The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing Countries International Meeting August 17-20

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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
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What do we mean by health equity?

• 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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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

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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

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Health Disparities Between Selected Countries
Deaths per 100,00 live births
Age
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Health Status of Poor Versus Non-poor in Selected
Countries (1990)
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Gender and Socioeconomic Inequality in CMR,
Matlab 1982
Source Bhuiya et al. 1998
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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 dont 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)

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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.
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Inverse Care in Public Health
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Counties by level of marginality, Mexico 1990-96
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Distribution of Health Resources, México 1990-96
by level of county marginality
Rate per 10,000 population
Physicians
Beds
Hospital deliveries
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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

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World Health Report 2000
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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

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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

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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

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IMR highest and lowest quintilesRelative
inequality/ Absolute InequalityHiLow Rate Ratio
Rate difference
Source DHS data 1992-1997 Pande and Gwatkin 1999
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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

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What unites these efforts?

• the need for greater capacity to monitor and act
  upon health systems inequities

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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

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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

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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

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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

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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

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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

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Gender shortfall in CMR by SES, Matlab 1982 and
1996