HEALTH EQUITY

Dr. Rakesh Kumar

Framework

• What is equity?• What is equity in health and health care?• Why Health Equity is important?• Why focus on equity in health and health care• Health inequity in India• Principles for action for equity in health• Dimensions of health equity• How to measure Health equity

– Concentric curves• How equity is/can be ensured

– through inter-sectoral coordination• References

What is Equity?

• Definition: Absence of avoidable or remediable differences among populations or groups defined socially, economically demographically, or geographically.

• It has a moral and ethical dimension

• Equity in development means a fair sharing of progress, not an equitable distribution of avoidable misery and deprivation

Equality means sameness

Equity in Health• Equity in health status

– Differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.

– Judgments on which situations are unfair will vary from place to place and from time to time, but one widely used criterion is the degree of choice involved.

– Attainment by all citizens of the highest possible level of physical, psychological and social well-being

• Equity in health care– Allocation of health care resources according to need – Health services are received according to need regardless of the

prevailing social attributes

Why Health Equity is important?

• Both ethical and pragmatic arguments for equity in health and health care.

• Ethical:– Equity means fairness– Both health and health care are human rights

• Pragmatic:– Equity along with effectiveness and efficiency, is practical imperative– Disregard for equity is socially destabilizing– Disregard for equity in health and in health care jeopardizes the health for

anyone because of spillover effects (crime, infectious disease, greater costs for treatment than for prevention)

– Disregard for equity in health and in health care is incompatible with long-term productivity

Why focus on equity in health and health care

• Social gaps in health and in health care are unacceptably wide and widening both in developing and industrialized countries– Gaps between socioeconomic groups: rich-poor, inverse

care law; nonprofessional and professional– Gaps between geographical groups: interstate, rural- urban– Gender gap in health: neglect and discrimination of

females– Gaps between racial/ethnic groups: indigenous/

noningenous ; white/ non white– Gaps between age groups

Why focus on equity in health …

• Countries are finding it difficult to implement and sustain equitable policies– Structural adjustment has been widely associated with deterioration in

conditions for vulnerable groups– Cost recovery in the health sector may be inherently iequitable and in

efficient – Economic recession and weak economic performance also threatens

equity

• Routine information often hides the gaps or fail to result in effective action

• Social spending is being constrained by many powerful pressures, both economic and political

• Equity in health and health care must be placed higher on public policy agenda

Framework for identifying pathways leading to health inequities

Source: Irwin A., Solar O. "A Conceptual Framework for Action on the Social Determinants of Health" Discussion paper for the Commission on Social Determinants of Health

Health Inequity in India

Selected Indicators By Wealth QuintileIndia, 2005-06

Coverage of DPT3vaccination

Coverage of skilledbirth attendance

Prevalence of stuntingin children

Prevalence of womenunderweight

0

10

20

30

40

50

60

70

80

90

100

33.9

19.4

59.9

51.547.1

31.8

54.3

46.3

58.4

49 48.9

38.3

68.5 67.2

40.8

28.9

81.9

88.8

25.3

18.2

Poorest Q2 Q3 Q4 Least poor

Per

cen

t

Infant and Under-Five Mortality by StratifiersIndia, 2005-06

Nation

al Average

Urb

an

Ru

ral

Male

Fem

ale

Illeterate

mid

dle sch

ool incom

plete

mid

dle sch

ool comp

lete

High

school an

d ab

ove

Poorest

Q2

Q3

Q4

least poor

0

10

20

30

40

50

60

70

80

90

100

57

41.5

62.2

43.739.1

61.3

53.348.1

30

64.8 62.4

49.846.2

27.4

74.3

51.7

82

52.3 51

81.4

59.455.2

35

92.1

82.5

65.3

53.9

32.8

Infant Mortality Rate Under-5 mortality rate

Area of residence

Sex Education Wealth Quintile

How to measure health Inequities?

• Lorenz curve (Gini Index) : plots the cumulative percentage of a health variable against the cumulative percentage of the sample, ranked by their health, starting with the sickest person and ending with the healthiest.

• Concentration curve and index—from income distribution - Apply to socioeconomic-related inequality in health variables

Concentration curve

L(s)

cumulative proportion of population

cumulativeproportionof ill-health

0

1

1

ranked by socioeconomic status

Curve above the diagonal concentration among the poor

Curve below the diagonal concentration among the rich

Curve on the diagonal = equality

•It plots the cumulative % of health variable against the cumulative % of population ranked by socioeconomic status•It assess income-related health inequity

In which country are child deaths distributed most unequally?

0

50

100

150

200

250

300

India Mali

U5M

R p

er

1000 liv

e b

irth

s

Poorest"quintile"2nd poorest"quintileMiddle "quintile"

2nd richest"quintile"Richest"quintile"

Comparison made difficult by differences in levels.And have to rely on top versus bottom relativities.

Comparison is easier using cumulative distributions - Concentration curves

0%

20%

40%

60%

80%

100%

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

cumul % births, ranked by wealth

cum

ul %

und

er-fi

ve d

eath

s

Line of equality

India

Mali

Child deaths are disproportionatelyconcentrated on the poorin both countries

But the disproportionate concentration (inequality)appears greater in India

Principles for action

• Equity policies should be

– concerned with improving living and working conditions– directed towards enabling people to adopt healthier

lifestyles– require a genuine commitment to decentralizing power and

decision making, encouraging people to participate in every stage of the policy-making process

– require health impact assessment together with inter-sectoral action

– based on appropriate research, monitoring and evaluation.

Initiative for equity in health• Strategies

– Economic growth can help create opportunities to achieve more equity– Equitable financing methods must be sought. Donor support must

reinforce, not undermine, equitable policies.– Progress towards equity requires changes in a way resources are

allocated to different social groups– Conscious, focused effort required to indentify and reach those in greater– Rural Credit: It is among the most promising approaches to achieving

greater equity both efficiently and effectively in recent years– Improving woman’s status– Strengthening local organization

• Activities are needed in following areas:– Policy oriented research– Policy oriented ongoing monitoring– Informed policy development and implementation

References

1. Equity in health and health care: a WHO/SIDA initiative. World health organization @ 1996

2. Whitehead M.The concepts and principles of equity and health. World Health Organization Regional Office for Europe Copenhagen

3. Closing the gap in a generation : Health equity through action on the social determinants of health. © Commission on Social Determinants of Health 2008

4. Health Equity Through Intersectoral Action: An Analysis of 18 Country Case Studies. World health organization @ 2008

5. Joe W, Mishra US, Navaneetham K. Health Inequality in India: Evidence from NFHS 3. Economic & Political Weekly, 2008 (Aug)

6. Achieving Health Equity: from root causes to fair outcomes. © Commission on Social Determinants of Health 2007

7. Health Inequities in the South-East Asia Region magnitude and trends what contributes and to health inequities. World Health Organization's South-East Asia Regional Office @ 2007

8. Braveman P & Gruskin S. Poverty, equity, human rights and health Bulletin of the World Health Organization 2003, 81 (7)