International Health Policy Program -Thailand Using STATA 10.0 for Health Equity Analysis Rachid Janta Vuthiphan Wongmongkol 4/12/2008 IHPP Meeting Room.

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Using STATA 10.0 for Health Equity Analysis

Rachid JantaVuthiphan Wongmongkol

4/12/2008 IHPP Meeting Room

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Outline of presentation

• Lecture Session– Definition of Health Equity– Difference of Health Inequity and Health Inequality– Determinants and Dimensions of health equity– Health Financing and data sources– Lorenz Curve– Gini coefficient

• Technical Session– basic technique on how to using STATA for equity

analyses

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Definition of Health Equity

The International Society for Equity in Health (ISEqH) defined equity in health as

“the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically”

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Difference of inequity and inequality

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Determinants of Health Inqualities

Seven Determinants of Health Inequalities

1. Natural, biological variation2. Differential health-damaging

behavior that is freely chosen3. Differential health-promoting

behavior that is freely chosen4. Differential health-damaging or

health-promoting behavior, where choices are restricted

5. Differential exposure to unhealthy, stressful conditions (home, work, etc…)

6. Inadequate access to basic social and essential health services

7. Health-related social mobility

Generally perceived as unavoidable or fair

Generally perceived as avoidable or unfair

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Example of Inequality

An old man has OP visit 10 time/year VS A young man has OP visit 3

time/year

Should this be considered as; - inequality?- equity?

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Inequality of Physician Distribution Worldwide

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Vertical and horizontal equity

• Horizontal equity applies to people in the same status or situation, and people who are alike should be treated in the same fashion, – in other words, equal treatment for equal need.

• Vertical equity focuses on the difference between individuals or groups of people, and people who are unlike in relevant respects (e.g. income, health needs), and states that the differences should be treated differently in a just way.

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Dimensions and Determinants of Health Equity

Health financing

Healthcare

utilization

Quality & responsive

-ness

Health status

Health risk

GeographicRegion

Urban vs. RuralDemographic

GenderAge group

SocialEducation

OccupationEconomic

IncomeWealth index

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Data requirements for health equity analysis

Health Utilization Living standards (ordinal)

Living standards (cardinal)

Unit subsidies

User payments

Back-ground vbls

Health inequality

Equity in utilization

Multivariate analysis

Or

Benefit-incidence analysis

()

Health financing

Progressivity

Catastrophic payments

Poverty impact

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ndLorenz Curve

• Lorenz curve is a graphical representation of the proportionality of a distribution (the cumulative percentage of the values). It was developed by Max O. Lorenz in 1905 for representing income distribution.

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Gini Coefficient

Note: Gini Coefficient is a tool for measuring inequality of income. The value of Gini coefficient ranges from 0 to 1. A low Gini coefficient indicates more equal income or wealth distribution, while a high Gini coefficient demonstrates more unequal distribution.

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Gini Coefficient

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The Kakwani index

• is defined as twice the area between the concentration curve of health payment and the Lorenz curve of household income.

• The value of the Kakwani index ranges from -2 to 1.

• A negative Kakwani index value indicates the regressive nature of health care payments.

• In contrast, a positive value indicates the progressive nature of health care payments.

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The concentration curve and index

• The concentration curve graphs on the x-axis the cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable.

• The concentration index is a means of

quantifying the degree of income-related inequality within a specific health variable, for example, health service use, and government health subsidies.

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The concentration index

• is defined as twice the area between the concentration curve and the line of equality (the 45-degree line running from the bottom-left corner to the top-right).

• In the case where there is no income-related inequality, the concentration index is zero.

• The index takes a negative value when the concentration curve lies above the 45-degree line of equality, indicating disproportionate concentration of health service use or other health variables among the poor, and a positive value when it lies below the 45-degree line of equality.

Selected concentration curves of ambulatory service use among different types of health facilities in 2003

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Household equivalence scale

• Equivalence scale (eh) = (Ah + 0.5Kh)0.75,

where A (K) is the no. of adults (kids) in the household

• OECD-modified equivalence scale

O - - 1 1 *0ecdscale = +(hhsize kids) . 5 + ( * 0 .3 )kids

The incidence of catastrophic health payments in 2000 and 2002

2000 2002 % change

Q1(poorest)

9.97 5.61 - 44 %

Q2 5.41 5.02 - 7 %

Q3 4.82 4.81 0 %

Q4 3.79 3.98 5 %

Q5(richest)

4.26 3.41 - 20 %

All quintiles 6.11 4.65 - 24 %

Note: Catastrophic health expenditure refers to household out-of-pocket payments for health over 10% of household income or expenditure

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Resources

• WBI “OVWL” book – http://siteresources.worldbank.org/INTPAH/Resources/Publications/459843-1195594469249/HealthEquityFINAL.pdf