2. Dr. Shahram Yazdani Equity in Health

3. Dr. Shahram Yazdani “Fancy what a game of chess would be if all the chessmen had passions and intellects, more or less small and cunning; if you were not only uncertain about your adversary’s men, but a little uncertain about your own; if your Knight could shuffle himself on to a new square on the sly; if your Bishop in disgust at your Castling, could wheedle your Pawns out of their places; and if your Pawns, hating you because they are Pawns, could make away from their appointed posts that you might get checkmate on a sudden. You might be the longest- headed of deductive reasoners, and yet you might be beaten by your own Pawns. You would be especially likely to be beaten, if you depended arrogantly on your mathematical imagination, and regarded your passionate pieces with contempt.” George Eliot, Felix Holt the Radical

4. Dr. Shahram Yazdani The Right to Health Preamble to the constitution of the WHO states “The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”

5. Dr. Shahram Yazdani The Right to Health The Declaration of Alma Ata, International Conference on Primary Health Care “The right to health is the most important social goal”

6. Dr. Shahram Yazdani The Right to Health The International Declaration of Human Rights “Everyone has a right to a standard of living adequate for the health and well being of his family including food, clothing, housing and medical care”

7. Dr. Shahram Yazdani Global disparities in life expectancy

8. Dr. Shahram Yazdani Inequity within countries African American age adjusted death rates exceeded those for whites  By 77% in stroke  By 47% for heart disease  By 34% for cancer  By 655% for HIV infection

9. Dr. Shahram Yazdani Burden of disease concentration index Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health 65% of ill health!!!

10. Dr. Shahram Yazdani Illness and expenditure concentration curves Now we know how illness is distributed. To assess fairness, we need to know the distribution of expenditure in relation to the distribution of ill health Cumulative percentage Of the population Cumulative % of illness And expenditure 100 0 0 Illness concentration curve Expenditure concentration curve 10 A B SOURCE: Wagstaff and Van Doorlaer 1993.

11. Dr. Shahram Yazdani Defining equity It is important to distinguish between equality and equity: Equality – concerned with equal shares Equity – about fairness and it may be fair to be unequal

12. Dr. Shahram Yazdani Defining equity in the UK NHS Beveridge (1942) argued for a health service which would provide treatment “ to every citizen without exception, without remuneration limit and without an economic barrier at any point to delay recourse to it ” This is about equality of access

13. Dr. Shahram Yazdani Equality of what? Equality of use Equality of access Equality of outcome Equality of Opportunity

14. Dr. Shahram Yazdani Equality of use There are many problems with this principle: Not everybody responds to treatment in the same way It requires that there are no differences in quality. It ignores differences in individual preferences over health and health care And it cannot be used as a proxy for equality of access or equality of outcomes

15. Dr. Shahram Yazdani Equality of access Access to health care may have instrumental value to promoting better outcomes but it may also be valued in its own right as contributing towards procedural justice

16. Dr. Shahram Yazdani Equality of health This is concerned with distributive justice and represents a consequentialist view in which the only concern is with the distribution of health It has been criticised on the grounds that it is paternalistic and ignores individual choice and differences in preferences But Culyer and Wagstaff (1993) argue that “There is a danger in straining out the gnat of offending personal liberty that one swallows the camel of enduring and outrageous inequalities of health.”

17. Dr. Shahram Yazdani Equality of opportunity Equality of opportunity of having a healthy life

18. Dr. Shahram Yazdani Equity in Health Equity in delivery Equity in financing

19. Dr. Shahram Yazdani Equity in Health Delivery in relation to health need Financing in relation to ability to pay

20. Dr. Shahram Yazdani Health LIFE Life length Life Quality        Genes Family Life Style Nutrition Education Environment Money Health services

21. Dr. Shahram Yazdani Health Inequality Life Span Life Quality Life Span Life Quality      Genes Family Life Style Nutrition Education Environment Money Health services Diseases Person or Population A Person or Population B

22. Dr. Shahram Yazdani Does equality of health status imply equity in delivery or in financing? Should a health system could be considered equitable if all citizens had the same health status  No. Too many factors other than health care influence health status. Still, although health status is an incomplete and sometimes misleading measure of equity in health, it is an important input in design of targeting policies and in design and evaluation of social welfare programs.

23. Dr. Shahram Yazdani Equity in Health Delivery in relation to health need Financing in relation to ability to pay

24.                                                                            Vertical Dimension Horizontal Dimension                                                     Equity in Delivery

25.                                                                            Horizontal Dimension                                                                Horizontal Equity

26.                                                                            Vertical Dimension                                                                                  Vertical Equity

27.                                                                            Vertical Dimension Horizontal Dimension                                                                Horizontal and Vertical Equity

28. Dr. Shahram Yazdani Equity in delivery Horizontal equity  Health care delivery system is horizontally equitable if all people with equal need for health care are equally likely to obtain the same type of health care.  “Equal treatment of equals” Vertical equity  “A health care delivery system is vertically equitable if people with greater need for health care are more likely to obtain care than those with a lower need.”  “More health care for those with more need”

29. Dr. Shahram Yazdani Equity in delivery: possible cases Horizontal equity EquitableInequitable Vertical equity Second or third best Ideal Second or third best Worst Equitable Inequitable

30. Dr. Shahram Yazdani Are equity and equality synonymous? Some think that: “Inequity will not necessarily arise as a result of differences in consumption levels among individuals, but will always be present when consumption by any one individual or group is below a minimum socially acceptable” = HEALTH CARE MINIMUM SOCIALLY ACCEPTABLE = EQUITY GAP

31. Dr. Shahram Yazdani Are equity and equality synonymous? In other words, some think that: As long as everybody has access to a minimum health benefits package, there is equity. If some have access to more than the minimum, there is inequality, but the system is still equitable. = HEALTH CARE MINIMUM SOCIALLY ACCEPTABLE = CONSUMPTION ABOVE MINIMUM

32. Dr. Shahram Yazdani Equity in Health Delivery in relation to health need Financing in relation to ability to pay

33.                                                                      Vertical Dimension Horizontal Dimension Equity in Finance

34.                                                             Horizontal Dimension Horizontal Equity in Finance

35.                                                                                                 Vertical Dimension Vertical Equity in Finance               

36.                                                             Vertical Dimension Horizontal Dimension Vertical And Horizontal Equity in Finance

37. Equity in financing Horizontal equity –Horizontal equity in financing is when people with equal ability to pay make equal payments for health care –“Equal payments by equals” Vertical equity –A health system is vertically equitable when payment and ability to pay are positively correlated –“Greater ability to pay  higher payment” –“Smaller ability to pay  lower payment” –To some, a financing system is considered to be vertically equitable if those with greater ability to pay contribute a greater share of their income to pay for health care (“progressive” financing.)

38. Assessing Vertical Equity in Finance 1.Proportional: Rich and poor pay the same percentage of their income 2.Progressive: Rich pay a higher proportion of their income than do the poor 3. Regressive: The poor pay a higher percentage of their income than the rich

39. Total Household Money Hhld. Money Spent On Health Proportional 0 ------------------------ ---------- ------------------------------------- H1H2H3

40. Dr. Shahram Yazdani Social health insurance If you work for a company that provides health insurance benefits, you (and your employer) typically contribute the same % share of your wage or salary. For example, if the employee contribution rate is 3% both the low wage janitor and the high wage boss will be “taxed” 3% of their earnings.

41. Total Household $$$ Money Hhld. Money Spent On Health Proportional Progressive H1H2H3 0

42. Annual income tax (a “direct tax”) There tends to be exemption from income tax for very low household income, whereas income tax rates climb with levels of household income and then become relatively high for highest income households.

43. Total Household Money Hhld. Money Spent On Health Regressive Proportional (1b) H1H2H3 0

44. User Fees (or Out-of-pocket payments) Both poor and rich tend to be charged the same amount for a health service, regardless of ability to pay. This applies especially to drugs, whereas exemptions may be in place with respect to out-patient and in-patient services.

45. Average Progressivity of Components of Health Care Financing (Kakwani Progressivity Indexes) Revenue SourceIndex (N=13) Direct taxes.169 Indirect taxes-.064 Social Insurance.054 Private Insurance-.005 Out-of-Pocket-.222

46. Progressivity Components of Health Care Financing (Kakwani Progressivity Indexes) Country Direct Taxes Indirect Taxes Social Insurance Private Insurance Out-of- Pocket Denmark (1987).062-.113.000.031-.265 Finland (1990).128-.097.090.000-.246 France (1989).000.094-.186-.228 Germany (1988).251-.092-.081.093-.103 Ireland (1987).267---.126-.021-.147 Italy (1991).161-.112.112.177-.077 Netherlands (1992).200.089-.129.083-.038 Portugal (1990).218-.035.185.137-.242 Spain (1990).214-.152.050-.012-.212 Sweden (1992).053-.083.010----.240 Switzerland (1992).172-.072.038-.270-.403 United Kingdom (1992).284-.152.187.077-.223 United States (1987).192-.065.019-.175-.461

47. Welfare Beyond Health LIFE Life length Life Quality        Genes Family Life Style Nutrition Education Environment Money Health services

48. Equity in Delivery and Finance does not Guarantee Equity in Health Socioeconomic Factors Have Crucial Role in Health Equity Health Needs More Radical policies for Redistribution of Wealth These Policies Should Ensure a Baseline Level of Welfare (and not merely health) for all Citizens

49. Dr. Shahram Yazdani Thank You ! Any Question?