Health Equity Dr Shahram Yazdani Shahid Beheshti University

Health Equity Dr. Shahram Yazdani Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 02

The Right to Health n 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. Shahram Yazdani

Global Disparities in Life Expectancy Dr. Shahram Yazdani

Inequity within Countries n 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. Shahram Yazdani

0 Dr. Shahram Yazdani Cumulative % of ill-health 100 Relation of socioeconomic conditions and ill health 0 Cumulative % of the population 100

40% of ill health Dr. Shahram Yazdani 40% or people 0 Perfect Equity Condition Cumulative % of ill-health 100 Relation of socioeconomic conditions and ill health 0 Cumulative % of the population 100

100 Cumulative % of expenditures 40% of ill health 40% or people 0 0 Dr. Shahram Yazdani Cumulative % of ill-health 100 Relation of socioeconomic conditions and health expenditures 0 Cumulative % of the population 100

100 40% of expenditures 0 Dr. Shahram Yazdani 40% or people Cumulative % of expenditures 40% of ill health 0 Perfect Equity Condition Cumulative % of ill-health 100 Relation of socioeconomic conditions and health expenditures 0 Cumulative % of the population 100

100 40% of expenditures 40% or people 0 Cumulative % of expenditures 40% of ill health 0 Dr. Shahram Yazdani Cumulative % of ill-health 100 Burden of Disease Concentration Index 0 Cumulative % of the population 100

100 40% of ill health 40% of expenditures 0 Dr. Shahram Yazdani 40% or people Cumulative % of expenditures 65% of ill health!!! 0 Inequity Condition Cumulative % of ill-health 100 Burden of Disease Concentration Index 0 Cumulative % of the population 100

100 40% of ill health 40% of expenditures 40% or people 0 Cumulative % of expenditures 65% of ill health!!! 0 Dr. Shahram Yazdani Cumulative % of ill-health 100 Burden of Health Expenditure Concentration Index 0 Cumulative % of the population 100

100 40% of ill health 40% of expenditures 40% or people 0 Dr. Shahram Yazdani 15% of expenditures Cumulative % of expenditures 65% of ill health!!! 0 Inequity Condition Cumulative % of ill-health 100 Burden of Health Expenditure Concentration Index 0 Cumulative % of the population 100

100 40% of ill health 40% of expenditures 15% of expenditures 40% or people 0 Cumulative % of expenditures 65% of ill health!!! 0 Dr. Shahram Yazdani Cumulative % of ill-health 100 The Paradox of Less Expenditure for Those with Ill-Health 0 Cumulative % of the population 100

Equity vs. Equality It is important to distinguish between equality and equity: n Equality – concerned with equal shares n Equity – about fairness and it may be fair to be unequal ¡ This usually incorporates the concept of “Minimum Social Acceptable Level” (MSAL) Dr. Shahram Yazdani

Definition of Health Equity: Different Approaches n n n 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. Shahram Yazdani

Equality of Access n n 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. Shahram Yazdani

Equality of Use Dr. Shahram Yazdani There are many problems with this principle: n Not everybody responds to treatment in the same way n It requires that there are no differences in quality. n It ignores differences in individual preferences over health and health care n And it cannot be used as a proxy for equality of access or equality of outcomes

Equity in Delivery n n Horizontal equity ¡ Health care delivery system is horizontally equitable if all people with equal need for health care 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 more likely to obtain care than those with a lower need. ” ¡ “More health care for those with more need” Dr. Shahram Yazdani

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” MINIMUM SOCIALLY ACCEPTABLE = EQUITY GAP Dr. Shahram Yazdani = HEALTH CARE

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. MINIMUM SOCIALLY ACCEPTABLE Dr. Shahram Yazdani = HEALTH CARE = CONSUMPTION ABOVE MINIMUM

Equity in Financing n n Dr. Shahram Yazdani 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. 2. 3. Dr. Shahram Yazdani Regressive: The poor pay a higher percentage of their income than the rich Proportional: Rich and poor pay the same percentage of their income Progressive: Rich pay a higher proportion of their income than do the poor

Proportional Contribution Financial Contribution Dr. Shahram Yazdani 0 Income

Regressive Contribution Financial Contribution Dr. Shahram Yazdani 0 Income

Progressive Contribution Financial Contribution Dr. Shahram Yazdani 0 Income

Social Health Insurance n n 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. Shahram Yazdani

Annual Income Tax (a “Direct Tax”) n 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. Shahram Yazdani

User Fees (or Out-of-Pocket Payments) n n 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. Shahram Yazdani

Average Progressivity of Components of Health Care Financing (Kakwani Progressivity Indexes) Revenue Source Index (N=13) Dr. Shahram Yazdani 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 Private Insurance Out-of. Pocket Dr. Shahram Yazdani Denmark (1987) . 062 -. 113 . 000 . 031 -. 265 Finland (1990) . 128 -. 097 . 090 . 000 -. 246 France (1989) . 000 . 094 -. 186 -. 228 Germany (1988) . 251 -. 092 -. 081 . 093 -. 103 Ireland (1987) . 267 --- . 126 -. 021 -. 147 Italy (1991) . 161 -. 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

n n Dr. Shahram Yazdani 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

Equity in Health n n Delivery in relation to health need Financing in relation to ability to pay Dr. Shahram Yazdani

Equality of Opportunity n Equality of opportunity of having a healthy life Dr. Shahram Yazdani

Equality of Health n n n Dr. Shahram Yazdani 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. Shahram Yazdani