Economic studies on social inequalities in health.

Summary This dissertation addresses social inequalities in health by attempting to identify their main determinants. The aim of this research is to examine the impact of health systems and their reforms on social inequality in health, focusing on a deeper understanding of the pathways and mechanisms by which socio-economic factors reduce or increase inequalities in health. Based on a review of the literature on the determinants of social inequalities in health, we propose a conceptual analysis of the links between health and socio-economic status, including the income of individuals and countries by studying the impact of the latter on the health status of a population. We propose to explore the relationship between income inequality, social inequality and disparities in health status in the context of the emergence of social inequalities in health (SII). According to the definitions of social determinants, health inequality must be considered from a systematic analysis perspective with particular reference to the most explicitly cited and proven socio-economic theories in the health economics literature. A conceptual framework on the methods of measuring social inequalities in health has been proposed to discuss the approaches to decompose inequalities in the consumption of health care, in particular with the concentration index as a hitherto little explored measure. This allowed to assess health inequalities, to make a judgment on the inequity of the distribution of health care, and to highlight the relevance of this measure in this field.Among the aspects of health inequality, several determinants support disparities in the demand for health services that are related to both economic situations and health systems. Many theoretical approaches assert that inequality in access to care is related to the characteristics and norms of health systems that lead to conditions of inequity in financial access to care and the use of the resources and services of these systems. This has been the motivation for successive and ongoing reforms of health financing and health insurance in several countries around the world. These reforms have also sought to improve the performance of health systems. Thus, in this thesis, we have tried to measure the levels of efficiency and equity in the Tunisian health system, by studying the causal factors of health inequalities in Tunisia and the reform of health insurance as well as the determinants of its development as a means of financing health care. We then presented an evaluation of the reform of the National Health Insurance Fund (CNAM) in 2007, examining its impact on access to care. A conceptual framework is presented concerning the evaluation of health system performance to discuss the methods of measurement and estimation of the level of technical and economic efficiency using in particular the DEA method.