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Health Equity

Health Equity. Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 02. The Right to Health.

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Health Equity

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  1. Health Equity Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 02

  2. 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”

  3. Global Disparities in Life Expectancy

  4. 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

  5. Relation of socioeconomic conditions and ill health 100 Cumulative % of ill-health 0 0 100 Cumulative % of the population

  6. Relation of socioeconomic conditionsand ill health 100 Perfect Equity Condition Cumulative % of ill-health 40% of ill health 40% or people 0 0 100 Cumulative % of the population

  7. Relation of socioeconomic conditionsand health expenditures 100 100 Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% or people 0 0 0 100 Cumulative % of the population

  8. Relation of socioeconomic conditionsand health expenditures 100 100 Perfect Equity Condition Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  9. Burden of Disease Concentration Index 100 100 Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of ill health 40% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  10. Burden of Disease Concentration Index 100 100 Inequity Condition 65% of ill health!!! Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  11. Burden of Health ExpenditureConcentration Index 100 100 65% of ill health!!! Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  12. Burden of Health Expenditure Concentration Index 100 100 Inequity Condition 65% of ill health!!! Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of expenditures 15% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  13. The Paradox of Less Expenditure for Those with Ill-Health 100 100 65% of ill health!!! Cumulative % of ill-health Cumulative % of expenditures 40% of ill health 40% of expenditures 15% of expenditures 40% or people 0 0 0 100 Cumulative % of the population

  14. 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)

  15. 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)

  16. 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

  17. 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

  18. 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”

  19. MINIMUM SOCIALLY ACCEPTABLE = EQUITY GAP = HEALTH CARE 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”

  20. = CONSUMPTION ABOVE MINIMUM = CONSUMPTION ABOVE MINIMUM MINIMUM SOCIALLY ACCEPTABLE = HEALTH CARE 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.

  21. 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.)

  22. Assessing Vertical Equity in Finance • Regressive:The poor pay a higher percentage of their income than the rich • Proportional:Rich and poor pay the same percentage of their income • Progressive:Rich pay a higher proportion of their income than do the poor

  23. Proportional Contribution Financial Contribution 0 Income

  24. Regressive Contribution Financial Contribution 0 Income

  25. Progressive Contribution Financial Contribution 0 Income

  26. 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.

  27. 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.

  28. 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.

  29. Average Progressivity of Components of Health Care Financing (Kakwani Progressivity Indexes)

  30. Progressivity Components of Health Care Financing (Kakwani Progressivity Indexes)

  31. 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

  32. Equity in Health • Delivery in relation to health need • Financing in relation to ability to pay

  33. Equality of Opportunity • Equality of opportunity of having a healthy life

  34. 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.”

  35. Thank You !

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