Equity or Equality MD-MPH, SDH Course اسفند هشتاد و شش

Equity or Equality MD-MPH, SDH Course

اسفند هشتاد و شش

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تاريخچه•تعريف: برابري يا عدالت•توزيع زماني و مكاني نابرابري•اندازه گيري نابرابري•

ضريب جيني––Concentration index

ابعاد نابرابري•

3

تاريخچه

1845 اولين نوشته هاي مربوط به عدالت به سال • باز مي گردد. Fredrick Engelsتوسط

تعلق سياسي و علمي به نابرابري 1980در سال •در سالمت و عوامل موثر بر آن افزايش مشهودي

داشت، و يكي از علل اصلي اين افزايش تعلق گزارشي با عنوان نابرابري در سالمت معروف

. بود "Black Report“به سازمان جهاني بهداشت توجه 1995در سال •

دولت ها و سازمان هاي جهاني را به اين موضوع .معطوف نمود

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تعريف

تفاوت در سالمتبي عدالتي در سالمت به معناي • غير ضروري و قابل اجتناباست به نحوي كه نه تنها

تلقي گرددناعادالنه و بي انصافانهباشد، بلكه و اختالفات سيستماتيكعدالت در سالمت به عدم وجود •

قابل اجتناب در يك يا چند بعد از سالمت در جوامع مختلف جغرافيايي، اجتماعي و دموگرافيكي اطالق

مي گردد. بي عدالتي در 1998سازمان جهاني بهداشت در سال •

ما وضعيت سلامت، عوامل خطر يا دسترسي به خدمات تندرستيسالمت را به شكل زير تعريف نمود: " نابرابري در بين افراد كه غير ضروري، قابل اجتناب و ناعادالنه

باشد" .

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مثال

ميزان سرطان ريه در افرادسيگاري بيش تر از •جامعه است.

سال بيش تر از 45-20خطر سكته قلبي در مردان •زنان در همين گروه سني است.

بيماري سل در قشر فقيرتر جامعه بيشتر است.• در افرادي كه رفتار پر خطر جنسي HIVشيوع •

دارند بيشتر است.افرادي كه به بيماري فنيل كتين اوري مبتال هستند، •

اميد به زندگي كوتاه تري دارند.

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رويكرد بين بخشيبرابري در سالمت مستلزم يك • شامل سياست هاي اجتماعياست كه تقريبا تمام

سياست هاي اقتصاديمحيط اجتماعي و فيزيكي، را در بر مي گيرد.سياست هاي آموزشيونيز

ارتقاي متوسط سطح سالمت لزوما با توزيع بهتر •سالمت، يعني عدالت، مربوط نيست. در نتيجه، سياست هايي كه متوسط سطح سالمت را ارتقا

مي بخشند، لزوما عدالت در سالمت را تامين نمي كنند و حتي مي توانند آن را كاهش دهند.

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8

Infant Mortality Rate

0

30

60

90

120

150

1980 1985 1990 1996

Bangladesh

India

Nepal

Pakistan

Sri Lanka

Half Full …

9

…Or Half Empty?


0

20

40

60

80

100

120

Pakistan(1990/91)

Bangladesh(1996/97)

Nepal (1996)

India (1992/93)

Poorest 20%Richest 20%

10

Is it Getting Better?


020406080

100120

Bang

lade

sh(1

996/

97)

Bang

lade

sh(2

004)

Nepa

l

(199

6)

Nepa

l(2

001)

Indi

a

(199

2/93

)

Indi

a (1

999)


11

How about in Africa?

0

20

40

60

80

100

120

140

Uganda SouthAfrica

Rwanda Nigeria

Poorest 20%

Richest 20%

12

Is Latin American any Different?

01020

3040

5060

7080

90

Bolivia Brazil Colom. Dom.Rep.

Poorest 20%

Richest 20%

13

Is East Asia any Different?

0

20

40

60

80

100

120

Vietnam Indonesia Cambodia Philipp.


14

How About the Middle East?

0

20

40

60

80

100

120

Morocco Egypt Yemen


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INFANT MORTALITY RATESamong Lowest and Highest 20% of the Population

56 Low- and Middle-Income Countries

0

20

40

60

80

100

120

East Asia,Pacific (4

Countries)

Europe,Central Asia (6

Countries)

Latin America,Caribbean (9Countries)

Mid.East,N.Africa (4Countries)

South Asia (4Countries)

S.Sahara Africa(29 Countries)

Total (56Countries)

Lowest 20% of Population Highest 20% of Population

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HOW ABOUT FERTILITY RATESamong Lowest and Highest 20% of the Population


0

1

2

3

4

5

6

7

East Asia,Pacific (4

Countries)

Europe, CentralAsia (6

Countries)


Mid.East,N.Africa (4Countries)


S.Sahara Africa(29 Countries)

Total (56Countries)


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HOW ABOUT SEVERE STUNTINGamong Lowest and Highest 20% of the Population


0

5

10

15

20

25

30

35

Europe, CentralAsia (6 Countries)


Mid.East, N.Africa(4 Countries)


S.Sahara Africa (29Countries)

Total (56Countries)


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كدام را اندازه مي گيريم ؟ برابري يا عدالت•

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20

Lorenz Curve

• X: Cumulative percent of population ranked by income

• Y: Cumulative percent of income

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Discussion question

• Look at spreadsheet

– Graph cumulative distribution of income

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Step 1: Income inequality

Cumulative proportion of population ranked by income

Cu

mu

lati

ve p

rop

ort

ion

of

inco

me

Diagonal: line of equality

Poorest Richest

Lorenz curve of income inequality

Gini coefficient: twice the area between the diagonal and the Lorenz curve

Range of Gini: 0-1

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Cumulative distribution of income

0,00%

20,00%

40,00%

60,00%

80,00%

100,00%C

um

ula

tiv

e %

of

inc

om

e

cumulative % of population ranked by income

20% 100%80%60%40%

income

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The Gini coefficient

• The diagonal reflects equal distribution of income

• The closer the Lorenz curve to the diagonal, the smaller the income inequality– When the Lorenz curve is close to the diagonal, the

area is small and the Gini coefficient is small – Small values of Gini indicate low inequality – The closer the Gini to 0, the less the inequality

• The further away the Lorenz curve from the diagonal, the greater the inequality

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Step 2: Inequality in health care payments

Cumulative proportion of population ranked by income

Cu

mu

lati

ve p

rop

ort

ion

of

healt

h c

are

paym

en

ts


Poorest Richest

Concentration curve of health care payments

Concentration index: Twice the area between the diagonal and the concentration curve

Range of CI: -1 & +1

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Concentration curve and index

• Increasingly popular measure of inequality• Summary measure capturing experience of

entire population • Helpful for comparison with other countries • Data needs

– Approach (a)– Household health data and direct measure of

SES

• See handout

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CI

• X: Cumulative percent of population ranked by income

• Y: Cumulative percent of diarrhea cases

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Cumulative share of diarrhea

Cumulative share of diarrhea cases

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%


cu

mu

lati

ve

%

of

dia

rrh

ea

ca

se

s

100604020 80

29

Cumulative share of diarrhea (2)


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%


cu

mu

lati

ve

%

of

dia

rrh

ea

ca

se

s

100604020 80

30



0.00%

20.00%

40.00%

60.00%

80.00%

100.00%


cu

mu

lati

ve

%

of

dia

rrh

ea

ca

se

s

100604020 80

31



0.00%

20.00%

40.00%

60.00%

80.00%

100.00%


cu

mu

lati

ve

%

of

dia

rrh

ea

ca

se

s

100604020 80

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Illness concentration curve

Poorest 50% of population

75% of disease burden

Cu

mu

lati

ve p

rop

ort

ion

of

illn

ess

Inequality where the poor bear a greater share of illness than their share in the population

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Cumulative proportion of population ranked by socio-economic status

Cu

mu

lati

ve p

rop

ort

ion

of

illn

ess



Poorest Richest

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Poorest 50% of population

25% of disease burdenC

um

ula

tive p

rop

ort

ion

of

illn

ess

Inequality where the rich bear a greater share of illness than their share in the population

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Turkey: distribution of IMR99.9

72.7 72.1

54.4

25.4

0102030405060708090

100

Poorest 2nd 3rd 4th Richest

Quintiles

IMR

Infa

nt

mort

alit

y r

ate

(per

1,0

00

LB

s)

Source: DHS, 1993 http://www.worldbank.org/poverty/health/data/turkey/turkey.pdf

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Turkey: concentration curve of IMR

100

0

92.2

75.4

53.2

30.8

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100

cumulative share of population ranked by assets

Cum

ula

tive s

hare

of

infa

nt

death

s

Source: DHS, 1993, author’s calculations

Concentration index = -0.19

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Concentration index of IMR in 44 countries from DHS

-0.30

-0.25

-0.20

-0.15

-0.10

-0.05

0.00

0.05Br

azil

Boliv

ia

Dom

inic

an R

ep.

Indi

a

CAR

Kyrg

yzst

an

Para

guay

Yem

en

Gha

na

Beni

n

Nig

eria

Burk

ina

Faso

Hai

ti

Togo

Nam

ibia

Con

cen

trati

on

in

dex

Data source: http://www.worldbank.org/poverty/health/data/

http://www.worldbank.org/poverty/health/data/

http://www.worldbank.org/poverty/health/data/

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Applying tools to health service use

• Concentration Curves apply to health services use:Q: If we draw a concentration curve for health service use that is pro rich, will the concentration curve be above or below the 45 degree line?

• Concentration index is negative if health services are pro poor and positive if they are pro-rich

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• glcurve7 case, sortvar(income)

• Ineqerr case

• Lorenz income

• Inequal income

• ..\educational folder\Equity & quality\asd.dta

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Dimensions To Inequality

• Outcomes, Outputs, Inputs1. Health Outcomes2. Financing Burden3. Service Use (Expenditures or Benefits)

• Dimensions1. Income 2. Residence (Geographic, Rural/Urban)3. Other Socio Economic Measures

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1. Health Outcomes

• Mortality Measures (Infant 1Q0 , Child 5Q0, Adult 45Q15)

• Morbidity Measures (quality of life)

• Nutritional Outcomes (stunting, BMI)

• Population Outcomes (fertility rates)

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2. Financial Burden• Direct out-of-pocket payments (drugs, co-

payments, fees, informal payment)

• Indirect out-of-pocket payments (time from work, transport)

• Private insurance premiums

• Tax Burden (direct tax, indirect tax, payroll tax)

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3. Service Use (Expenditures or Benefits)

• Basic Utilization – Preventive care – Curative care (primary, outpatient

specialist, hospital)– Delivery related

45

Dimensions

• Income– Consumption-based– Income-based– Asset-based

• Residence– Geography (State, province, oblast, etc.)– Rural/Urban (within Urban—Slums)

46

Discussion question

• Identify important equity issues in Iran’s health system – What important outcomes, outputs, and inputs

are distributed inequitably?– What are the main dimensions of these

inequality?

• What are the main causes of these persistent inequalities?

Equity or Equality MD-MPH, SDH Course اسفند هشتاد و شش

Documents

sdh course slide

concentration index

equality mdmph