Dr. Shahram Yazdani Health Equity Shahid Beheshti University of Medical Sciences School of Medical...
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Dr. Shahram Yazdani Health Equity Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 02
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Transcript of Dr. Shahram Yazdani Health Equity Shahid Beheshti University of Medical Sciences School of Medical...
Dr. Shahram Yazdani
Health Equity
Shahid Beheshti University of Medical SciencesSchool of Medical Education
Strategic Policy Sessions: 02
Dr. S
hahra
m
Yazd
ani
The Right to Health
The International Declaration of Human Rights “Everyone has a right to a standard of living adequate for the health and well being of his family including food, clothing, housing and medical care”
Dr. S
hahra
m
Yazd
ani
Global Disparities in Life Expectancy
Dr. S
hahra
m
Yazd
ani
Inequity within Countries
African American age adjusted death rates exceeded those for whites By 77% in stroke By 47% for heart disease By 34% for cancer By 655% for HIV infection
Dr. S
hahra
m
Yazd
ani
Relation of socioeconomic conditions and ill health
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
Dr. S
hahra
m
Yazd
ani
Relation of socioeconomic conditionsand ill health
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
Perfect Equity Condition
Dr. S
hahra
m
Yazd
ani
Relation of socioeconomic conditionsand health expenditures
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of ill health
Dr. S
hahra
m
Yazd
ani
Relation of socioeconomic conditionsand health expenditures
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures40% of ill health
Perfect Equity Condition
Dr. S
hahra
m
Yazd
ani
Burden of Disease Concentration Index
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures40% of ill health
Dr. S
hahra
m
Yazd
ani
Burden of Disease Concentration Index
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
65% of ill health!!!
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures
Inequity Condition
Dr. S
hahra
m
Yazd
ani
Burden of Health ExpenditureConcentration Index
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
65% of ill health!!!
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures
Dr. S
hahra
m
Yazd
ani
Burden of Health Expenditure Concentration Index
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
65% of ill health!!!
15% of expenditures
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures
Inequity Condition
Dr. S
hahra
m
Yazd
ani
The Paradox of Less Expenditure for Those with Ill-Health
Cumulative % of the population
Cu
mu
lati
ve %
of
ill-
he
alt
h10
0
1000
0
40% or people
40% of ill health
65% of ill health!!!
15% of expenditures
Cu
mu
lati
ve %
of
ex
pen
dit
ure
s10
00
40% of expenditures
Dr. S
hahra
m
Yazd
ani
Equity vs. Equality
It is important to distinguish between equality and equity:
Equality – concerned with equal shares Equity – about fairness and it may be fair to be
unequal This usually incorporates the concept of
“Minimum Social Acceptable Level” (MSAL)
Dr. S
hahra
m
Yazd
ani
Definition of Health Equity: Different Approaches
Access to Healthcare (Equal or MSAL) Delivery/Utilization of Healthcare (Equal or MSAL) Financial Contribution (in Relation to Ability to Pay) Opportunity to be Healthy (Equal or MSAL) Health Outcomes (Equal or MSAL)
Dr. S
hahra
m
Yazd
ani
Equality of Access
Access to health care may have instrumental value to promoting better outcomes
but it may also be valued in its own right as contributing towards procedural justice
Dr. S
hahra
m
Yazd
ani
Equality of Use
There are many problems with this principle: Not everybody responds to treatment in the
same way It requires that there are no differences in
quality. It ignores differences in individual preferences
over health and health care And it cannot be used as a proxy for equality of
access or equality of outcomes
Dr. S
hahra
m
Yazd
ani
Equity in Delivery
Horizontal equity Health care delivery system is horizontally equitable
if all people with equal need for health care are equally likely to obtain the same type of health care.
“Equal treatment of equals” Vertical equity
“A health care delivery system is vertically equitable if people with greater need for health care are more likely to obtain care than those with a lower need.”
“More health care for those with more need”
Dr. S
hahra
m
Yazd
ani
Are Equity and Equality Synonymous?
Some think that:
“Inequity will not necessarily arise as a result of differences in consumption levels among individuals, but will always be present when consumption by any one individual or group is below a minimum socially acceptable”
= HEALTH CARE
MINIMUM SOCIALLY ACCEPTABLE
= EQUITY GAP
Dr. S
hahra
m
Yazd
ani
Are Equity and Equality Synonymous?
In other words, some think that:As long as everybody has access to a minimum
health benefits package, there is equity. If some have access to more than the minimum, there is inequality, but the system is still equitable.
= HEALTH CARE
MINIMUM SOCIALLY ACCEPTABLE
= CONSUMPTION ABOVE MINIMUM
= CONSUMPTION ABOVE MINIMUM
Dr. S
hahra
m
Yazd
ani
Equity in Financing Horizontal equity
Horizontal equity in financing is when people with equal ability to pay make equal payments for health care
“Equal payments by equals” Vertical equity
A health system is vertically equitable when payment and ability to pay are positively correlated
“Greater ability to pay higher payment” “Smaller ability to pay lower payment” To some, a financing system is considered to be
vertically equitable if those with greater ability to pay contribute a greater share of their income to pay for health care (“progressive” financing.)
Dr. S
hahra
m
Yazd
ani
Assessing Vertical Equity in Finance
1. Regressive: The poor pay a higher percentage of their income than the rich
2. Proportional: Rich and poor pay the same percentage of their income
3. Progressive: Rich pay a higher proportion of their income than do the poor
Dr. S
hahra
m
Yazd
ani
Income
Financial Contribution
0
Proportional Contribution
Dr. S
hahra
m
Yazd
ani
Income
Financial Contribution
0
Regressive Contribution
Dr. S
hahra
m
Yazd
ani
Income
Financial Contribution
0
Progressive Contribution
Dr. S
hahra
m
Yazd
ani
Social Health Insurance
If you work for a company that provides health insurance benefits, you (and your employer) typically contribute the same % share of your wage or salary.
For example, if the employee contribution rate is 3% both the low wage janitor and the high wage boss will be “taxed” 3% of their earnings.
Dr. S
hahra
m
Yazd
ani
Annual Income Tax (a “Direct Tax”)
There tends to be exemption from income tax for very low household income, whereas income tax rates climb with levels of household income and then become relatively high for highest income households.
Dr. S
hahra
m
Yazd
ani
User Fees (or Out-of-Pocket Payments)
Both poor and rich tend to be charged the same amount for a health service, regardless of ability to pay.
This applies especially to drugs, whereas exemptions may be in place with respect to out-patient and in-patient services.
Dr. S
hahra
m
Yazd
ani
Average Progressivity of Components of Health Care Financing (Kakwani Progressivity Indexes)
Revenue Source Index (N=13)
Direct taxes .169
Indirect taxes -.064
Social Insurance .054
Private Insurance -.005
Out-of-Pocket -.222
Dr. S
hahra
m
Yazd
ani
Progressivity Components of Health Care Financing (Kakwani Progressivity Indexes)
Country
Direct Taxes
Indirect Taxes
Social
Insurance
Private
Insurance
Out-of-
Denmark (1987) .062 -.113 .000 .031 -.265
Finland (1990) .128 -.097 .090 .000 -.246
France (1989) .000 .000 .094 -.186 -.228
Germany (1988) .251 -.092 -.081 .093 -.103
Ireland (1987) .267 --- .126 -.021 -.147
Italy (1991) .161 -.112 .112 .177 -.077
Netherlands (1992) .200 .089 -.129 .083 -.038
Portugal (1990) .218 -.035 .185 .137 -.242
Spain (1990) .214 -.152 .050 -.012 -.212
Sweden (1992) .053 -.083 .010 --- -.240
Switzerland (1992) .172 -.072 .038 -.270 -.403
United Kingdom (1992) .284 -.152 .187 .077 -.223
United States (1987) .192 -.065 .019 -.175 -.461
Dr. S
hahra
m
Yazd
ani
Equity in Delivery and Finance does not Guarantee Equity in Health
Socioeconomic Factors Have Crucial Role in Health
Equity Health Needs More Radical policies for Redistribution of Wealth
These Policies Should Ensure a Baseline Level of Welfare (and not merely health) for all Citizens
Dr. S
hahra
m
Yazd
ani
Equity in Health
Delivery in relation to health need Financing in relation to ability to pay
Dr. S
hahra
m
Yazd
ani
Equality of Opportunity
Equality of opportunity of having a healthy life
Dr. S
hahra
m
Yazd
ani
Equality of Health
This is concerned with distributive justice and represents a consequentialist view in which the only concern is with the distribution of health
It has been criticised on the grounds that it is paternalistic and ignores individual choice and differences in preferences
But Culyer and Wagstaff (1993) argue that “There is a danger in straining out the gnat of offending personal liberty that one swallows the camel of enduring and outrageous inequalities of health.”
Dr. S
hahra
m
Yazd
ani
