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I. V. Chapitre, Migrations 26. Peut-être que si nous disposions de l'information sur coût de transport vers l'hôpital l'efet sur les dépenses hospitalières serait plus signiicatif

, Cette piste est actuellement explorée dans le cadre d'une extension de l'article en anglais en cours de rédaction, reprenant en partie ce chapitre 28. L'efet des remises est moins marqué lorsque nous utilisons l'indice de consommation totale, 16%, parce que celui-ci est plus fortement corrélé aux dépenses de santé que l

, Lorsque les efets ixes locaux sont introduits, l'endogénéité est nettement moins probable. Même dans la spéciication (8), dans laquelle l'instrument est à la limite d'être faible (F-stat de 10.7), le test d'inférence robuste à un instrument faible valide la non endogénéité de RR

, Comme évoqué précédemment, les variables de besoin de soins favorisent bien le renoncement, selon un mécanisme connu de la littérature en économie de la santé : plus l'individu a un état de santé qui nécessite des soins, plus il a de chances d'avoir déjà dû renoncer à des soins. La part de femmes augmente aussi le renoncement, ce qui est probablement lié au même mécanisme puisque les femmes recourent plus aux soins ou ont plus de besoin sur toute une période du cycle de vie. Enin, l'éducation supérieure diminue les chances de ne pas recourir aux soins. Notons que cela coïncide avec certaines prénotions des médecins sur le terrain qui disent que leurs patients peu éduqués préfèrent attendre de voir si cela passe et c'est pourquoi, selon eux, lorsque les patients arrivent dans les services de soins leur état de santé s'est déjà dégradé (voir I). Il faut cependant contrebalancer cette observation par le fait que la plupart de ceux qui renoncent disent le faire pour des raisons économiques et géographiques de distance à l'hôpital particuliè, Ensuite, recevoir des remises diminue signiicativement le renoncement total et le renoncement partiel. Cela conirme que la réception de remises agit comme une protection et favorise l'accès aux soins

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, En outre, le montant des restes-à-charge représente souvent une dépense catastrophique pour les ménages. Même s'il varie entre régions, il peut décourager une part de la population de se faire soigner ou l'inciter à trouver des recours alternatifs. Enin, un climat de déiance vis-à-vis de certains soignants a été observé, principalement à Douchanbé. Or, c'est aussi à Douchanbé et dans les villes que les paiements informels aux soignants sont les plus fréquents et les plus élevés en moyenne. C'est pourquoi nous nous sommes demandés dans le chapitre II si ces pratiques de rémunérations informelles à la in d'une prise en charge étaient une des raisons de cette déiance ou un moyen d'instaurer une relation de coniance. Les pratiques de paiements informels ne sont pas toutes équivalentes. Il y a la norme -donner 5 à 20 TJS après que le médecin a pris soin de soi -, il y a la logique incitative -donner un peu plus au médecin pour l'encourager à mieux prendre soin de soi -et il y a le paiement qui n'est pas donné mais réclamé par un médecin abusif. D'autres formes et expressions ont été entendues montrant combien le sens du paiement dépend du contexte et prouvant qu'il n'y a pas une forme ixe de paiement informel. L'évolution des représentations associées aux paiements informels se fait conjointement à l'évolution institutionnelle du système de santé, d'un système universel public à un système privé informel par transfert de la charge inancière. Les représentations inluencent les pratiques ; les pratiques et les choix politiques entraînent la marchéisation des soins, qui fait évoluer les représentations. La comparaison des résultats des chapitres I et II sur le lien entre la déiance et les paiements informels donne une idée de la raison pour laquelle le paiement informel normal semble lui-même mettre à mal la convention. Le paiement informel a un efet ambigu sur la déiance. En efet, dans les témoignages, la déiance envers la profession médicale portait d'une part sur l'incompétence des médecins et d'autre part sur leur intégrité. Or, Enin, en laissant la diférenciation à la discrétion des médecins, Principaux résultats Les éléments de contextualisation exposés dans le chapitre introductif montrent tout d'abord qu'il existe des obstacles à la fois physiques et inanciers à l'universalité des soins. Si le maillage du système de santé hérité de l'époque soviétique s'étend sur tout le territoire, l'accessibilité des soins de qualité n'est pas garantie dans tous les districts, dans ce pays majoritairement montagneux

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