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<JournalTitle>Journal of Medical and Surgical Research</JournalTitle>
<PISSN>I</PISSN>
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<Volume-Issue>Vol. XIII, n 1</Volume-Issue>
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<IssueTopic>Multidisciplinary</IssueTopic>
<IssueLanguage>English</IssueLanguage>
<Season>June 2026</Season>
<SpecialIssue>N</SpecialIssue>
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<IssueOA>Y</IssueOA>
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<Year>-0001</Year>
<Month>11</Month>
<Day>30</Day>
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<ArticleType>JMSR Public Health</ArticleType>
<ArticleTitle>From nominal coverage to effective financial protection: A panel cointegration analysis of public and household health spending in 24 middle-income countries, with Morocco as the reference case</ArticleTitle>
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<ArticleLanguage>English</ArticleLanguage>
<ArticleOA>Y</ArticleOA>
<FirstPage>1574</FirstPage>
<LastPage>1587</LastPage>
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<Author>
<FirstName>Aazelarab</FirstName>
<LastName>Boughaleb</LastName>
<AuthorLanguage>English</AuthorLanguage>
<Affiliation/>
<CorrespondingAuthor>N</CorrespondingAuthor>
<ORCID/>
<FirstName>Mounir Jerry</FirstName>
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<AuthorLanguage>English</AuthorLanguage>
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<Abstract>Introduction: Morocco__ampersandsign#39;s health financing reform has produced a large, sustained increase in public health expenditure since 2021, yet whether this translates into effective financial protection for households remains untested. This study examines whether public health spending substitutes for household out-of-pocket spending across middle-income countries, and situates Morocco within that broader pattern.Methods: We assembled a balanced panel of 24 middle-income countries observed annually from 2000 to 2023 (576 country-year observations), drawn from the WHO Global Health Expenditure Database and the World Bank World Development Indicators, with institutional quality from the 2025 revision of the Worldwide Governance Indicators. Household and public health expenditure per capita and GDP per capita were expressed in logarithms and tested for unit roots using the cross-sectionally augmented panel unit root test. Cointegration was assessed through residual-based tests and error-correction dynamics. Long-run elasticities were estimated with two-way fixed effects, mean group, and common correlated effects mean group estimators, with Driscoll-Kraay standard errors. Slope homogeneity across countries was tested, and the resulting heterogeneity was examined by country group and by leave-one-country-out sensitivity analysis.Results: Household and public health spending per capita, and GDP per capita, are integrated of order one and cointegrated. No estimator yielded a significant negative long-run elasticity of household to public health spending at the panel level (common correlated effects mean group: 0.134, p = 0.117). Slope homogeneity was rejected (Cochran Q, p < 0.001; 82% of the dispersion of country coefficients exceeded sampling error). Regional peers of Morocco in the Middle East and North Africa displayed a significant positive elasticity (0.278, p = 0.040), indicating complementarity rather than substitution, a result that survived country-trend specifications, alternative samples, and the removal of any single country. Morocco__ampersandsign#39;s own elasticity was positive (0.559) but not individually significant. Generic governance indicators did not explain the cross-country heterogeneity (p = 0.80__ampersandsignndash;0.95). Morocco__ampersandsign#39;s public health expenditure per capita rose ninefold between 2000 and 2023, while household spending never declined.Conclusion: Increasing public health expenditure is not sufficient, by itself, to reduce household financial exposure in Morocco or in comparable middle-income health systems. The absence of substitution appears to be a regional rather than a uniquely Moroccan pattern, and is not explained by standard governance indicators, pointing instead to health-system-specific determinants such as provider payment mechanisms and private-sector regulation.</Abstract>
<AbstractLanguage>English</AbstractLanguage>
<Keywords>Cointegration, Health financing, Middle-income countries, Morocco, Out-of-pocket expenditure, Panel data, Universal, health coverage</Keywords>
<URLs>
<Abstract>https://journal-jmsr.net/ubijournal-v1copy/journals/abstract.php?article_id=16354&title=From nominal coverage to effective financial protection: A panel cointegration analysis of public and household health spending in 24 middle-income countries, with Morocco as the reference case</Abstract>
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<References>
<ReferencesarticleTitle>References</ReferencesarticleTitle>
<ReferencesfirstPage>16</ReferencesfirstPage>
<ReferenceslastPage>19</ReferenceslastPage>
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