dr. shahram yazdani health equity shahid beheshti university of medical sciences school of medical...

Dr. Shahram Yazdani

Health Equity

Shahid Beheshti University of Medical SciencesSchool of Medical Education

Strategic Policy Sessions: 02

Dr. S

hahra

m

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

hahra

m

Yazd

ani

Global Disparities in Life Expectancy

Dr. S

hahra

m

Yazd

ani

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

hahra

m

Yazd

ani

Relation of socioeconomic conditions and ill health

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

Dr. S

hahra

m

Yazd

ani

Relation of socioeconomic conditionsand ill health

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

Perfect Equity Condition

Dr. S

hahra

m

Yazd

ani

Relation of socioeconomic conditionsand health expenditures

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of ill health

Dr. S

hahra

m

Yazd

ani

Relation of socioeconomic conditionsand health expenditures

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures40% of ill health

Perfect Equity Condition

Dr. S

hahra

m

Yazd

ani

Burden of Disease Concentration Index

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures40% of ill health

Dr. S

hahra

m

Yazd

ani

Burden of Disease Concentration Index

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

65% of ill health!!!

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures

Inequity Condition

Dr. S

hahra

m

Yazd

ani

Burden of Health ExpenditureConcentration Index

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

65% of ill health!!!

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures

Dr. S

hahra

m

Yazd

ani

Burden of Health Expenditure Concentration Index

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

65% of ill health!!!

15% of expenditures

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures

Inequity Condition

Dr. S

hahra

m

Yazd

ani

The Paradox of Less Expenditure for Those with Ill-Health

Cumulative % of the population

Cu

mu

lati

ve %

of

ill-

he

alt

h10

0

1000

0

40% or people

40% of ill health

65% of ill health!!!

15% of expenditures

Cu

mu

lati

ve %

of

ex

pen

dit

ure

s10

00

40% of expenditures

Dr. S

hahra

m

Yazd

ani

Equity vs. Equality

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 This usually incorporates the concept of

“Minimum Social Acceptable Level” (MSAL)

Dr. S

hahra

m

Yazd

ani

Definition of Health Equity: Different Approaches

Access to Healthcare (Equal or MSAL) Delivery/Utilization of Healthcare (Equal or MSAL) Financial Contribution (in Relation to Ability to Pay) Opportunity to be Healthy (Equal or MSAL) Health Outcomes (Equal or MSAL)

Dr. S

hahra

m

Yazd

ani

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

hahra

m

Yazd

ani

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

hahra

m

Yazd

ani

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

hahra

m

Yazd

ani

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

m

Yazd

ani

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.)

Dr. S

hahra

m

Yazd

ani

Assessing Vertical Equity in Finance

1. Regressive: The poor pay a higher percentage of their income than the rich

2. Proportional: Rich and poor pay the same percentage of their income

3. Progressive: Rich pay a higher proportion of their income than do the poor

Dr. S

hahra

m

Yazd

ani

Income

Financial Contribution

0

Proportional Contribution

Dr. S

hahra

m

Yazd

ani

Income

Financial Contribution

0

Regressive Contribution

Dr. S

hahra

m

Yazd

ani

Income

Financial Contribution

0

Progressive Contribution

Dr. S

hahra

m

Yazd

ani

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.

Dr. S

hahra

m

Yazd

ani

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.

Dr. S

hahra

m

Yazd

ani

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.

Dr. S

hahra

m

Yazd

ani

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

Dr. S

hahra

m

Yazd

ani

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

Dr. S

hahra

m

Yazd

ani

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

Equity in Health

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

Dr. S

hahra

m

Yazd

ani

Equality of Opportunity

Equality of opportunity of having a healthy life

Dr. S

hahra

m

Yazd

ani

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