www.worldbank.org/analyzinghealthequity

1. www.worldbank.org/analyzinghealthequity Book published by the World Bank in 2008. Presentations accompany the book and are designed as a course on health equity analysis. The book contents can be downloaded from the website above.

2. Analyzing Health Equity Using Household Survey Data Lecture 1 Introduction “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

3. Huge rich-poor inequalities in health outcomes and health care in Bolivia “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

4. And Bolivia is not an isolated example in Latin America and the Caribbean…. “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

5. Health inequality and inequity • Rich-poor inequalities in health largely, if not entirely, derive from differences in constraints (e.g. incomes, time costs, health insurance, environment) rather than in preferences. • Hence they are often considered to represent inequities. • But in high-income countries the poor often use more health care and this may not be represent inequity. • Drawing conclusions about health equity involves consideration of the causes of health inequalities. “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

6. Equity of what? • Health outcomes, e.g. infant mortality, child growth, disability, incidence of illness, general health, life expectancy. • Health care utilisation, e.g. doctor visits, inpatient stays, vaccinations, maternity care. • Subsidies received through use of public health care. • Payments for health care (both direct and indirect). “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

7. Equity in relation to what? • Equity in health, health care and health payments could be examined in relation to gender, ethnicity, geographic location, education, income…. • This course focuses on equity by socioeconomic status, usually measured by income, wealth or consumption. • Many of the techniques are applicable to equity in relation to other characteristics but they often require that individuals can be ranked by that characteristic. “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

8. Course objectives • To provide a step-by-step practical guide to the measurement of various aspects of health equity. • To introduce the relevant theory and literature. • To provide hands-on experience of computing health equity measures using Stata®. • To illustrate the interpretation of results through worked examples. • To stimulate analysis that will facilitate more comprehensive monitoring of health equity, especially in developing countries. “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

9. Questions addressed by health equity analyses • Snapshots. Does inequality in child survival between the poor and better-off exist? How large is it? • Movies. Is inequality in child survival smaller now than in the 1990s? • Cross-country comparisons. Is inequality in child survival larger in Brazil than in Cuba? • Decompositions. To what extent is inequality in child survival explained by inequalities in education, health insurance cover, access to maternal and child health care, etc? • Cross-country detective exercises. To what extent is greater inequality in child survival in Brazil than Cuba explained by greater income inequality, given differences in health systems? • Program impact evaluations. To what extent is inequality in child survival reduced by an intervention such as a vaccination program, expanded health insurance cover or improved water supply? “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

10. Ingredients of health equity analysis • Data usually from a household survey. • Measurement of the key variables - health/health care/health payments and of socioeconomic status. • Quantitative measures of inequality or inequity. • Multivariate methods to explain inequality, identify its causes and the impact on it of interventions “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

11. Course content • The course is structured around these four ingredients, plus applications. • Part I – Data • data requirements and sources (lecture 2) • measurement of the key variables – child survival, anthropometrics, adult health & living standards (3-6). • Part II – Tools • measures of socioeconomic inequality in health variables (7-9) • multivariate analysis (10-11) • decomposition methods (12-13). • Part III – Applications • to health care utilisation (14-15) • to health payments (16-19). “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

12. Concentration curves (lecture 7) are central to the assessment of socioeconomic inequality in health “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

13. Concentration index (lecture 8) is a tie-breaker, but rests on certain value judgments “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

14. Multivariate methods • Estimation and inference with complex survey data (lecture 10) • Nonlinear models for health and medical expenditure data (11) • Explaining differences between groups: Oaxaca decomposition (12) • Explaining socioeconomic-related health inequality: Decomposition of the concentration index (13) “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

15. Lecture 14: Who (really) benefits from health care subsidies? Often the better off! “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

16. Lecture 16: Who (really) pays for health care? “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

17. Lecture 18: Incidence of catastrophic out-of-pocket payments varies across countries “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

18. Lecture 19: Health care payments and poverty “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity

19. Acknowledgements • Participants in the ECuity and Equitap projects • The European Commission INCO-DEV programme (ICA4-CT-2001-10015) that funded the Equitap project. • The Dutch government for financial support for the production and printing of the book and these slides through Reaching the Poor II • Davidson Gwatkin and Abdo Yazbeck for encouragement and support during the production and market-testing of the technical notes, and the production of the volume • John Didier, Tanya Ringland, Chialing Yang and others at the World Bank Institute for managing the production and dissemination of the book “Analyzing Health Equity Using Household Survey Data” Owen O’Donnell, Eddy van Doorslaer, Adam Wagstaff and Magnus Lindelow, The World Bank, Washington DC, 2008, www.worldbank.org/analyzinghealthequity