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The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing Countries International Meeting August 17-20. Tim Evans. A world in which any group of individuals defined by age, gender, race-ethnicity, class or residence can achieve its full health potential.
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The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing CountriesInternational Meeting August 17-20 Tim Evans
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 do we mean by health equity?
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 Age
Health Status of Poor Versus Non-poor in Selected Countries (1990)
Gender and Socioeconomic Inequality in CMR, Matlab 1982 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) 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.
Marginality Very high High Moderate Low Very low Counties by level of marginality, Mexico 1990-96
% 20 100 80 15 60 10 40 5 20 0 0 Very low Low Medium High Very high Distribution of Health Resources, México 1990-96 by level of county marginality Rate per 10,000 population Physicians Beds Hospital deliveries
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
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 InequalityHi:Low Rate Ratio Rate difference 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