dr. shahram yazdani equity in health dr. shahram yazdani “fancy what a game of chess would be if...

Dr. Shahram Yazdani

Equity in Health

Dr. S

hahra

m

Yazd

ani

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”

Dr. S

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Yazd

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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”

Dr. S

hahra

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Yazd

ani

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”

Dr. S

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Global disparities in life expectancy

Dr. S

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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

Dr. S

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Burden of disease concentration index

Cumulative % of the population

Cu

mu

lati

ve %

of

ill

-hea

lth

100

1000

0

40% or people

40% of ill health

65% of ill health!!!

Dr. S

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Yazd

ani

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 percentageOf the population

Cu

mu

lati

ve

% o

f il

lne

ss

An

d e

xp

en

dit

ure

10

0

1000

0

Illness concentration

curveExpenditure

concentration curve

10

A

B

SOURCE: Wagstaff and Van Doorlaer 1993.

Dr. S

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Yazd

ani

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

Dr. S

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Yazd

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Equality of what?

Equality of use Equality of access Equality of outcome Equality of Opportunity

Dr. S

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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

Dr. S

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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

Dr. S

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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.”

Dr. S

hahra

m

Yazd

ani

Equality of opportunity

Equality of opportunity of having a healthy life

Dr. S

hahra

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Yazd

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Equity in Health

Equity in delivery

Equity in financing

Dr. S

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Yazd

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Equity in Health

Delivery in relation to health need Financing in relation to ability to pay

Dr. S

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Health

LIFE

Life

le

ng

th

Life Quality

GenesFamilyLife StyleNutritionEducationEnvironmentMoneyHealth services

Dr. S

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Health Inequality

Life

S

pa

n

Life Quality

Life

S

pa

n

Life Quality

GenesFamilyLife StyleNutritionEducationEnvironmentMoneyHealth services

Diseases

Person or Population A

Person or Population B

Dr. S

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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.

Dr. S

hahra

m

Yazd

ani

Equity in Health

Delivery in relation to health need Financing in relation to ability to pay

Vertical D

imension

Horizontal Dimension

Equity inDelivery

Horizontal Dimension

HorizontalEquity

Vertical D

imension

VerticalEquity

Vertical D

imension

Horizontal Dimension

Horizontal and

VerticalEquity

Dr. S

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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”

Dr. S

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Equity in delivery: possible cases

Horizontal equityEquitable Inequitable

Ver

tica

l eq

uit

y

Second or third bestIdeal

Second or third best

Worst

Eq

uit

ab

leIn

equ

itab

le

Dr. S

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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

Dr. S

hahra

m

Yazd

ani

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

= CONSUMPTION ABOVE MINIMUM

Dr. S

hahra

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Yazd

ani

Equity in Health

Delivery in relation to health need Financing in relation to ability to pay

Vertical D

imension

Horizontal Dimension

Equity in Finance

Horizontal Dimension

HorizontalEquity in Finance

Vertical D

imension

Vertical Equity in Finance

V

ertical Dim

ension

Horizontal Dimension

Vertical And

HorizontalEquity in Finance

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.)

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

Total Household Money

Hhld.

Money

Spent

On

Health Proportional

0

----------------------------------

-------------------------------------

H1 H2 H3

Dr. S

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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.

Total Household $$$ Money

Hhld.

Money

Spent

On

Health Proportional

Progressive

H1 H2 H30

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.

Total Household Money

Hhld.

Money

Spent

On

Health

Regressive

Proportional

(1b)

H1 H2 H30

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.

Average Progressivity of Components of Health Care Financing

(Kakwani Progressivity Indexes)

Revenue Source Index (N=13)

Direct taxes .169

Indirect taxes -.064

Social Insurance .054

Private Insurance -.005

Out-of-Pocket -.222

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 .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

Welfare Beyond Health

LIFE

Life

le

ng

th

Life Quality

GenesFamilyLife StyleNutritionEducationEnvironmentMoneyHealth services

• 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

Dr. S

hahra

m

Yazd

ani

Thank You !

Any Question?