Ole F. Norheim Department of Public Health and Primary Care, University of Bergen, Norway

1. Have we got our priorities right?Child mortality, the Millennium Development Goal 4 and its impact on inequality in health in sub-Saharan Africa Ole F. Norheim Department of Public Health and Primary Care, University of Bergen, Norway Mira Johri Département d’administration de la santé, Faculté de médecine, Université de Montréal, CanadaYukiko Asada Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Canada P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

2. I M A G I N E Ethiopia: 120 out of 1000 kids will die before they reach their fifth birthday

3. Have we got our priorities right? • Background • Methods • Inequality, Gini Index • Data from life tables • Results • Changes in Gini from 1990-2006 • Potential MDG 4 impact on Gini • Policy implications

4. Background • The Millennium Development Goal 4 of reducing under-five mortality by two-thirds before 2015 is not on track. • Worldwide under-5 mortality is expected to decline by 27% from 1990 to 2015 (Murray et al Lancet 2007) • The target is 67% reduction P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

5. The Gini index can be used as a population summary measure of overall inequality in age at death (Le Grand and Rabin 1986) • No study has previously linked high child mortality to overall inequality in health P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

6. Two concepts of inequality • Inequality in mortality associated with unequal socioeconomic status is well known. • Overall inequality in the age of death is less well understood. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

7. Two measures of inequality(Wolfson and Rowe, 2001) • Bivariate measures: Concentration index • “The poor have higher mortality than the less poor” P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

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9. Univariate measures: Ginih • “Those who die young have had less life years than those who complete a normal life span” P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

10. Japan: LE: 82.6 - GINI: 0.09 Niger: LE: 42.2 - GINI: 0.41 P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

11. Example showing how key variables are derived from a life table (Niger 2006) P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

12. Ginih (Brown, 1994) • Xi = a groups proportion of the total population • Yi = that group’s age at death as a proportion of life expectancy • G = 0.0  perfect equality • G = 1.0  perfect inequality P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

13. Aim • Taking the realization of MDG4 in sub-Saharan Africa as a case study… • …our aim was to assess the potential contribution of a univariate measure of health inequalities – the Gini index for health – to equity-based analysis of health policies. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

14. Aim • For all countries in sub-Saharan Africa we • Estimated overall inequality in the age of death for the years 1990 and 2006 • Estimated potential reduction in overall inequality if Millennium Development Goal 4 was achieved. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

15. Methods • To estimate inequality in the age of death (Ginih ) • ….we used data on mortality patterns from WHO life tables for 1990 and 2006 • Ginih is based on exactly the same data as estimates of life expectancy P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

16. To estimate the potential reduction in inequality in age at death if the Millennium Development Goal 4 was achieved • …we calculated a two-third reduction in under-five mortality rates from the 1990 baseline and used these as modified input to the WHO life tables for 2006. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

17. Changes in mortality for the other age groups were calculated using Chiang’s standard life table method. • From the modified tables we calculated impact on Ginih. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

18. Results • If Millennium Development Goal 4 is achieved the potential reduction in overall inequality is substantial for most countries • The largest reduction in overall inequality is seen in Niger, from 0.48 to 0.31, an absolute change of 0.17 P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

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22. Japan: LE: 82.6 - GINI: 0.09 Ethiopia: LE: 56.5 - GINI: 0.26 United Republic of Tanzania: LE: 50.3 - GINI: 0.29 Malawi: LE: 49.9 - GINI: 0.30 P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

23. Potential MDG impact • Fifteen countries would see an absolute change in Gini that is equal or above 0.10 P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

24. Countries with more than 0.10 reduction in Gini P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

25. Is Ginih relevant for health policy? • The life table approach to inequality measurement provides a comprehensive (all-cause) portrait of mortality in the population. • Because age is invariant, Ginih permits absolute comparisons between populations and within populations at different time points. P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

26. Taking as a case study the realization of MDG4 in sub-Saharan Africa, we demonstrate that the Gini index for health provide information useful for equity-based analysis of health policies. • If we value equal lifetime health, Ginih is relevant P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

27. Japan: LE: 82.6 - GINI: 0.09 Niger: LE: 42.2 - GINI: 0.41 P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

28. Have we got our priorities right? • No • High child mortality means that a high proportion of the population lives fewer life years than the others • This is unfair P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

29. Criteria to judge unfairness: • Is there inequality in lifetime health? • Yes, this study (high Ginih) • Are the health conditions amendable to interventions? • Yes: neonatal infections, malaria, pneumonia, HIV, and malnutrition (Jones et al, Lancet 2003) • Is the problem concentrated in socially disadvantaged groups? • Yes (Demographic Health Surveys) P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

30. Full implementation of the MDG goal 4 will have a substantial impact on reducing overall inequality of health for most sub-Saharan African countries. • Existing inequalities in age of death suggest that higher priority should be assigned to interventions targeting under-five mortality. • Ginih: a population summary measure that should be further explored P r i o r i t y S e t t i n g i n G l o b a l H e a l t h

31. Although there is disagreement about perfect justice …we agree and know enough to identify injustice … and do something about it Amartya Sen: The Idea of Justice, 2009