Quantitative M & E of Health Care Equity

1. Quantitative M & E of Health Care Equity Supon Limwattananon, MPHM, PhD

2. Analysis of Health Care Equity • Progressivity (or regressivity) of health financing • Benefit Incidence Analysis (BIA) of health care utilization and subsidy • Impacts of OOP payments • Health catastrophe or catastrophic impact • Post-OOP impoverishment or poverty impact

3. Data Sources

4. Measures of Ability to Pay and Living Standards Source: O’Donnell et al. (2005)

5. Data Sources

6. (X-axis)(Y-axis) Amount of Rank Cumulative Amount of Cumulative wealth/ATP population (pi) health care (Yi) health care Poorest$ 1 1% Y1Y1/Y % $$ 2 . Y2 (Y1+Y2)/Y % . . 20% . . . . . . . . . 40% Y40 (Y1+Y2+… +Y40)/Y % . . . . . . . . . . . . . . . . . . . . Richest$$$$$$$$$$$$ . 100% Y100 100% Q1 Q2 Q5 Y = Y1+Y2+Y3+ … +Y100

7. Concentration Curve and Concentration Index

8. Lorenz curve for ability to pay (ATP) 100 80 Equality line 60 ATP (in cumulative %) L(p) 40 20 0 20 40 60 80 100 Population cumulative % (p) ranked by ATP L(p) “Lorenz curve” for ATP (wealth or total consumption/income) Area between the diagonal line and Lorenz curve Gini coefficient = Area under the diagonal line (or perfect equality line) 0 < GC < 1.0

9. Concentration curve for health care utilization 100 LH(p) 80 60 Health care use (in cumulative %) 40 20 0 20 40 60 80 100 Population cumulative % (p) ranked by ATP LH(p) Concentration curve for health care use Concentration Index for health use has a negative sign: -1.0 < CI < 0 Health care is progressive in favor of the poor (pro-poor)

10. Concentration curve for health care utilization 100 80 60 Health care use (in cumulative %) 40 LH(p) 20 0 20 40 60 80 100 Population cumulative % (p) ranked by ATP LH(p) Concentration curve for health care use Concentration Index for health use has a positive sign: 0 < CI < 1.0 Health care is regressive against the poor (pro-rich)

11. Index for absolute equity Concentration Index (CI) = 2 x Area between equality line and concentration curve Area between equality line and Lorenz curve Gini coeffcient (GC) = Area under the equality line (diagonal line) Index for relative equity (1977) Kakwani Index (KI) = Concentration Index – Gini coefficient

12. Lorenz curve for ATP and concentration curve for health care 100 80 60 ATP & health care (in cumulative %) 40 LH(p) 20 L(p) 0 20 40 60 80 100 Population cumulative % (p) ranked by ATP In this case, Concentration Index for health care has a positive sign but Kakwani Index has negative sign, CI < GC The health care is pro-rich but it reducestherelative inequality

13. Lorenz curve for ATP and concentration curve for health care 100 80 60 ATP & health care (in cumulative %) 40 L(p) 20 LH(p) 0 20 40 60 80 100 Population cumulative % (p) ranked by ATP In this case, CI > GC Both Concentration Index and Kakwani Index have positive signs, The health care is pro-rich and increasestherelative inequality

14. Health Care Financing • Sources of Funds • Direct payments • Household’s out-of-pocket (OOP) payments • Prepayments • General government revenue • Taxation • Direct tax • Indirect tax • Earmarked tax • Contribution • Compulsory: Social health insurance • Voluntary: Private insurance

15. Source: O’Donnell et al. (2005)

16. Source: O’Donnell et al. (2005)

17. Source: O’Donnell et al. (2005)

18. Distribution of Taxation and ATP by Household Living Standards Poorest quintile Richest quintile Source: O’Donnell et al. (2005)

19. Source: O’Donnell et al. (2005)

20. Source: O’Donnell et al. (2005)

21. Source: O’Donnell et al. (2005)

22. Equitable distribution of health care Amount of health care received • correlates highly with health needs • is independent of thingsnot related to health needs A. Socio-economic status • Ability to pay (wealth): consumption or expenditure, income, asset index • Education or schooling • Occupation B. Geographical area • Urban/rural, region/province C. Demographic • Gender • Ethnicity: language, tribal, religion, immigrant vs. native-born Ref: Anderson R. Health service distribution and equity (1975)

23. Maternal and Child Health Services(50 developing and transitional countries) Source: Gwatkin DR et al. Lancet (2004)

24. Maternal and Child Health: Public / Private Services(50 developing and transitional countries) Coverage in lowest wealth quintile Coverage ratio (highest : lowest wealth) Source: Gwatkin DR et al. Lancet (2004)

25. Source: Technical Note #13 (EQUITAP Project)

26. Source: Technical Note #13 (EQUITAP Project)

27. Health Care Utilization(OP Care, 2004)

28. Health Care Utilization (IP Care, 2001 and 2004)

29. Subsidy to Health Care Subsidy = Cost incurred in health care – OOP paid by individuals

30. Source: O’Donnell et al. (2005)

31. Health Care Public Subsidy(OP Care, 2004)

32. Public Subsidy to OP Care -2004

33. BIA of Public Subsidy to OP Care(2004) Richest quintile Poorest quintile Source: Limwattananon et al. (2005)

34. Health Care Public Subsidy(IP Care, 2001 and 2004)

35. Public Subsidy to IP Care -2004

36. BIA of Public Subsidy to IP Care(2004) Richest quintile Poorest quintile Source: Limwattananon et al. (2005)

37. Equity in OOP health expenditure Health is financed according to ability to pay (ATP) 1. Vertical equity Those with unequal ATP pay unequally (the rich pay more, the poor pay less) • Horizontal equity Those with equal health needs pay equally Those with equal ATP pay equally

38. Source: van Doorslaer et al. (2005)

39. Large share of out-of-pocket payments in total health funding Source: van Doorslaer et al. (2005)

40. Source: O’Donnell et al. (2005)

41. Impacts of OOP Health Payments • Catastrophic impact • Poverty impact

42. Catastrophic Health Expenditures

43. Incidence of Catastrophic Expenditures Source: van Doorslaer et al. (2005)

44. Incidence of Catastrophic Expenditures % Households exceeding thresholds Source: van Doorslaer et al. (2005)

45. Catastrophe vs. OOP Payments & Income Source: van Doorslaer et al. (2005)

46. Catastrophe* vs. OOP Payments(OOP > 40% of Income net of needs, N=59 countries) Source: Xu et al. Household catastrophic health expenditure: a multicountry analysis (Lancet 2003)

47. Source: van Doorslaer et al. (2005)

48. Distribution of Catastrophic Health Expenditure*(OOP payments > 10% total consumption expenditure) Source: Limwattananon et al. (2005)

49. Incidence of Catastrophic Health Expenditure

50. Catastrophic Incidence by Types of Health Care Source: Limwattananon et al. (2005)