Is there always a tradeoff between efficiency and equity A review of evidence from immunization prog

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Is there always a trade-off between efficiency
and equity? A review of evidence from
immunization programs

• Damian Walker, Benjamin Johns David Peters
• Health Systems Program
• Department of International Health

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Introduction (and Conclusions)

• Little information has been compiled on how
  efficiency or equity varies with the scale of
  production
• It is assumed that there is trade-off between
  efficiency and equity
• Country-specific empirical evidence on how the
  efficiency and equity of vaccination programs
  change as coverage changes is, despite its
  importance for policy, lacking

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Aim of the paper

• Review evidence from health care, including
  vaccination programs, to assess the relationships
  between coverage, efficiency and equity
• Present a preliminary analysis of DHS data that
  empirically examines relationship between
  coverage and equity

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Literature review

• Growing body of literature on the efficiency of
  health care
• There is an abundance of evidence that inequities
  exist in the receipt of health care
• BUT CEAs typically do not address issues of
  equity
• However, we should not fully blame CEA for
  ignoring equity concerns since it is often
  ignored in clinical trials and other
  effectiveness data that is, epidemiological
  studies tend to control for, rather than stratify
  by, important equity variables (Williams and
  Cookson 2006)

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Research question

• Is GAVI support to a country associated with
  national level changes in coverage and / or
  pro-poor distribution for either DPT3 (or
  measles) vaccination?

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Data

• 32 low- and middle-income countries
• Two most recent available DHS surveys
• 1st survey conducted between 1992-2000
• 2nd survey conducted between 1998-2005
• Data on coverage of vaccination status and
  concentration index, which measures the
  cumulative distribution of vaccination status
  ranked by an indicator of socio-economic status
  as a deviation from a perfectly equal
  distribution
• 22 out of 32 of the countries are GAVI-eligible
• 12 out of 22 of these countries received GAVI
  funds between the two surveys

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Attainable concentration index

• It measures the distance from perfect equity (if
  concentration index 0 then measles vaccination
  is equally distributed across children ranked by
  their household wealth status) as a of the
  total possible distance from perfect equity for a
  given level of coverage
• Thus, the attainable index is a number between 0
  and 100 (or 0 and -100 if the service is
  pro-poor)

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GAVI-eligible
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Preliminary findings

• GAVI support to a country does not appear to be
  associated with national level changes in
  coverage or pro-poor distribution of either DPT3
  (or measles) vaccination among those countries
  where two DHS surveys have been conducted

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Next steps

• Further statistical analysis
• Consider sub-national analysis for certain
  countries
• Analyze urban and rural results separately for
  each country, as the national-level combined
  asset indices tend to be heavily influenced by
  the degree of urbanization
• Incorporate measure of efficiency

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Potential sources of efficiency data

• Costing alongside DHS surveys
• Costing alongside lot quality assessment surveys
• Health Management Information Systems
• Use of existing data, e.g. Matlab DSS
• Exploit planned studies

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Conclusions

• Country-specific empirical evidence on how the
  efficiency and equity of vaccination programs
  change as coverage changes is, despite its
  importance for policy, lacking
• Resource use and equity data should be collected
  alongside services over time where possible
• Is there always a trade-off between efficiency
  and equity?