public health facilities, when located in the highlands or in southern regions, often lack obstetrician-gynecologists (Zehnati, 2014).
The results, which are not shown here for reasons of space, are available from the authors upon request.
Before and after the matching, and for each variable, we perform a t-test of mean equality between the two groups. The results, which are not shown here for reasons of space, are available from the authors upon request.
References
Abu-Zaineh, M., Romdhane, H. B., Ventelou, B., Moatti, J.-P., & Chokri, A. (2013). Appraising financial protection in health: The case of Tunisia. International Journal of Health Care Finance and Economics, 13(1), 73–93. https://doi.org/10.1007/s10754-013-9123-8.
Arpino, B., & Cannas, M. (2016). Propensity score matching with clustered data. An application to the estimation of the impact of caesarean section on the Apgar score. Statistics in Medicine, 35(12), 2074–2091. https://doi.org/10.1002/sim.6880.
Baubeau, D., & Buisson, G. (2003). La pratique des césariennes: Evolution et variabilité entre 1998 et 2001 (No. Études et Résultats, 273). DREES (Ministère des Affaires sociales, du Travail et de la Solidarité).
Betran, A. P., Torloni, M. R., Zhang, J., Ye, J., Mikolajczyk, R., Deneux-Tharaux, C., Oladapo, O. T., Souza, J. P., Tunçalp, Ö., Vogel, J. P., & Gülmezoglu, A. M. (2015). What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reproductive Health, 12, 57. https://doi.org/10.1186/s12978-015-0043-6.
Betrán, A. P., Ye, J., Moller, A.-B., Zhang, J., Gülmezoglu, A. M., & Torloni, M. R. (2016). The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014. PLoS ONE, 11(2), e0148343. https://doi.org/10.1371/journal.pone.0148343.
Bousmah, M.-A.-Q., Ventelou, B., & Abu-Zaineh, M. (2016). Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region. Health Policy, 120(8), 928–935. https://doi.org/10.1016/j.healthpol.2016.06.005.
Cameron, A. C., & Trivedi, P. K. (2009). Microeconometrics using Stata. (Vol. 5). Stata Press.
Cavalieri, M., Guccio, C., Lisi, D., & Pignataro, G. (2014). Financial incentives and inappropriateness in health care: Evidence from Italian cesarean sections. FinanzArchiv: Public Finance Analysis, 70(3), 430–457. https://doi.org/10.1628/001522114X684538.
Di Renzo, G. C., & Malvasi, A. (2016). Cesarean delivery: A comprehensive illustrated practical guide. CRC Press.
Filippi, V., Ganaba, R., Calvert, C., Murray, S. F., & Storeng, K. T. (2015). After surgery: The effects of life-saving caesarean sections in Burkina Faso. BMC Pregnancy and Childbirth, 15(1), 348. https://doi.org/10.1186/s12884-015-0778-7.
Flamm, B. L. (2000). Cesarean section: A worldwide epidemic? Birth, 27(2), 139–140. https://doi.org/10.1046/j.1523-536x.2000.00139.x.
Fritel, X. (2015). Epidémie de césariennes et crainte du traumatisme obstétrical. Gynecologie Obstetrique & Fertilite, 43(7–8), 483–484. https://doi.org/10.1016/j.gyobfe.2015.03.020.
Garrido, M. M., Kelley, A. S., Paris, J., Roza, K., Meier, D. E., Morrison, R. S., & Aldridge, M. D. (2014). Methods for constructing and assessing propensity scores. Health Services Research, 49(5), 1701–1720. https://doi.org/10.1111/1475-6773.12182.
Gruber, J., Kim, J., & Mayzlin, D. (1999). Physician fees and procedure intensity: The case of cesarean delivery. Journal of Health Economics, 18(4), 473–490. https://doi.org/10.1016/s0167-6296(99)00009-0.
Gruber, J., & Owings, M. (1996). Physician financial incentives and cesarean section delivery. The Rand Journal of Economics, 27(1), 99–123.
Johnson, E. M., & Rehavi, M. M. (2016). Physicians treating physicians: Information and incentives in childbirth. American Economic Journal: Economic Policy, 8(1), 115–141. https://doi.org/10.1257/pol.20140160.
Khawaja, M., Choueiry, N., & Jurdi, R. (2009). Hospital-based caesarean section in the Arab region: An overview. Eastern Mediterranean Health Journal, 15(2), 458–469.
Lamri, L. (2014). Comptes Nationaux de la Santé. Programme PASS, MSPRH - Union Européenne. MSPRH (Ministère de la Santé, de la Population et de la Réforme Hospitalière).
Leone, T., Padmadas, S. S., & Matthews, Z. (2008). Community factors affecting rising caesarean section rates in developing countries: An analysis of six countries. Social Science & Medicine, 67(8), 1236–1246. https://doi.org/10.1016/j.socscimed.2008.06.032.
Makhloufi, K., Ventelou, B., & Abu-Zaineh, M. (2015). Have health insurance reforms in Tunisia attained their intended objectives? International Journal of Health Economics and Management, 15(1), 29–51. https://doi.org/10.1007/s10754-014-9157-6.
McCourt, C., Weaver, J., Statham, H., Beake, S., Gamble, J., & Creedy, D. K. (2007). Elective cesarean section and decision making: A critical review of the literature. Birth, 34(1), 65–79. https://doi.org/10.1111/j.1523-536X.2006.00147.x.
McGuire, T. G., & Pauly, M. V. (1991). Physician response to fee changes with multiple payers. Journal of Health Economics, 10(4), 385–410. https://doi.org/10.1016/0167-6296(91)90022-f.
Mikki, N., Abu-Rmeileh, N. M. E., Wick, L., Abu-Asab, N., & Hassan-Bitar, S. (2009). Caesarean delivery rates, determinants and indications in Makassed Hospital, Jerusalem 1993 and 2002. Eastern Mediterranean Health Journal, 15(4), 868–879.
Milcent, C., & Rochut, J. (2009). Tarification hospitalière et pratique médicale. Revue Économique, 60(2), 489–506.
Mood, C. (2010). Logistic regression: Why we cannot do what we think we can do, and what we can do about it. European Sociological Review, 26(1), 67–82. https://doi.org/10.1093/esr/jcp006.
MSPRH. (2001). Développement du système national de santé: Stratégie et perspectives. MSPRH (Ministère de la Santé, de la Population et de la Réforme Hospitalière).
MSPRH. (2017). Statistiques sanitaires. MSPRH (Ministère de la Santé, de la Population et de la Réforme Hospitalière).
Ngandu, N. K., Manda, S., Besada, D., Rohde, S., Oliphant, N. P., & Doherty, T. (2016). Does adjusting for recall in trend analysis affect coverage estimates for maternal and child health indicators? An analysis of DHS and MICS survey data. Global Health Action, 9(1), 32408. https://doi.org/10.3402/gha.v9.32408.
Penna, L., & Arulkumaran, S. (2003). Cesarean section for non-medical reasons. International Journal of Gynaecology and Obstetrics, 82(3), 399–409. https://doi.org/10.1016/s0020-7292(03)00217-0.
Porreco, R. P., & Thorp, J. A. (1996). The cesarean birth epidemic: Trends, causes, and solutions. American Journal of Obstetrics and Gynecology, 175(2), 369–374. https://doi.org/10.1016/s0002-9378(96)70148-5.
Stanton, C. K., & Holtz, S. A. (2006). Levels and trends in cesarean birth in the developing world. Studies in Family Planning, 37(1), 41–48. https://doi.org/10.1111/j.1728-4465.2006.00082.x.
Stivanello, E., Rucci, P., Lenzi, J., & Fantini, M. P. (2014). Determinants of cesarean delivery: A classification tree analysis. BMC Pregnancy and Childbirth, 14(1), 215. https://doi.org/10.1186/1471-2393-14-215.
Tlilane, N. K. (2004). Healthcare funding problems in Algeria. International Social Security Review, 57(4), 91–110. https://doi.org/10.1111/j.1468-246X.2004.00204.x.
Triunfo, P., & Rossi, M. (2009). The effect of physicians’ remuneration system on the caesarean section rate: The Uruguayan case. International Journal of Health Care Finance and Economics, 9(4), 333–345. https://doi.org/10.1007/s10754-008-9054-y.
UNICEF. (2015). Enquête par grappes à indicateurs multiples (MICS) Algérie 2012–2013. Suivi de la situation des enfants et des femmes. UNICEF.
United Nations. (2015). Transforming our world: The 2030 agenda for sustainable development (No. Report No. A/RES/70/1). United Nations, Department of Economic and Social Affairs.
World Health Organization. (1985). Appropriate technology for birth. Lancet, 2(8452), 436–437.
World Health Organization. (2015). WHO statement on caesarean section rates. World Health Organization.
World Health Organization. (2017). Global health expenditure database. World Health Organization.
World Health Organization, UNICEF, UNFPA, World Bank Group, & United Nations Population Division. (2015). Trends in maternal mortality: 1990 to 2015. World Health Organization.
Ye, J., Betrán, A. P., Guerrero Vela, M., Souza, J. P., & Zhang, J. (2014). Searching for the optimal rate of medically necessary cesarean delivery. Birth, 41(3), 237–244. https://doi.org/10.1111/birt.12104.
Zehnati, A. (2014). Analyse économique de l’émergence et du développement d’une offre privée de soins en Algérie. Université de Bourgogne/Université de Béjaia.
Zehnati, A., & Peyron, C. (2013). Les raisons de la double activité des médecins: Le cas de l’Algérie. Maghreb-Machrek, No, 217(3), 89–112.
Acknowledgements
This work has been carried out thanks to the support of the A*MIDEX project (No. ANR-11-IDEX-0001-02) funded by the “Investissements d’Avenir” French Government program, managed by the French National Research Agency (ANR). We are also grateful to four anonymous reviewers and to researchers from the AHEAD research network for helpful comments.
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Zehnati, A., Bousmah, MaQ. & Abu-Zaineh, M. Public–private differentials in health care delivery: the case of cesarean deliveries in Algeria. Int J Health Econ Manag. 21, 367–385 (2021). https://doi.org/10.1007/s10754-021-09300-x
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DOI: https://doi.org/10.1007/s10754-021-09300-x