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The Equity Gauge: An approach to Monitoring Equity in Health and Health
Care in Developing Countries
International Meeting August 17-20
Tim Evans
What do we mean by health equity?
• A world in which any group of individuals defined by age, gender, race-ethnicity, class or residence can achieve its full health potential
What do we mean by health equity?
• ‘health inclusion’: continued improvements in health for all but bringing the bottom up at the same rate or faster than the top
• ‘tolerable’ vs ‘intolerable’ inequalities: in the context of rapid change
What are the dimensions of inequity in health?
• Equity strata: sex, race, ethnicity, region, education, occupation, place
• Dimensions of health status across which inequities exist: risk, disease, death, social consequences of illness
• Health care inequities: access, quality & cost of treatment
Health Disparities Between Selected Countries
0
10
20
30
40
50
60
70
80
Life Expectancy 1994 JapanSierra Leone
0
200
400
600
800
1000
1200
1400
1600
Maternal Mortality 1990NorwayGuinea
Age
Dea
ths
per
100
,00
live
bir
ths
Health Status of Poor Versus Non-poor
in Selected Countries (1990)
Probability of dyingper 1000 (females)
Betweenbirth - 5
Betweenages 15 - 59
Prevalenceof
tuberculosisCountry
Percentageof
populationin absolutepoverty a Poor:non-poor
ratioPoor:non-poor
ratioPoor:non-poor
ratio
Aggregate 4.8 4.3 2.6Malaysia 6 15.0 5.1 3.2Ecuador 8 4.9 4.4 1.8Chile 15 8.3 12.3 8.0China 22 6.6 11.0 3.8Kenya 50 3.8 3.8 2.6India 53 4.3 3.7 2.5
Adapted from Table 2.1, The World Health Report, World Health Organization, 1999. a Poverty is defined as income per capita of less than or equal to $1 per day, expressed in dollars adjusted forpurchasing power.
Gender and Socioeconomic Inequality in CMR, Matlab 1982
39.2
25.4
17.6
19.112.8 11.9
0
10
20
30
40
O year 1-6 years 7+ years
Mal
e
Fem
ale
Schooling of Household Head
CMR
Male Female
Source: Bhuiya et al. 1998
Inverse Care Laws
• Rich consume more hospital and public health care than the poor (Hart 1971)
• Immunization coverage strongly correlated with socioeconomic status (Gwatkin et al. 1999)
• poor with illness don’t access care: 2x more likely to self treat; 10x more likely to do nothing (Uganda,
HH Survey, 1994/5).• poor that access health care risk medical
impoverishment (Liu and Hsiao, 1997; WB, Voices of the Poor, 2000)
Smoking is more common among the less educated in India
(Men, Chennai)
0
10
20
30
40
50
60
70
Smok
ing
Pre
vale
nce
(%)
Illiterate <6 yrs 6-12 yrs >12 yrs
Source: Gajalakshmi, CK et al. Patterns of Tobacco Use and Health Consequences, Background Paper for “Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.
Inverse Care in Public Health2.80% 6.10%
bottom quintiletop quintile2.50% 3.30%2.50% 8.40%
0.00%
5.00%
10.00%
Clinics Hospitals
Public Health Service Use, Ghana
bottom quintile
top quintile
Physicians
Beds
Hospital deliveries
Distribution of Health Resources, México 1990-96
by level of county marginalityR
ate
pe
r 1
0,0
00
p
op
ula
tion
Very low Low Medium High Very high0
5
10
15
20
0
20
40
60
80
100
%
Benchmarks of Fairness
• Evaluating fairness of health systems reform
• nine benchmarks covering risks to health such as education, safe water and barriers to access both financial and non-financial etc.
• must develop capacity to monitor health status inequities
• benchmark encourage “debate” on reform
World Health Report 2000
Measure of Health System
Performance
Aggregate Distribution
Health Outcomes
Responsiveness
Financing
Source: WHR 2000 Quality Equity
Equity Gauge: South Africa
• Health equity explicit goal of • government policy • Problem: how to monitor progress?• Partnership: parliamentarians, researchers, NGOs• Gauge development - district and province
resource allocation, utilisation of health care, health status
What constitutes an equity gauge?
1) Fair distribution: an organizing principle
2) Key health systems stakeholders
3) Community ownership/integration
4) Technical competency: scope/reach, measures - valid, reliable, sustainable
5) Informing decision- making: awareness/demand, accessibility, user-friendliness, timeliness
Central challenges
• To identify valid indicators to assess short and longer term change
• To integrate policy link from the outset
• To ensure that gauges provide voice and visibility to the needs of the vulnerable and marginalized
IMR highest and lowest quintilesRelative inequality/ Absolute Inequality
Hi:Low Rate Ratio Rate difference
0
0.5
1
1.5
2
2.5
3
IMR
rate
rat
io (l
o:hi
)
0102030405060708090
100
IMR r
ate di
fferen
ce
Source: DHS data 1992-1997; Pande and Gwatkin 1999
Range of approaches• City or municipality based ‘gauges’
• National systems with broad partnerships
• Innovative household-based monitoring mechanisms
• Involvement of indigenous groups
• Redesign of surveys for equity focus
• Resource allocation focus
• Broader social determinants focus
What unites these efforts?
• the need for greater capacity to monitor and act upon health systems inequities
What led up to this meeting?
• Global Health Equity Initiative 1995-2000 (research to reveal inequities within LDCs)
• Arlington Health Equity meeting June 1999 (move from research on gaps to monitoring for action)
• Puyuhuapi, Chile meeting October 1999 (strengthen country capacity for monitoring)
• South Africa- August 2000
Who is here?
• Asia: Bangladesh, China, Lao, Philippines, Thailand
• Africa: Ethiopia, Kenya, Malawi, Mozambique, South Africa, Uganda, Zambia, Zimbabwe
• Latin America: Argentina, Bolivia, Chile, Cuba, Ecuador, Peru
Meeting objectives
• Embrace the “common” challenge– Exchange ideas and experiences – Lay foundations for greater competency via
three working groups- technical, advocacy and policy;
– Identify potential and mechanisms for longer-term collaboration
Vision
By the year 2015 every country should have an integrated system for monitoring health system inequities that informs, monitors and evaluates health and other socioeconomic policies
--Puyuhuapi Conference position statement
Measurement and Monitoring
• Correct the first injustice - making people count - vital registration systems with local ownership.
• Regular reporting of inequities - need better measurement tools for policy
• Prospective assessment of health system policy -Health equity impact assessments
Reversing the Inverse Care Laws
• Equity targets - both outcomes and access, symbolic and practical (Dahlgren and Whitehead, 1997)
• Financing reforms - to remove disincentives to access and protect from medical impoverishment
• Prevention of health risks that cluster with poverty and are cumulative over time e.g. tobacco
• Evidence on what works - both within and beyond the health care sector