FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Table 2.1 Health expenditures and availability of medical staff(various indicators, 2018) Current health expenditure(CHE) as% of gross domestic product(GDP) Current health expenditure(CHE) per capita in PPP Primary health care(PHC) expenditure as % of current health expenditure(CHE) Primary health care(PHC) expenditure per capita in PPP Medical doctors(per 10,000 population) Nursing and midwifery personnel(per 10,000 population) Out-of-pocket spending(OOPS) as% of current health expenditure Senegal 3.98 146.4 65.9 96.5 0.691* 3.127* 55.9 Benin 2.49 83.2 n.a. n.a. 0.791 3.888 45.5 Côte d’Ivoire 4.19 176.3 80.4 141.7 2.314*** 6.048 39.4 Note:*= 2017;**= 2016;***= 2014. Source: https://apps.who.int/nha/database/ViewData/Indicators/en; https://apps.who.int/gho/data/node.main Ethiopia 3.29 66.6 82 54.6 0.769 7.135 35.5 Kenya 5.17 179.2 72.5 129.9 1.565 11.656 23.6 Zambia 4.93 208.4 78.5 163.6 1.628** 13.376 10 tion. In some regards, they do relatively well, while in others they perform worse. 11 To that extent, the supply indicators for health services correspond to respondents’ views on the use of medical care. The data show similarities and differences between the countries and clearly allocate an outstanding role for» better health services« and» better schools and education« as top priorities for the informally employed. 2.3 DEMAND FOR BETTER STATE SERVICES For the purpose of ranking people’s expectations for im­proved state services, eight services are considered»key responsibilities« of the state to society and offered for se­lection:»better schools and education«,»health services«, »water supply«,»roads and bridges«,»electricity supply«, »pensions for the elderly«,»food supplies in times of crisis« and»police services«. 12 Respondents 13 were first asked to assess in each case whether the government should improve a respective service on the list. Thereafter, they were asked to rank the services as their first, second or third priority. 14 2.3.1 Priorities for better state services Figure 2.5 provides an overview of respondents’ answers regarding their highest priority in the list. – In all six countries,»better health« is ranked top or sec­ond; in Benin, Senegal and Côte d’Ivoire»better health« is the top runner by far; in Kenya, Zambia and Ethiopia, it is relegated to second place by a low margin; on average, in a six-country average, 31.5 per cent of respondents make»better health services« their top choice. – Similar prominence is given to»better schools and education«. In Kenya and Zambia, it comes ahead of health in top position; in Senegal and Côte d’Ivoire it is ranked second; and only in Benin and Ethiopia it is »downgraded« to third and fourth place, respectively. – The bottom end of the ranking is unambiguous. In all countries,» better police services« and» better pensions for the elderly» are found at the bottom of the demand hierarchy. 11 While some countries fare better than others in relation to a spe­cific indicator, none of them is anywhere close to the 4.5 workers per 1,000 people that the WHO estimates are needed to meet the SDG target of universal health coverage. 12 See Traub-Merz and Öhm(2021: Appendix I) for more information on the construction of the service ranking. 13 The interviews were structured into two parts. The question on the use of medical care belonged to part one and was answered by the household head; the assessment of state services belonged to the second part and was answered by the»selected person«. The se­lected person was in some 60 per cent of the cases again the house­hold head, but in 40 per cent of cases a different member of the household. We compared the answers of the two groups(household head vs other member) and found no statistically relevant difference. Obviously, members of the same household can be seen as a commu­nity of norms( Normengemeinschaft), exchange views on the quality of state services and»conclude a united household view«. We there­fore found no reason to separate respondents into heads of house­hold and other members. 14 We limit ourselves here to findings according to the first priority. – Five of the six countries produce a middle cluster con­sisting of various infrastructural components:» better water supply«,» better food programmes in times of crisis«,» better roads and bridges« and»better electricity supply«. The rankings of these services vary between countries, but none comes first or last. – Ethiopia is a case on its own. There, respondents put better water supply and better roads significantly higher in their needs hierarchy than do respondents from the other countries. Calls for improved infrastructural ser­vices are level with calls for better health services. 2.3.2 Demand for health services by residence, age, income and gender Demand for a service reflects the gap between needs and shortage of supply. Various factors may impact on percep­12