1. Equity Health Economic Course Series: 3 of 12 www.diankusuma.wordpress.com

2. Table of Contents The concept of equity Equity and equality Examples of equity matter

3. What do we mean by health equity? A world in which any group of individuals defined by age, gender, race-ethnicity, class or residence can achieve its full health potential.

4. Inverse Care Laws Rich consume more hospital and public health care than the poor ( Hart 1971, Ruger et al. 2001 ) Immunization coverage strongly correlated with socioeconomic status (Gwatkin et al. 1999) Poor with illness don’t access care: 2x more likely to self treat; 10x more likely to do nothing (Uganda HH Survey, 1994/5) Poor that access health care risk medical impoverishment (Liu and Hsiao, 1997; WB, Voices of the Poor, 2000)

5. Differences, disparities… Under 5 mortality 30-fold higher in Africa compared to Europe Mortality amongst working-age adults in USA 2x higher in blacks than whites Mortality 3-fold in unskilled workers compared to professionals in UK Twice as high in infants and children in lowest economic 20% compared to richest in 56 developing countries Health expenditures well over 100-fold in high income countries compared to low income

6. Disparities in health: a public health concern 1.Existence of large health disparities between socio-economic groups, but also by gender, ethnic origin, etc. 2.The poor use fewer public resources than the middle and upper income groups

7. Social privileges varie among groups of people…. Depending on: Economic resources, income Gender Geographical location Education Ethnicity Religion

8. Equity defined Justice according to natural law or right; specifically: freedom from bias or favoritism. –Webster’s New Collegiate Dictionary The state, ideal, or quality of being just, impartial, and fair. –American Heritage Dictionary ‘Equity, like beauty, is in the mind of the beholder…’ –McLachlan and Maynard (1982)

9. Distinction inequality - inequity Health inequality : Differences, variations or disparities in health achievements of individuals or groups; descriptive term, NOT implying moral judgment; Health inequity : Those inequalities that are considered to be unfair or stemming from some form of injustice; they are avoidable or unnecessary; this entails a normative (subjective) judgment;

10. Equality vs Equity Equality is sameness, and equity is fairness. In any particular situation, equal may not be equitable, or equal may be precisely equitable. Unequal may be a way to be equitable.

11. What are the dimensions of inequity in health? Equity strata: sex, race, ethnicity, region, education, occupation, place Dimensions of health status across which inequities exist: risk, disease, death, social consequences of illness Health care inequities: access, quality & cost of treatment

12. Equitable distribution of what? Health (status) Access to health services Utilisation and quality of health services Resources (facilities, personnel, expenditures, technology) Financial contributions Determinants of health (water & sanitation, housing, education, etc.) Consequences of ill health (social, financial)

13. Smoking is more common among the less educated in India (Men, Chennai) Source: Gajalakshmi, CK et al. Patterns of Tobacco Use and Health Consequences, Background Paper for “Curbing the Epidemic: Governments and the Economics of Tobacco Control, World Bank, 1999.

14. Horizontal Equity: the allocation of equal or equivalent resources for equal need; persons with same ability to pay make same contributions; Vertical Equity: the allocation of different resources for different levels of need; persons with unequal ability to pay make dissimilar contributions;

15. Operationalising the definition of equity Equity in access to health services (access in accordance to need) Equity in financing health care (paying according to ability…) Equity in health outcomes Equity in the distribution of other determinants (education, political participation, living conditions, etc.)

16. Equity in health outcomes: 7 determinants of disparities (Whitehead) 1.Natural, biological variation 2.Freely chosen health damaging behavior 3.Transient advantage of a group that first adopts health promoting behavior 4.Health damaging behavior where degree of choice of lifestyle is severely restricted 5.Unhealthy, stressful living/working conditions 6.Inadequate access to essential basic services 7.Tendency for sick to move down the social scale

17. Criteria of health inequity (looking at underlying differences in distribution of determinants) 1.Are the differences avoidable? (technically, financially, morally) 2.Do they reflect a free choice? 3.Is there an agent/actor responsible for this situation? (culpability, accountability: “can you blame anyone”?)

19. Measuring equity What? –DOH (employment, housing, risk factors,…) –Health status, –Access & Utilisation –Resources (human, infra-structure, equipment,..) –Finance (who pays: ‘incidence’; distribution: progressive/regressive) Over what population groups? Age, Sex, Ethnic, Area (rural/urban), Income Is it fair?

20. “Equity refers to differences that are unnecessary or reducible and are unfair and unjust. The concept of fairness obviously involves a moral judgement and is, therefore, intrinsically difficult. As is the case with health outcomes, similarly the inequities in health determinants are those that should not exist. Every person should, in terms of equity, have the opportunity to access those sanitary and social measures necessary to protect, promote and maintain or recover health.” George Alleyne

21. Thank You