Social determinants and health inequalities in Oran and Tlemcen

Social inequalities in health exist in all countries, regardless of the insurance system that regulates access to healthcare, as highlighted in the report of the Commission on Social Determinants of Health of the World Health Organization (WHO). Achieving universal health coverage has become a key objective for the international community following its adoption by the WHO, alongside recommendations to generate stronger evidence to ensure its effective implementation.

Despite an overall and undeniable improvement in health indicators in both developed and developing countries—particularly in Algeria, as evidenced by a life expectancy exceeding 75 years—the origins of social inequalities in health remain multifactorial and complex. They are linked to socio-economic conditions, individual circumstances and life-course trajectories. These inequalities are reflected in differences in life expectancy according to occupation, amounting to a gap of seven years between manual workers and senior managers, as well as differences by gender. For example, the rate of premature mortality among men without educational qualifications is 2.5 times higher than that of men with qualifications, while among women this rate is 1.9 times higher. The importance of early childhood in the construction of these inequalities has also been clearly established.

In response to the worsening of social inequalities in health over the past two decades, several European countries, within the policy framework of “Health for All”, have developed projects and conducted various comparative studies. These works have revealed the existence of social differences in perceived health status, exposure to disease risk, disability, and risk of death. This has led to a better understanding of the causes of social inequalities in health and to the identification of specific determinants, such as cardiovascular diseases, digestive cancers and diseases of the digestive system. Following this phase of identification and measurement, several countries—including the United Kingdom, the Netherlands and France—have committed themselves to reducing these inequalities through the implementation of targeted health policies. Monitoring social inequalities in health and accumulating knowledge about their causes are clearly essential prerequisites for guiding health policies.

Algeria is currently undergoing a demographic and epidemiological transition, as demonstrated by various studies (TAHINA, WHO STEPS, PAPFAM 2002), as well as an economic transition. Significant reductions in mortality indicators have been achieved since the 1990s; however, these remain insufficient to meet the fourth and fifth Millennium Development Goals relating to maternal and infant mortality.

The Human Development Report produced by the National Economic and Social Council (CNES) in 2006 highlights disparities between districts across the country. In terms of mortality, the Wilaya of Oran ranked second after Algiers, with 7,433 deaths recorded in 2008 (5.4%), and its infant mortality rate exceeds the national average.

Regarding the identification of causes of death, notable progress has been made in improving both the quantitative and qualitative aspects of mortality statistics through the establishment of a dedicated causes-of-death unit at the National Institute of Public Health (INSP). However, socio-economic and geographical criteria have not yet been incorporated into mortality analyses. The TAHINA study and research on hospital mortality among children under 15 years of age have shown that avoidable mortality represents a significant proportion of overall mortality.

The aim of this research is to contribute to the identification of social inequalities in health in terms of mortality and morbidity among populations. In this context, the project is based, on the one hand, on the study of overall and premature mortality, and on the other hand, on the analysis of morbidity and self-perceived health among users of healthcare services, using focus groups, interviews and panels.

Inequality is examined through the outcomes of the healthcare system—mortality and morbidity—understood as differences in health status between population groups. These differences will be highlighted using a qualitative approach. This study does not aim to analyse inequalities in terms of accessibility to healthcare services or service provision.

To this end, a comparative study was conducted across research sites differing according to the following criteria: type of settlement and level of wealth (high, medium and low). Three municipalities were selected within the Wilaya of Oran.