Equity and Efficiency in Health Financing: Classical Opposition or Potential Complementarity? A Critical Narrative Review with Implications for Morocco

Abstract

The relationship between equity and efficiency is central to health financing and is often presented as an unavoidable trade-off between distributive justice and the optimal use of scarce resources. This article provides a critical narrative review of the literature to examine whether this opposition should be considered structural or whether it partly results from narrow analytical frameworks. The review shows that conventional approaches have often reduced efficiency to aggregate productive or budgetary performance, while treating equity as an external constraint or a secondary distributive correction. Such a perspective tends to fragment the analysis of financial protection, health system performance, resource allocation and the distribution of policy effects. The article argues that although real trade-offs exist in some contexts of scarcity and priority setting, they do not fully capture the relationship between equity and efficiency. In many settings, reducing out-of-pocket payments, strengthening risk pooling, investing in primary health care, improving strategic purchasing and explicitly considering distributive effects may enhance financial protection, access to care and the social efficiency of health systems. Recent approaches, particularly Extended Cost-Effectiveness Analysis and Distributional Cost-Effectiveness Analysis, provide useful tools for integrating distributional consequences into economic evaluation. The article concludes that a more integrated approach to health financing can better identify both genuine trade-offs and potential synergies between social justice and system performance, with important implications for Morocco and other low- and middle-income countries.