Transcript Equity Gauge: An approach to Monitoring Equity in Health

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
Deaths per 100,00 live births
80
70
60
Age
50
40
30
20
10
0
Life Expectancy 1994
Japan
Sierra Leone
1600
1400
1200
1000
800
600
400
200
0
Maternal Mortality 1990
Norway
Guinea
Health Status of Poor Versus Non-poor
in Selected Countries (1990)
Country
Aggregate
Malaysia
Ecuador
Chile
China
Kenya
India
Percentage
of
population
in absolute
a
poverty
6
8
15
22
50
53
Probability of dying
per 1000 (females)
Between
Between
birth - 5
ages 15 - 59
Prevalence
of
tuberculosis
Poor:non-poor
ratio
Poor:non-poor
ratio
Poor:non-poor
ratio
4.8
15.0
4.9
8.3
6.6
3.8
4.3
4.3
5.1
4.4
12.3
11.0
3.8
3.7
2.6
3.2
1.8
8.0
3.8
2.6
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 for
purchasing power.
Gender and Socioeconomic Inequality in
CMR, Matlab 1982
CMR
39.2
40
30
25.4
17.6
19.1
12.8
11.9
1-6 years
7+ years
0
O year
Schooling of Household Head
Source: Bhuiya et al. 1998
Female
10
Male
Female
Male
20
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
Smoking Prevalence (%)
(Men, Chennai)
70
60
50
40
30
20
10
0
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 Health
2.80%
6.10%
Public Health Service Use, Ghana
bottom quintile
top quintile
10.00%
2.50% 3.30%
2.50% 8.40%
bottom quintile
5.00%
top quintile
0.00%
Clinics
Hospitals
Counties by level of marginality, Mexico 1990-96
Marginality
Very high
High
Moderate
Low
Very low
Distribution of Health Resources, México 1990-96
by level of county marginality
%
Rate per 10,000 population
20
100
80
15
60
10
40
5
20
0
0
Very low
Low
Medium
High
Physicians
Beds
Hospital deliveries
Very high
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
Aggregate
Distribution
Health Outcomes


Responsiveness


Performance

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 quintiles
Relative inequality/ Absolute Inequality
Hi:Low Rate Ratio
Rate difference
1.5
1
0.5
0
V
am
n
t
ie
oz
M
e
u
q
bi
am
V ie
tna
m
2
biq
ue
IMR ra te diffe re nce
2.5
100
90
80
70
60
50
40
30
20
10
0
Mo
z am
IMR rate ratio (lo:hi)
3
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 longerterm 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
CM R
(Shortfall
F -M )
25
21.1
20
15
13.6
10
1996
1982
6.7
2.1
2.3
O year
1-6 years
1.8
7+ years
Schooling of H ousehold H ead
1982
0
1996
5