Social inequalities, regional disparities and health inequity in North African countries
© Boutayeb and Helmert; licensee BioMed Central Ltd. 2011
Received: 22 January 2011
Accepted: 31 May 2011
Published: 31 May 2011
During the last decades, North African countries have substantially improved economic, social and health conditions of their populations in average. In all countries, human development in general and life expectancy, literacy and per capita income in particular have increased. However, improvement was not equally shared between groups of different milieu, regions or level of income. Social inequalities and health inequity have persisted or even worsened. Data are generally scarce and few studies were devoted to this topic in North Africa as a region. In this paper, we carry out a comparative study on the achievements of these countries, not only in terms of human development and its components but also in terms of inequalities' reduction and health equity.
This study is based on data available for comparison between North African countries. The main data sources are provided by reports released by the World Health Organisation (WHO), United Nations Development Programme (UNDP), United Nations Children's Fund (UNICEF), the World Bank, surveys such as Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) and finally recent papers published on equity in different countries of the region.
Results and discussion
There is no doubt that education, health and human development in general have improved in North Africa during the last decades. Improvement was, however, uneven and unequally enjoyed by different socioeconomic groups. Indeed, each country included in this study shows large urban-rural disparities, discrepancies between advantaged and disadvantaged regions and cities; and unacceptable differences between rich and poor. Health inequity is particularly seen through access to health services and infant mortality.
During the last decades, North African decision makers have endeavoured to improve social and economic conditions of their populations. Globally, health, education and living standard in general have substantially improved in average. However, North African countries have still a long way to go to reduce social inequalities and health inequity at different levels: rural-urban, advantaged-marginalised regions and cities, between groups of different level of income and wealth. The challenge for the next decade is not only to improve economic, social and health conditions in average but also and mainly to reduce avoidable inequalities in parallel.
During the last decades, North African countries have seen a substantial improvement in the living standard of their populations. Life expectancy, literacy and per capita income improved in all countries and consequently, human development index has been steadily increasing. Beyond the global trend, however, improvement was not equally enjoyed. Indeed, urban-rural disparities, discrepancies between regions and inequalities among socioeconomic groups have persisted or even increased in North African countries during the last decades.
North African countries: Demographic data as published by UNDP in 2010
Population (in million)
% of Urban population
GDP per capita (PPP$)
Adult literacy (%)
Fertility (births per woman)
Life expectancy (years)
Infant Mortality Ratio (IMR) (Deaths per 1000 live births)
Maternal Mortality Ratio (MMR) (Deaths per 100,000 live births) 180
2. Human development: similarities and disparities
The introduction by the United Nations of human development index (HDI) as a mean of three indicators weighed equally: health (life expectancy at birth), standard of living (purchasing power parity income) and education (literacy and enrolment) illustrated clearly the importance of health and education and proved that an increase in national income alone does not capture development in its fullest sense [8, 9]. As part of the Arab region, North African countries were concerned by the five Arab Human Development Reports [10–14]. While noting the substantial economic and social progress made during the last decades, the previous reports stressed that North African countries and Arab countries in general have accomplished less than expected in terms of human development globally and in education, health and social justice in particular.
In a previous paper dedicated to human development and health indicators in the Arab region , the authors carried out data analysis on education and health measures (omitting income), focusing on the link between human development and health indicators. Compared to oil-rich countries, North African countries were seen to have low rates of literacy and unacceptable low rates of access to health care and facilities, especially in rural areas.
From 1980 to 2010, Morocco achieved the best relative increase in human development index (61%) whereas Algeria had the lowest relative increase (53%). Egypt and Tunisia accomplished nearly the same relative increase (58% and 57% respectively). According to the Human Development Report 2010 , Libya (53d), Tunisia (81st) and Algeria (84th) belong to the High Human Development group whereas Egypt (101st) and Morocco (114th) fall in the medium group. It should be noted, however, that UNDP has made some changes in the way of computing HDI (shifting from arithmetic mean to geometric mean) and also in the classes by HDI (Very high group, high group, medium group and low group).
The human development index being an average of three components, more details can be obtained by looking at the achievement of each country separately on health, education and income. In 2010, all North African countries had a mean life expectancy at birth greater than 70 years (Table 1). If we consider, however, the expectation of lost healthy years, these numbers will be amputated by 10 years or more.
In terms of literacy and education achievements, North African countries embarked upon the third millennium burdened by millions of illiterate adults. For instance, in 2010 Morocco had nearly half of the adult population illiterate and around 60% of combined gross enrolment in primary, secondary and tertiary education. For Egypt, Algeria, and Tunisia adult literacy rates were respectively 66.4, 72.6 and 78 whereas Libya had a rate of 88.4%. Similarly, the rates of combined gross enrolment in primary, secondary and tertiary education where around 75% for Algeria, Egypt and Tunisia, and a higher rate for Libya (94.1%) [1, 14].
Looking at the between countries difference in income, it appears that GDP per capita in Tunisia ($7979) is much higher than in Morocco ($4628) and Egypt ($5889) and, although Algeria and Libya are both oil-countries producers, the Algerian GDP per capita ($8320) is less than half that of Libya ($17068).
As a conclusion, human development in North Africa is relatively uneven. For instance, life expectancy in Libya and Tunisia is three years higher than life expectancy in Egypt and Morocco. In terms of adult literacy, the gap between Libya and Morocco is 32% and finally the Libyan GDP per capita is 3 times higher than GDP in Egypt and 3.7 times higher than GDP in Morocco.
3. Inequalities and inequity within countries
Human development index is among the most used indicator giving a summary measure of Human development and allowing for comparison between countries around the world. However, although HDI deals with achievements in education, health and income in a given country, measurements are national average numbers which may hide inter-groups inequalities and regional disparities. Different forms of inequity remain not captured even with the use of measurements such as human poverty index (HPI), gender-related development index (GDI) and gender empowerment measure (GEM).
3.1 Measures of inequality
Consumption or income index is often used to measure economic inter-groups inequalities. For pragmatic reasons, however, wealth index is becoming the most used in research on economic disparities. This tendency is justified by the use of data collected through demographic health surveys (DHS) which contain no information on consumption and income but on the other hand, they do have sufficient data on assets necessary for a decent living standard and wellbeing (housing, access to water and sanitation, health services and health outcomes, education, employment, violence, leisure, etc...). Nevertheless, neither consumption/income nor wealth index is sufficient to define the multidimensional inter-group inequalities. Disparity and inequity can also be measured through education, gender, place of residence and other factors like ethnicity and stigma .
3.2 Inequality in income or consumption in North Africa
3.3 Inequality measured by Gini Index
Evolution of Gini index in some Arab countries
3.4 Inequality in education and literacy
Since the launch of the Millennium Development Goals , North African countries made noticeable achievements in terms of primary education enrolment for both boys and girls. Considering, however, the combined enrolment ratio for primary, secondary and tertiary education shows that the rates are around 75 for Algeria, Egypt and Tunisia, with a small difference between male and female whereas for Morocco the rates are 55% for females and 62% for males. These figures stress that efforts made to increase primary enrolment may be hampered by high rates of dropping out of school, child labour and difficult access to secondary and tertiary education especially for poor girls and/or those living in rural areas. Indeed, in Egypt, a global study on child poverty and disparities recently conducted by UNICEF showed that 1/5 of children live in poverty and that one in four children are deprived of one or more dimensions of welfare. Stressing that vulnerability is the same for boys and girls, the study indicates that child-poverty in Egypt is regional, with higher concentrations in rural areas and Upper Egypt. For instance more than 30% of children in rural areas live in households that are poor compared with 12.6% in urban areas . The consequences for education are obvious since a child born in the poorest quintile is 11 times likely to be deprived from education than a child born in the richest quintile.
In Morocco, the educative system efficiency is very low (57.5 for primary school and 35.4 for secondary level). The lost is due to high levels of dropping out and repetition. Analysis of data in the poorest 404 rural districts identified by the National Initiative for Human Development (NIDH) revealed that socioeconomic conditions and proximity of school are the main factors explaining dropping out .
In Tunisia, a multivariate analysis of data from MICS3 showed that the proportion of children reaching the fifth level of primary school was principally correlated with milieu and children work .
Despite the efforts devoted by North African countries during half a century in order to reduce the rate of illiteracy, the problem is still burdening these countries with more or less acuteness as illustrated by the following examples.
Example 1. Literacy rate in Morocco (1999)
Example 2. Evolution of illiteracy in Algeria
Absolute or relative differences: which to choose?
4. Health inequity
4.1 General pattern
4.2 Rural-urban and/or regional inequalities
In general, all North African countries show rural-urban and/or regional discrepancies in health indicators and access to care.
According to a review on social determinants of health carried out by WHO in seven countries in the Eastern Mediterranean Region, health indicators vary regionally between Lower Egypt and Upper Egypt, and, in each region, discrepancies are found between rural and urban populations . Similarly, in Morocco, more than 30% of the rural population has to travel at least 10 kilometres to reach the nearest health facility, the number of inhabitants per physician ranges from 6362 in the rural area of Taounate (in the remote north east) to 380 in the capital, Rabat. The number of public hospital beds per 100 000 population ranges from 31 in the rural area of Berkane (in the remote north-east), to 444 in Rabat [2, 22]. As shown in Figure 5, A Moroccan rural woman is twice unlikely to attend antenatal care or to deliver with assistance of medical personnel; and nearly four times likely to deliver at home than a Moroccan urban woman. For Egyptian women, the ratios are respectively 0.5, 0.6 and 2.2. In Libya, effect of socioeconomic factors on child development were considered in a cross sectional study carried out in two regions (Al Jabel and Tripoli) of the Jamahiriya on the growth and nutritional status of children under five years of age. The prevalence of stunting was higher among Al Jabel children (6.1%) than in Tripoli (2.5%) and in rural (6.8%) rather than in urban areas (2.8%) .
Evolution of the rate of non assisted deliveries in Tunisia
Decrease by 1.6
Decrease by 1.8
4.3 Poor-Rich inequalities
Few data on rich-poor health inequity in North Africa are published. However existing evidence indicates that exacerbated inequalities are found in the use of health services such as antenatal visits, births assisted by skilled medical personnel and births given in a medical centre. Consequently, indicators like infant mortality and maternal mortality will show gaps between rich and poor.
Women who did not receive antenatal care
Women who had no postnatal visit
Women who gave birth at home
Women who delivered with assistance of a traditional midwife
In Egypt, more recent data from DHS 2008 indicate that the gaps between rich and poor women who did not receive antenatal care, had no postnatal visit, gave birth at home or delivered with assistance of a traditional midwife are similar to those in Morocco. The ratios are respectively 6.1, 5, 10 and 15 (Table 5) .
In Egypt, the proportion of the richest women having multiple antenatal visits and that of women giving birth in presence of skilled personnel are threefold that of the poorest women. The gap in births given at home is fivefold. The poorest children (respectively infant) are two and half time likely to die than the richest children and infant. Stunting and under weight reveal similar levels of inequality . More generally, it is estimated that 7 million children are deprived of one or more of their rights, which include nutrition, access to basic health care, education and shelter .
Disparities in delivery, Egypt (1995-2005) 
Any prenatal care
CI by Education
CI by Wealth index
Skilled birth attendant
CI by Education
CI by Wealth index
Delivery at home
CI by Education
CI by Wealth index
During the last decades, North African countries have seen a noticeable growth in terms of economic, social and health indicators [2–4, 24]. Unfortunately, this growth has not been enjoyed equally by different socioeconomic groups of the same country. Sharp social inequalities and health inequities are found between rural and urban, regions and wealth income groups. For instance, social status is a major determining factor of survival for children. In North African countries, illustration is particularly given by post-natal mortality which is mainly due to factors such as food, primary health care and hygiene. It is striking to see that in these countries, postnatal mortality may be five times greater in children belonging to the poorest quintile, compared to children living in the richest quintile. Similarly, a child of an illiterate woman is three times more likely to die than a child of a woman with secondary or higher level of education, and finally, post natal mortality is 2.5 times greater in rural areas than in urban cities.
As stressed by the WHO Commission on Social Determinants of Health in its report entitled "closing the gap", where systematic differences in health are judged to be avoidable by reasonable action, they are quite simply unfair . Like other developing countries, North African countries are struggling to reach the Millennium Development Goals by 2015. But in doing so, they may improve average indicators with persistent or even increasing inequalities. Moreover, facing the double burden of communicable and non communicable diseases with limited health budget, North African decision makers need to adopt optimal and efficient strategies. Health decisions need to focus on targeted and equitable health programmes that aim to enhance the mean status of the whole population but at the same time to reduce regional disparities between developed and disadvantaged regions; inequalities between rich and poor, and marginalisation of the rural population. In the light of the general uprising affecting most of Arab and North African countries, decision makers are urged to act on unjustifiable and avoidable inequalities, otherwise they will have no (or very few) chances to achieve a sustainable development.
Part of this work was undertaken during a visit of BA to the CRP at the Faculty of Health Sciences of the American University of Beirut which was funded by the Wellcome Trust. The second part of the work was accomplished under a DAAD grant which allowed BA to visit UH at the Centre for Social Policy Research of Bremen University, Germany.
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