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The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing Countries International Meet PowerPoint Presentation
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The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing Countries International Meeting August 17-20 Tim Evans A world in which any group of individuals defined by age, gender, race-ethnicity, class or residence can achieve its full health potential

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The Equity Gauge: An approach to Monitoring Equity in Health and Health Care in Developing CountriesInternational Meeting August 17-20

Tim Evans

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 potentialWhat do we mean by health equity?
what do we mean by health equity3
‘health inclusion’: continued improvements in health for all but bringing the bottom up at the same rate or faster than the top

‘tolerable’ vs ‘intolerable’ inequalities: in the context of rapid change

What do we mean by health equity?
what are the dimensions of inequity in health
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
health disparities between selected countries
Health Disparities Between Selected Countries

Deaths per 100,00 live births

Age

inverse care laws
Inverse Care Laws
  • Rich consume more hospital and public health care than the poor (Hart 1971)
  • 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)
smoking is more common among the less educated in india men chennai
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.

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Marginality

Very high

High

Moderate

Low

Very low

Counties by level of marginality, Mexico 1990-96

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%

20

100

80

15

60

10

40

5

20

0

0

Very low

Low

Medium

High

Very high

Distribution of Health Resources, México 1990-96

by level of county marginality

Rate per 10,000 population

Physicians

Beds

Hospital deliveries

benchmarks of fairness
Benchmarks of Fairness
  • Evaluating fairness of health systems reform
  • nine benchmarks covering risks to health such as education, safe water and barriers to access both financial and non-financial etc.
  • must develop capacity to monitor health status inequities
  • benchmark encourage “debate” on reform
equity gauge south africa
Equity Gauge: South Africa
  • Health equity explicit goal of
  • government policy
  • Problem: how to monitor progress?
  • Partnership: parliamentarians, researchers, NGOs
  • Gauge development - district and province resource allocation, utilisation of health care, health status
what constitutes an equity gauge
What constitutes an equity gauge?

1) Fair distribution: an organizing principle

2) Key health systems stakeholders

3) Community ownership/integration

4) Technical competency: scope/reach, measures - valid, reliable, sustainable

5) Informing decision- making: awareness/demand, accessibility, user-friendliness, timeliness

central challenges
Central challenges
  • To identify valid indicators to assess short and longer term change
  • To integrate policy link from the outset
  • To ensure that gauges provide voice and visibility to the needs of the vulnerable and marginalized
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IMR highest and lowest quintilesRelative inequality/ Absolute InequalityHi:Low Rate Ratio Rate difference

Source: DHS data 1992-1997; Pande and Gwatkin 1999

range of approaches
Range of approaches
  • City or municipality based ‘gauges’
  • National systems with broad partnerships
  • Innovative household-based monitoring mechanisms
  • Involvement of indigenous groups
  • Redesign of surveys for equity focus
  • Resource allocation focus
  • Broader social determinants focus
what unites these efforts
What unites these efforts?
  • the need for greater capacity to monitor and act upon health systems inequities
what led up to this meeting
What led up to this meeting?
  • Global Health Equity Initiative 1995-2000 (research to reveal inequities within LDCs)
  • Arlington Health Equity meeting June 1999 (move from research on gaps to monitoring for action)
  • Puyuhuapi, Chile meeting October 1999 (strengthen country capacity for monitoring)
  • South Africa- August 2000
who is here
Who is here?
  • Asia: Bangladesh, China, Lao, Philippines, Thailand
  • Africa: Ethiopia, Kenya, Malawi, Mozambique, South Africa, Uganda, Zambia, Zimbabwe
  • Latin America: Argentina, Bolivia, Chile, Cuba, Ecuador, Peru
meeting objectives
Meeting objectives
  • Embrace the “common” challenge
    • Exchange ideas and experiences
    • Lay foundations for greater competency via three working groups- technical, advocacy and policy;
    • Identify potential and mechanisms for longer-term collaboration
vision
Vision

By the year 2015 every country should have an integrated system for monitoring health system inequities that informs, monitors and evaluates health and other socioeconomic policies

--Puyuhuapi Conference position statement

measurement and monitoring
Measurement and Monitoring
  • Correct the first injustice - making people count - vital registration systems with local ownership.
  • Regular reporting of inequities - need better measurement tools for policy
  • Prospective assessment of health system policy -Health equity impact assessments
reversing the inverse care laws
Reversing the Inverse Care Laws
  • Equity targets - both outcomes and access, symbolic and practical (Dahlgren and Whitehead, 1997)
  • Financing reforms - to remove disincentives to access and protect from medical impoverishment
  • Prevention of health risks that cluster with poverty and are cumulative over time e.g. tobacco
  • Evidence on what works - both within and beyond the health care sector