Equity analysis in PH Intervention Research: A...

Equity analysis: social gaps

Vertical & Horizontal equity

Concentration curve dominance

Progressivity - redistribution

Regression approach

© UdeM / S. Haddad, 2012

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Equity analysis in PH Intervention Research: A framework

Q: Equity of social

arrangements?

Q1: Pop. Needs

& Outcomes?

Q2: Resource

Allocation?

Q11: Benefits?

Q12: ill-health

consequences?

Needs of the vulnerable

Financial equity

Impoverishment

Appropriateness of targeting

Benefit Incidence Analysis

Social gaps

(vertical - horizontal)


-0,8

-0,6

-0,4

-0,2

0,0

0,2

0,4

0,6

0,8

0,0 0,2 0,4 0,6 0,8 1,0

De

via

nc

e

Income percentile

0,0

0,2

0,4

0,6

0,8

1,0

0 0,2 0,4 0,6 0,8 1

Income percentile

Horizontal equity

Obj = Min (Gi = L(p)i – p) in each stratum (of equal needs)


Outc

om

e

Income percentile

Concentration curves

0,0 0,2 0,4 0,6 0,8 1,0

Devia

nce

Income percentile

Deviance curve

Vertical equity: (1) reducing social gradient over time

F = Min (C– C*)

K/2


Vertical equity: concentration curve dominance

5

-0,8

-0,6

-0,4

-0,2

0,0

0,2

0,4

0,6

0,0 0,2 0,4 0,6 0,8 1,0

Deviance curve

-0,6

-0,4

-0,2

0,0

0,2

0,4

0,6

0,0 0,2 0,4 0,6 0,8 1,0

Deviance curve


Testing concentration curve dominance

•! Is the dominance statistically significant?

•! Sample variations

•! Decision rules

•! at least one significant difference between curves in one direction and not in another (corrected for multiple testing).

•!Significant differences at all quantile points (v. strict)

•! Number of comparison points

•! often 19 points (interval: p= 0.05)

•! Software: DAD

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Equity Gaps in Kottathara Panchayat (2003)-

(2) Health Needs - Health Consumption

0%

20%

40%

60%

80%

100%

0% 20% 40% 60% 80% 100%

Income percentile

Cu

mu

late

d o

utc

om

es

p

C(Needs)

C(H Care)

EG2 = - 0.234


Vertical equity: (2) departures from proportionality

•! Extent to which a social arrangement (T) departs from proportionality.

•! Applications: Taxation, HC payment

•! Can be extended to consumption, participation.

KIR = Payment concentration – Income share

KIR = CT – GX / K ! N (0, !2)

•! May reflect the progressivity of current social arrangements (If H=0, RE=0)

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Example: Burden of health care costs

F: K = (CXH – LX) > 0 / LX = income distribution

Concentration curves

0.0

0.2

0.4

0.6

0.8

1.0

0 0.2 0.4 0.6 0.8 1

Income percentile

Ou

tco

me

L(p) = p

L(X)

C(H Exp)

Deviance curve

-0.4

-0.2

0.0

0.2

0.4

0.6

! " ! ! " # ! " $ ! " % ! " & '" !

Income percentile

Devia

nce

L(x)

C(H_exp)

H_Exp=p

K/2

Is the financing mechanism progressive / regressive?


0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

L(p)

C(p)

L(p) = p

KIR = - 0,075

ET = (0,038)

Example: Progressivity of health care expenditures in Burkina Faso (MAPHealth study)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

L(p)

C(p)

L(p) - C(p)

KIR = + 0,158

ET = (0,151)

Zone rurale Zone urbaine


Distributive effects: summary of results

Income Health Exp. Residual

Measure PEqA Income

GI CC (M) (SE) CC

All 0.558 0.571 0.023 -0.029 0.559

Bobo-Urban 0.535 0.443 -0.077 0.038 0.529

Nouna_1/2Urban 0.573 0.738 0.178 -0.048 0.590

Nouna_Rural 0.396 0.550 0.117 -0.048 0.403

Bazega_1/2Urban 0.479 0.574 -0.001 -0.065 0.490

Bazega_rural 0.356 0.520 0.158 -0.052 0.371

HC < 5km 0.521 0.510 -0.011 -0.033 0.522

HC > 5km 0.358 0.497 0.139 -0.046 0.348

Distributive effects

Progressivity and redistribution

Redistributive effect of health financing

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Redistribution (taxation – health care financing)

•! Vertical redistribution (between strata)

•!Horizontal inequality

(within strata)

•!Reranking

S1

S2

S1

S4


Illness, health expenditures and impoverishment in Burkina Faso

Health expenditures

•! Some non poor cross the poverty line

•! Some poor get impoverished


Redistribution effect

•! Definition: reduciton in the Gini coefficient

RE = GX-T - CX-T

= Postpaym. ineq. - Postpaym. conc. Index

•! ARL Decomposition:

•! Progressivity of the HC financing system

•! Proportion of income going to finance health care

•! Degree of horizontal inequality raised (H)

•! Extent of any re-ranking among households (R)

RE = V – E –R

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Regression

community intervention to increase access to PHC services in Dori, Burkina Faso.

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Design

•! Intervention:

•! Free care for children, pregnant women (2009)

•! Interrupted time series (ITS) analysis

•! all health centers of 4 Districts, 78 Communities, 96-month

•! stratified random sample of health centres

•! intervention district (12) & non-intervention district (6).

•!56-month pre-intervention ; 12-month period of intervention.

•! Panel survey of 1,214 households

•! one of the two districts exposed to the intervention (Dori).

•! waves: 2008 (M-1), 2009 (M11), 2012

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Interrupted time series

•! Administrative records

•! Efficient

•! Versatile (counterfactuals):

•!Single – multiple series (intervention sites)

•!With – without (comparative)

•!Non-equivalent dependent variables

•! Powerful

•! Random effects models

•! Pooled series

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Pooled Time Series + Multilevel Analysis: Impact of 2 consecutive interventions in Dori (Burkina Faso)

0

10

20

30

40

50

60

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71

Assisted deliveries Per Month 4 Districts, 78 Communities, 96-month Follow=Up

ITS - Predicted values by District

Adjustments: Population size-growth, Seasonality, Communities © UdeM / S. Haddad, 2012

Evolution of the number of consultations per month in health centres (children 0-5)

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Attributable effects of the intervention per site

30


Net gains: consultations per month per centre

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Heterogeneity of the response to the intervention. Random effect models

32


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Attendance in health centres: estimates gains in monthly consultations over time (1 M, 1Y, 2Y, 3Y)

34

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Did the wealthier benefit more (panel survey)?

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Equity analysis in PH Intervention Research: A...

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