Abstract
An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). We examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities we find that wealth is the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typically less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that our findings are likely to even underestimate actual inequities in health care. At a macro level, we find that a better match of needs and use is realized in those countries with better governance and more physicians. Given the absence of social health insurance in most of these countries, policies that aim to reduce inequities in access to and use of health care must include an enhanced capacity of the poor to generate income.

KEY MESSAGES
- Healthcare use is mainly determined by wealth instead of need in Sub-Saharan Africa.
- Countries with better need responsiveness are those with higher income and a better educated population.
- Conventional tools for measuring inequity in healthcare delivery tend to underestimate inequities in Sub-Saharan Africa.
- The poor not only understate their needs, they or the healthcare system—on average—also respond inadequately to needs.

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doi.org/10.1093/heapol/czt074, hdl.handle.net/1765/50226
Health Policy and Planning
Erasmus School of Health Policy & Management (ESHPM)

Bonfrer, I.E.J, Van de Poel, E, Grimm, M, & van Doorslaer, E.K.A. (2013). Does the distribution of healthcare utilization match needs in Africa?. Health Policy and Planning, 2013, 1–17. doi:10.1093/heapol/czt074