The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing Countries International Meeting August 17-20 Tim Evans.

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

Counties by level of marginality, Mexico 1990-96

Marginality

Very highHighModerateLowVery low

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

Gender shortfall in CMR by SES, Matlab 1982 and 1996

21.1

13.6

6.7

2.1 2.3 1.80

5

10

15

20

25

O year 1-6 years 7+ years

1996 19

82

Schooling of Household Head

CMR (Shortfall

F-M)

19961982