1. Measuring Health Inequities within a Health Equity Gauge Martín Valdivia Grupo de Análisis para el Desarrollo Presented at the Global Equity Gauge Alliance (GEGA) Technical Workshop, February 10-16, 2002, Entebbe, Uganda

2. Measuring health inequity has several aspects 4 Selecting health-related variables (health status, access to quality health care, health-related expenditures) 4 Selecting indicators of SES (education, income, expenditures, wealth) 4 SES at individual or household-level? 4 Indicators of health inequity 4 Poor/rich ratio 4 relative gap 4 concentration index 4 regression-based indicators

3. Key message 4 Look at all inequity indicators and the whole distribution 4 None of them may be enough to capture the situation for all health-related indicators 4 Report confidently those inequities that are robust 4 Is all this really important?

4. Let me give you an example 4 Estimating health inequities in Peru 4 First, look at children’s chronic malnutrition: z-score for height for age 4 Rate of chronic malnutrition in Peru: 24% 4 Let’s look at their distribution by SES and place of residence (urban/rural) 4 Which group is more equitable 4 See the poor/rich ratio, CI, and relative gap

5. Urban vs Rural 4 Global health inequity is higher than within urban and rural areas. 4 Feature of deviation indicators 4 Warning: That is, significant component of inequities relate to differences between urban and rural areas. 4 There is less SES related health inequalities in rural areas. Is that population group better?

6. How important are these urban-rural differences in inequity? 4 Poor/rich ratio would say they are large. Less true with relative gap 4 There is definitely less inequality in rural areas, but... 0.59 0.53

7. Chronic malnutrition rates: the whole distribution 4 Malnutrition rate in rural areas is 40% in rural areas, but it drops to 12% in urban areas 4 The issue is: rural kids face higher nutritional risk than their SES-equivalent urban counterparts. 0 10 20 30 40 50 60 70 5.56.06.57.07.58.08.59.0 Promedio del ln del gasto per cápita Tasa de desnutrición UrbanaRural decil 1 decil 10 decil 1

8. What do we do? 4 We could use absolute differences between poorest and richest decile 4 It is 45.2 percentage points in rural areas 4 and only 26.7 points in urban areas 4 Rural areas are worse according to this indicator 4 problem is … we are trying to resolve with an inequality indicator an issue that has more to do with other aspects of the distribution 4 Another way is to use a regression-based approach 4 isolate “income” effect from related effects such as education, district marginality, etc 4 helps to identify effect of interventions on health status and in the income effect itself

9. Income effect in urban and rural areas 4 In urban areas, 38% of poor-rich nutritional differences are explained by income differences 4 That percentage is 63% in rural areas. 4 Conclusion 1: Rural safety nets are less efficient in isolating health from income differences and fluctuations 4 Conclusion 2: inequality indicators are not sufficient to describe overall health and nutritional differences between societies

10. Grupo de Análisis para el Desarrollo www.grade.org.pe