dr. shahram yazdani equity in health dr. shahram yazdani “fancy what a game of chess would be if...
TRANSCRIPT
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
hahra
m
Yazd
ani
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
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
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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
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Yazd
ani
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
hahra
m
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
hahra
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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
hahra
m
Yazd
ani
Equality of what?
Equality of use Equality of access Equality of outcome Equality of Opportunity
Dr. S
hahra
m
Yazd
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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
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 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
m
Yazd
ani
Equity in Health
Equity in delivery
Equity in financing
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
Health
LIFE
Life
le
ng
th
Life Quality
GenesFamilyLife StyleNutritionEducationEnvironmentMoneyHealth services
Dr. S
hahra
m
Yazd
ani
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
hahra
m
Yazd
ani
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
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
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
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 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
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.
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-
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?