1. International Health Policy Program -Thailand Using health equity approaches for assessing equity in maternal and child health care in Thailand Phusit Prakongsai Kanjana Tisayaticom Sudarat Tuntivivat International Health Policy Program (IHPP), Ministry of Public Health, Thailand The 3 rd Global Forum on Gender Statistics 11-13 October 2010 Manila, Philippines

2. International Health Policy Program -Thailand Outline of presentation Rationale of health equity approach Data availability in Thailand Concentration curve and concentration index (CI) Examples of assessing health equity in selected Maternal and Child Health (MCH) indicators in Thailand Discussion and conclusions The way forward

3. International Health Policy Program -Thailand Rationale Improving health equity is a key outcome indicator for assessing health system performance of a country  WHO framework on health system performance assessment (HSPA) Determinants of health equity – By gender and sex-disaggregated analysis, – other determinants (socio-economic status, educational level, residential areas, etc.) Various dimensions of health equity – Access to and utilization of health care, – health care financing, – Health status, – Health risk behaviors, etc. Available MCH data from MICS 2006 in Thailand and insertion of household asset variables for computing ‘wealth index’

4. Monitoring & Evaluation of health systems reform /strengthening A general framework Data sources Indicator domains Analysis & synthesis Communication & use Administrative sources Financial tracking system; NHA Databases and records: HR, infrastructure, medicines etc. Policy data Facility assessments Population-based surveys Coverage, health status, equity, risk protection, responsiveness Clinical reporting systems Service readiness, quality, coverage, health status Vital registration Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems Targeted and comprehensive reporting; Regular country review processes; Global reporting Improved health outcomes & equity Social and financial risk protection Responsiveness Financing Infrastructure / ICT Health workforce Supply chain Information Intervention access & services readiness Intervention quality, safety and efficiency Coverage of interventions Prevalence risk behaviours & factors Governance Inputs & processesOutputsOutcomesImpact

5. International Health Policy Program -Thailand Rationale Improving health equity is a key outcome indicator for assessing health system performance of a country  WHO framework on health system performance assessment (HSPA) Determinants of health equity – By gender and sex-disaggregated analysis, – other determinants (socio-economic status, educational level, residential areas, etc.) Various dimensions of health equity – Access to and utilization of health care, – health care financing, – Health status, – Health risk behaviors, etc. Available MCH data from MICS 2006 in Thailand and insertion of household asset variables for computing ‘wealth index’

6. International Health Policy Program -Thailand Dimensions and Determinants of Health Equity Healthcare utilization Health financing Quality & responsive- ness Health status Government subsidy on health Health risk behavior Demographic Gender Age group Geographic Region Urban vs. Rural Social Education Occupation Economic Income Wealth index

7. Data availability for M&E system in Thailand (1) InputOutputOutcomeImpact HCF HRH Infra struct ure Gov er nan ce Med/ Healt h tech HISacc ess qual ity safet y effic ienc y Interve n coverag e Risk factor s H outco me Re sp on siv e Equit y Finan prote ct ion Civil registration and vital statistics Biennial SES Biennial HWS Census / SPC NHES MICS Reproductive H survey NHA Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey, MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes

8. Data availability for M&E system in Thailand (2) InputOutputOutcomeImpact HCF HRHInfra structu re Gove r nanc e Med/ Health tech HISacc ess quali ty safet y effici ency Interven coverage Risk factors H outco me Res pon sive EquityFinan protect ion Facility-based report H resource survey HIS electronic IP database Dis surveillance Behavioral H survey Sero-sentinel Survey Specific dis registration Quality assurance (HA)

9. The concentration curve The concentration curve graphs on the x-axis the cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable.

10. International Health Policy Program -Thailand The concentration index is defined as twice the area between the concentration curve and the line of equality (the 45-degree line running from the bottom-left corner to the top-right). In the case where there is no income-related inequality, the concentration index is zero. The index takes a negative value when the concentration curve lies above the 45-degree line of equality, indicating disproportionate concentration of health service use or other health variables among the poor, and a positive value when it lies below the 45-degree line of equality. The index is bounded between -1 and +1

11. Selected concentration curves of ambulatory service use among different types of health facilities in 2003

12. International Health Policy Program -Thailand Concentration curves of selected MCH indicators in Thailand, MICS data 2005-2006

13. Selected MCH indicators in Thailand from MICS data 2005-2006 Average prevalence or coverage (%) Relative risk between urban and rural Relative risk between Q5:Q1 Concentration index Teenage pregnancy 37.30.76***0.51***-0.1073 Family planning 72.60.92***0.99***-0.0005 Prenatal care by skilled health workers 97.81.0006**1.05***0.0078 Low birth weight 8.31.15***0.92***0.0367 Underweight children 9.30.52***0.24***-0.2192 Stunting11.90.66***0.34***-0.1767

14. RR = 2.8 (95% CI 2.5-3.0) RR = 1.8 (95% CI 1.6-2.0) 55% (39%-68%) reduction Error bars are 95% CIs Source: Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez AD, Lim SS. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369:850-855 Child mortality by quintile of household economic status from 1990 and 2000 census

15. International Health Policy Program -Thailand Discussion and conclusion Most MCH services in Thailand are concentrated to the poor, and the poor can access to MCH care with no financial barrier. Major challenges in health inequity still remain in health outcomes, particularly teenage pregnancy and child malnourishment. Remaining gaps between the rich and the poor, and between urban and rural areas require policy interventions and multi-sectoral actions. This analytical approach shows possibility in using health inequity intra- and inter-groups for gender- based analysis.

16. International Health Policy Program -Thailand The way forward Including sex-aggregated and gender-based analyses in health- related M& E system. Insert a list of household assets and gender in the nationally representative household surveys which household income or expenditure is unavailable. Intra- and inter-group analyses in other dimensions of health equity e.g. health status, health risk behavior, disease burden, etc. Dissemination of key research findings and policy communication of gender-based health equity analysis. Establishment of Health Equity Monitoring Network (HEM-Net) for domestic and international networks.

17. International Health Policy Program -Thailand 17 Thank you for your attention