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Equity in Health

Equity in Health. The Right to Health. Preamble to the constitution of the WHO states “The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”.

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Equity in Health

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  1. Equity in Health

  2. The Right to Health • Preamble to the constitution of the WHO states “The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”

  3. The Right to Health • The Declaration of Alma Ata, International Conference on Primary Health Care “The right to health is the most important social goal”

  4. 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”

  5. Global disparities in life expectancy

  6. 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

  7. 100 40% of ill health 65% of ill health!!! Cumulative % of ill-health 40% or people 0 0 100 Cumulative % of the population Burden of disease concentration index

  8. Illness concentration curve 100 Expenditure concentration curve Cumulative % of illness And expenditure B A 0 0 10 100 Cumulative percentage Of the population SOURCE: Wagstaff and Van Doorlaer 1993. Illness and expenditure concentration curves • Now we know how illness is distributed. • To assess fairness, we need to know the distribution of expenditure in relation to the distribution of ill health

  9. Defining equity 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

  10. Equality of what? • Equality of use • Equality of access • Equality of outcome • Equality of Opportunity

  11. 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

  12. Equality of access • Access to health care may have instrumental value to promoting better outcomes • but it may also be valued in its own rightas contributing towards procedural justice

  13. 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.”

  14. Equality of opportunity • Equality of opportunity of having a healthy life

  15. Equity in delivery Equity in financing Equity in Health

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

  17. Health   LIFE  Genes Family Life Style Nutrition Education Environment Money Health services  Life length    Life Quality

  18.   Life Span Life Span   Life Quality Life Quality Health Inequality Person or Population A Person or Population B Diseases Genes Family Life Style Nutrition Education Environment Money Health services

  19. Does equality of health status imply equity in delivery or in financing? • Should a health system could be considered equitable if all citizens had the same health status • No. Too many factors other than health care influence health status. • Still, although health status is an incomplete and sometimes misleading measure of equity in health, it is an important input in design of targeting policies and in design and evaluation of social welfare programs.

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

  21.                                                                                                                                     Vertical Dimension Equity in Delivery Horizontal Dimension

  22.                                                                                                             Horizontal Equity                                     Horizontal Dimension

  23.                                                                                 Vertical Dimension        Vertical Equity                                                                                  

  24.                                                                                     Vertical Dimension       Horizontal and Vertical Equity                                                       Horizontal Dimension

  25. 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”

  26. Equity in delivery: possible cases Horizontal equity Equitable Inequitable Ideal Second or third best Equitable Vertical equity Second or third best Worst Inequitable

  27. 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”

  28. = 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.

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

  30.                                                                                                    Vertical Dimension Equity in Finance Horizontal Dimension

  31.                                                                                                    Horizontal Equity in Finance Horizontal Dimension

  32.                                                                                                           Vertical Dimension   Vertical Equity in Finance          

  33.                                                                                                    Vertical Dimension Vertical And Horizontal Equity in Finance Horizontal Dimension

  34. 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.)

  35. Assessing Vertical Equity in Finance • Proportional:Rich and poor pay the same percentage of their income • Progressive:Rich pay a higher proportion of their income than do the poor 3. Regressive:The poor pay a higher percentage of their income than the rich

  36. Hhld. Money Spent On Health ------------------------------------- ------------------------ ---------- Proportional 0 H1 H2 H3 Total Household Money

  37. 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.

  38. Hhld. Money Spent On Health Progressive Proportional H1 H2 H3 0 Total Household $$$ Money

  39. 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.

  40. (1b) Hhld. Money Spent On Health Regressive Proportional H1 H2 H3 0 Total Household Money

  41. 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.

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

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

  44. Welfare Beyond Health   LIFE  Genes Family Life Style Nutrition Education Environment Money Health services  Life length    Life Quality

  45. 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

  46. Thank You ! Any Question?

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