equity in health system

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Equity in health: Principals and measurements

Abdur Razzaque SarkerMHE (Health Economics), MSS (Economics)

Health Economics and Financing Research, icddrband

PhD Fellow in Strathclyde University, UKEmail: razzaque.sarker@gmail.com

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What is equity?

Principle of being fair to all, with reference

to a defined and recognized set of values.

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Equity concepts

� Market mechanism is considered fair/Nozick.� Maximising greatest happiness for greatest numbers, but

ignores distributional aspects /Utilitarianism.� Goods are distributed so that the position of the least

well off in society is maximized/ Rawls� Equal shares of a distribution of a commodity which

means equality in health and health care/ Egalitarianism

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Equity in what ?

� Health� Health care delivery � Health care utilization � Health care financing

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Dimensions in Equity

� Vertical equity The principle that says that those who are in different circumstances should be treated differently.

� Horizontal equity

The principle that says that those who are in identical or similar circumstances should be treated equally.

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Measurements

The range

The index of dissimilarity

The slope and relative indices of inequality

The Gini-coefficient

The concentration index

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Criteria to be a good measurement of inequality in health

1. It reflects the experiences of the entire population.

2. It reflects the socioeconomic dimension of health.

3. It is sensitive to changes in the distribution of the population across the socioeconomic groups.

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GINI-COEFFICIENT

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Gini-Coefficient

2 * (Area under diagonal – area under lorenz curve)

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Calculating Gini-Coefficient

Brown’s formula

Index =

Y = Cumulative proportion populationX = Cumulative proportion health or ill-health k = Number of individualsi = Individual and corresponding health in specific position

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Gini-coefficient

Pop Prop pop Cum. Prop.

Pop (X)

Xi-Xi-1

(A)Sickdays

Prop

sickdays Cum prop

sickdays (Y)

Yi+Yi-1 (B)

A*B

1 0.1 0.1 0.1 2 0.02 0.02 0.02 0.0021 0.1 0.2 0.1 4 0.04 0.06 0.08 0.0081 0.1 0.3 0.1 6 0.06 0.12 0.18 0.0181 0.1 0.4 0.1 7 0.07 0.19 0.31 0.0311 0.1 0.5 0.1 9 0.09 0.28 0.47 0.0471 0.1 0.6 0.1 11 0.11 0.39 0.67 0.0671 0.1 0.7 0.1 12 0.12 0.51 0.9 0.091 0.1 0.8 0.1 14 0.14 0.65 1.16 0.1161 0.1 0.9 0.1 15 0.15 0.8 1.45 0.1451 0.1 1 0.1 20 0.2 1 1.8 0.1810 1 100 Sum = 0.704 Gini-coefficient = 1-sum(A*B)= 0.296

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CONCENTRATION INDEX

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A variant of Lorenz curve. Socioeconomic dimension of health is included in the concentration curve.

Concentration curve plots cumulative proportion population (ranked from the poorest to the richest socioeconomic condition) in x-axel against poportion injuries in y-axel.

Concentration curve

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Lorenz CurveLorenz Curve

Lorenz curve plots cumulative proportion population (ranked from the sickest to the healthiest one) in x-axel against poportion health in y-axel.

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Serial Pop Sick days

1 1 102 1 103 1 104 1 105 1 106 1 107 1 108 1 109 1 10

10 1 10Sum 10 100

Equal distribution of sick days

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Lorenz curve with perfect equality

Cumulative proportion populationCu

mu

lative prop

ortion H

ealthy D

ays

20%

40%

60%

80%

100%

20% 40% 60% 80% 100%O

B

C

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Inequal distribution of sickdays

Serial Pop Sickdays

1 1 22 1 43 1 64 1 75 1 96 1 117 1 128 1 149 1 15

10 1 20Total 10 100

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Cumulative proportion population

Cu

mu

lative prop

ortion Q

AL

Ys

Lorenz curve with inequality in QALYs

20%

40%

60%

80%

100%

20% 40% 60% 80% 100%

•

•

•

•

O

B´

B

C

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Cumulative proportion population (ranked from poorest to richest)

Cu

mu

lative prop

ortion sick

days

Concentration curve of sickdays

20%

40%

60%

80%

100%

20% 40% 60% 80% 100%

•

•

•

•

O

B´

B

C

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Concentration Index

2*(area under diagonal – area under concentration curve)

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Calculating concentration index

Pop Prop pop Cum. Prop. Pop

(X)

Xi-Xi-1 (A) Sickdays Prop sickdays

Cum prop

sickdays (Y)

Yi+Yi-1 (B)

A*B

1 (Poorest) 0.1 0.1 0.1 14 0.184 0.184 0.184 0.0181 0.1 0.2 0.1 12 0.158 0.342 0.526 0.0531 0.1 0.3 0.1 10 0.132 0.474 0.816 0.0821 0.1 0.4 0.1 9 0.118 0.592 1.066 0.1071 0.1 0.5 0.1 8 0.105 0.697 1.289 0.1291 0.1 0.6 0.1 7 0.092 0.789 1.487 0.1491 0.1 0.7 0.1 6 0.079 0.868 1.658 0.1661 0.1 0.8 0.1 5 0.066 0.934 1.803 0.181 0.1 0.9 0.1 3 0.039 0.974 1.908 0.1911 (Richest) 0.1 1 0.1 2 0.026 1 1.974 0.197 1 76 1.271 Concentration Index = 1-sum(A*B)= -0.271

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1. It reflects the experiences of the entire population.

2. It reflects the socioeconomic dimension of health.

3. It is sensitive to changes in the distribution of the population across the socioeconomic groups.

Check if Gini-coefficient and concentration index satisfy the following criteria.

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Email: razzaque.sarker@gmail.com

THANK YOU