Equity or Equality MD-MPH, SDH Course اسفند هشتاد و شش

2 تاريخچه تعريف: برابري يا عدالت توزيع زماني و مكاني نابرابري اندازهگيري نابرابري –ضريب جيني –Concentration index ابعاد نابرابري

3 تاريخچه اولين نوشتههاي مربوط به عدالت به سال 1845 توسط Fredrick Engels باز ميگردد. در سال 1980 تعلق سياسي و علمي به نابرابري در سلامت و عوامل موثر بر آن افزايش مشهودي داشت، و يكي از علل اصلي اين افزايش تعلق گزارشي با عنوان نابرابري در سلامت معروف بهBlack Report " بود. در سال 1995 سازمان جهاني بهداشت توجه دولتها و سازمانهاي جهاني را به اين موضوع معطوف نمود.

4 تعريف بيعدالتي در سلامت به معناي تفاوت در سلامت است به نحوي كه نه تنها غير ضروري و قابل اجتناب باشد، بلكه ناعادلانه و بيانصافانه تلقي گردد عدالت در سلامت به عدم وجود اختلافات سيستماتيك و قابل اجتناب در يك يا چند بعد از سلامت در جوامع مختلف جغرافيايي، اجتماعي و دموگرافيكي اطلاق ميگردد. سازمان جهاني بهداشت در سال 1998 بيعدالتي در سلامت را به شكل زير تعريف نمود: " نابرابري در وضعيت سلامت، عوامل خطر يا دسترسي به خدمات تندرستي ما بين افراد كه غير ضروري، قابل اجتناب و ناعادلانه باشد".

5 مثال ميزان سرطان ريه در افرادسيگاري بيشتر از جامعه است. خطر سكته قلبي در مردان سال بيشتر از زنان در همين گروه سني است. بيماري سل در قشر فقيرتر جامعه بيشتر است. شيوع HIV در افرادي كه رفتار پر خطر جنسي دارند بيشتر است. افرادي كه به بيماري فنيلكتين اوري مبتلا هستند، اميد به زندگي كوتاهتري دارند.

6 برابري در سلامت مستلزم يك رويكرد بين بخشي است كه تقريبا تمام سياستهاي اجتماعي شامل محيط اجتماعي و فيزيكي، سياستهاي اقتصادي ونيز سياستهاي آموزشي را در بر ميگيرد. ارتقاي متوسط سطح سلامت لزوما با توزيع بهتر سلامت، يعني عدالت، مربوط نيست. در نتيجه، سياستهايي كه متوسط سطح سلامت را ارتقا ميبخشند، لزوما عدالت در سلامت را تامين نميكنند و حتي ميتوانند آن را كاهش دهند.

7 تاريخچه تعريف: برابري يا عدالت توزيع زماني و مكاني نابرابري اندازهگيري نابرابري –ضريب جيني –Concentration index ابعاد نابرابري

8 Infant Mortality Rate Half Full …

9 … Or Half Empty?

10 Is it Getting Better?

11 How about in Africa?

12 Is Latin American any Different?

13 Is East Asia any Different?

14 How About the Middle East?

15 INFANT MORTALITY RATES among Lowest and Highest 20% of the Population 56 Low- and Middle-Income Countries

16 HOW ABOUT FERTILITY RATES among Lowest and Highest 20% of the Population 56 Low- and Middle-Income Countries

17 HOW ABOUT SEVERE STUNTING among Lowest and Highest 20% of the Population 56 Low- and Middle-Income Countries

18 كدام را اندازه ميگيريم ؟ برابري يا عدالت

19 تاريخچه تعريف: برابري يا عدالت توزيع زماني و مكاني نابرابري اندازهگيري نابرابري –ضريب جيني –Concentration index ابعاد نابرابري

20 Lorenz Curve X: Cumulative percent of population ranked by income Y: Cumulative percent of income

21 Discussion question Look at spreadsheet –Graph cumulative distribution of income

22 Step 1: Income inequality Cumulative proportion of population ranked by income Cumulative proportion of income Diagonal: line of equality PoorestRichest Lorenz curve of income inequality Gini coefficient: twice the area between the diagonal and the Lorenz curve Range of Gini: 0-1

23 Cumulative distribution of income income

24 The Gini coefficient The diagonal reflects equal distribution of income The closer the Lorenz curve to the diagonal, the smaller the income inequality –When the Lorenz curve is close to the diagonal, the area is small and the Gini coefficient is small –Small values of Gini indicate low inequality –The closer the Gini to 0, the less the inequality The further away the Lorenz curve from the diagonal, the greater the inequality

25 Step 2: Inequality in health care payments Cumulative proportion of population ranked by income Cumulative proportion of health care payments Diagonal: line of equality PoorestRichest Concentration curve of health care payments Concentration index: Twice the area between the diagonal and the concentration curve Range of CI: -1 & +1

26 Concentration curve and index Increasingly popular measure of inequality Summary measure capturing experience of entire population Helpful for comparison with other countries Data needs –Approach (a) –Household health data and direct measure of SES See handout

27 CI X: Cumulative percent of population ranked by income Y: Cumulative percent of diarrhea cases

28 Cumulative share of diarrhea

29 Cumulative share of diarrhea (2)

30 Cumulative share of diarrhea (3)

31 Cumulative share of diarrhea (4)

32 Illness concentration curve Poorest 50% of population 75% of disease burden Cumulative proportion of illness Inequality where the poor bear a greater share of illness than their share in the population

33 Illness concentration curve Cumulative proportion of population ranked by socio-economic status Cumulative proportion of illness Illness concentration curve Diagonal: line of equality PoorestRichest

34 Illness concentration curve Poorest 50% of population 25% of disease burden Cumulative proportion of illness Inequality where the rich bear a greater share of illness than their share in the population

35 Turkey: distribution of IMR Infant mortality rate (per 1,000 LBs) Source: DHS,

36 Turkey: concentration curve of IMR Cumulative share of infant deaths Source: DHS, 1993, authors calculations Concentration index = -0.19

37 Concentration index of IMR in 44 countries from DHS Concentration index Data source:

38 Applying tools to health service use Concentration Curves apply to health services use: Q: If we draw a concentration curve for health service use that is pro rich, will the concentration curve be above or below the 45 degree line? Concentration index is negative if health services are pro poor and positive if they are pro-rich

39 glcurve7 case, sortvar(income) Ineqerr case Lorenz income Inequal income..\educational folder\Equity & quality\asd.dta..\educational folder\Equity & quality\asd.dta

40 تاريخچه تعريف: برابري يا عدالت توزيع زماني و مكاني نابرابري اندازهگيري نابرابري –ضريب جيني –Concentration index ابعاد نابرابري

41 Dimensions To Inequality Outcomes, Outputs, Inputs 1.Health Outcomes 2.Financing Burden 3.Service Use (Expenditures or Benefits) Dimensions 1.Income 2.Residence (Geographic, Rural/Urban) 3.Other Socio Economic Measures

42 1. Health Outcomes Mortality Measures (Infant 1Q0, Child 5Q0, Adult 45Q15) Morbidity Measures (quality of life) Nutritional Outcomes (stunting, BMI) Population Outcomes (fertility rates)

43 2. Financial Burden Direct out-of-pocket payments (drugs, co- payments, fees, informal payment) Indirect out-of-pocket payments (time from work, transport) Private insurance premiums Tax Burden (direct tax, indirect tax, payroll tax)

44 3. Service Use (Expenditures or Benefits) Basic Utilization –Preventive care –Curative care (primary, outpatient specialist, hospital) –Delivery related

45 Dimensions Income –Consumption-based –Income-based –Asset-based Residence –Geography (State, province, oblast, etc.) –Rural/Urban (within UrbanSlums)

46 Discussion question Identify important equity issues in Irans health system –What important outcomes, outputs, and inputs are distributed inequitably? –What are the main dimensions of these inequality? What are the main causes of these persistent inequalities?