Graduate training: MPH

Department : Health Planning & Health

Services Management
Instructor: Yohannes H/Michael, (BSc,
MPH, DVLDP)
1
 Session Objectives
 Over view of why we focus on
health
 Define Equity;
 Appreciate the justifications of
equity;
 Outline the dimensions of
equity;
 Appreciate the implications of
equity in the health sector

2
 What are the determinants of
Health?

3
 Determinants of health….
 The debate about what determines good
health ought to be wide-ranging study,
for health is a complex and difficult
concept and its determinants are not only
biological and economic, but also
historical, social and political
(Barker.C.1996).
 At least seven of them may be identified:
 Level of poverty- it is the product of and
the main contributor to ill-health.

4
 Determinants of health….
 Education level.
 Employment and the level of income.
 Supply of food and nutritious food intake.
 Access to clean water, sanitation and
housing conditions.
 Personal hygiene including healthy
practice.
 Last but not least, the level of health
care delivery and pattern of consumption
in the society.
5
 Determinants of health….
 Individuals value health but do not value it
above all else (if they did, they would not over-
eat, smoke, drink too much, or drive too fast). 
 We have limited incomes with which to finance
health and other activities, and neither is
costless 
 We exert a relatively high degree of control
over our health by virtue of the fact that we
can influence our health-affecting consumption
patterns, our health care utilisation and our
environment.

6
 Why do we all focus on
Health?.

there is a growing recognition that :

1.Health is seen as basic human right.
2.Health is seen as consumption good.
3. Health is seen as investment in
human capital.
4. A broader variant regards health not
only as an economic investment but
also as a social investment (Green &
Barker, 1988).
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Health as basic human right

 WHO in its constitution stated that,

“…. the enjoyment of the highest
attainable standard of health is one
of the fundamental rights of every
human being without distinction of
race, religion, political belief,
economic or social conditions”.
 At least in principle, virtually all
countries recognize this right.

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Health as consumption good

 Health is also recognized as an

important individual objective of the
material aspects of life. In fact for
some, good health is ‘not as a
means, but an end in itself, a
personal and social objective’ (Green
& Barker, 1988) which could be
enjoyed.

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 Health as investment in human
capital

 The relationship between health and

economic development is well known. The
later promotes better health, but the former
facilitates the later. Health- a form of capital-
is a factor in the further development of the
country (Mills and Gilson, 1988; Gertler &
van der Gaag, 1990; Carol Barker, 1996).
 Perhaps this one appeals more to many
Governments in developing countries.

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Health as social investment
 From this perspective, ‘health
improvements in certain areas may
be seen as a way of reducing social
tensions caused by ill-health at the
family or at the community level
(e.g. through reductions in
alcoholism)’ (Green & Barker, 1988).

11
 Why do individuals and governments
make expenditure on Health?
 the ultimate purpose of expenditures upon
health is to purchase inputs for slowing or
retarding the rate of depreciation of the
human body and mind.
 In this respect, health, or “healthy time” has
both consumption and investment aspects
that are highly pertinent with a
developmental context.
 All other things being equal (pitrus paribus),
a healthy (and educated) population should
be able to produce more goods and services
over the long run than unhealthy (and
uneducated) population.
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What does ‘Equity’ in Health
mean?

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 Equity
“Fate has allowed
humanity such a
pityfully meagre
coverlet, that in
pulling it over one
part of the world,
another has to be
left bare.”
(Rabindranath Tagore)

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 What do we mean by health
equity?

A world in which
any group of
individuals
defined by age,
gender, race-
ethnicity, class or
residence can
achieve its full
health potential

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 Inverse Care Laws
 Rich consume more hospital and public health
care than the poor (Hart 1971, Ruger et al.
2001)
 Immunization coverage strongly correlated with
socioeconomic status (Gwatkin et al. 1999)
 poor with illness don’t access care: 2x more
likely to self treat; 10x more likely to do
nothing (Uganda, HH Survey, 1994/5).
 poor that access health care risk medical
impoverishment (Liu and Hsiao, 1997; WB,
Voices of the Poor, 2000)
 Nearly 30-fold difference in <5-mortality
between Europe and Africa.

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 Disparities in health:
a public health concern

1. Existence of large health disparities

between socio-economic groups, but
also by gender, ethnic origin, etc.

2. The poor use fewer public resources

than the middle and upper income
groups

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Social privileges varies
among groups of people….

Depending on:
 Economic resources, income

 Gender

 Geographical location

 Education

 Ethnicity

 Religion

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Equity defined
 Justice according to natural law or
right; specifically: freedom from bias
or favoritism.
 Webster’s New Collegiate Dictionary

 The state, ideal, or quality of being

just, impartial, and fair.
 American Heritage Dictionary

 ‘Equity, like beauty, is in the mind of the

beholder…’
 McLachlan and Maynard (1982)

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What does ‘Equity in Health’ mean?

 Equity in health implies

addressing differences in health
status that are unnecessary,
avoidable and unfair.

 In other words, health

inequalities count as inequities
when they are avoidable,
unnecessary, and unfair.

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Distinction inequality - inequity

Health inequality:
Differences, variations or disparities in
health achievements of individuals or
groups; descriptive term, NOT implying
moral judgment;
Health inequity:
Those inequalities that are considered to
be unfair or stemming from some form of
injustice; they are avoidable or
unnecessary; this entails a normative
(subjective) judgment;

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Equality vs Equity
 Equality is sameness, and equity is
fairness.
 In any particular situation, equal
may not be equitable, or equal may
be precisely equitable.
 Unequal may be a way to be
equitable.

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The Bases of Equity’ in Health

1. Economic – Externality
2. Theories of Social Justice
 Marxism
 Egalitarianism
 Libertarianism
 Market

23
The Bases of Equity’ in Health…
Externalities or spillover effects:
 Externality exists when the level of
consumption or production of some good
or services by a consumer or firm has a
direct effect on the level of welfare of
another consumer or firm. These effects
may be desirable or undesirable.
 An often quoted example in the health
field is the protection against disease
provided to others when an individual is
immunized (positive externalities)
 Exercise: provide example for negative
externality

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The Bases of Equity’ in Health…
 In policy terms, one school of thought
equates equity with offering equal goods,
resources and opportunities to all
individuals, regardless of need;
individuals can then exercise freedom of
choice as to how things are used.
 The opposite view is that, to achieve
equity, goods, resources and
opportunities must be shared unequally,
because people start from unequal
positions.

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The Bases of Equity’ in Health…

 According to Mills.A(1988),strict
equality (equal shares for all) is
probably not possible for health
services or in general; what is
sought is equity, fair share for all
obtained through the avoidance of
inequalities which are not necessary
or socially acceptable

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Criteria of health inequity

looking at underlying differences in

distribution of determinants
1. Are the differences avoidable?
(technically, financially, morally)
2. Do they reflect a free choice?
3. Is there an agent/actor responsible
for this situation? (culpability,
accountability: “can you blame
anyone”?)

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 Equity in health outcomes:
7 determinants of disparities (Whitehead)
1. Natural, biological variation
2. Freely chosen health damaging behavior
3. Transient advantage of a group that first
adopts health promoting behavior
4. Health damaging behavior where degree of
choice of lifestyle is severely restricted
5. Unhealthy, stressful living/working
conditions
6. Inadequate access to essential basic services
7. Tendency for sick to move down the social
scale

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Two ways of looking at fairness

Egalitarianism/ Libertarianism:
social
determinism: Emphasising freedom to
chooose, people can
“from each according to express their
ability, of each preferences; only the
according to need” very poor are
Choices are result of protected.
unfair circumstances
(eg. targeting of Viewing inequalities as
tobacco outcome of individual
advertisements to low choices (eg. smoking)
income children)

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 Dimension of equity

 Horizontal Equity: the allocation of

equal or equivalent resources for equal
need; persons with same ability to pay
make same contributions;

 Vertical Equity: the allocation of

different resources for different levels
of need; persons with unequal ability
to pay make dissimilar contributions;

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Dimension of equity…
 If two individuals are in fact unequal
in capacity, equal treatment would
be unfair to the more capable of the
two.
 In such a case, equity might well
call for un equal treatment

32
 Equitable distribution of what?
 Health (status)
 Access to health services
 Utilisation and quality of health services
 Resources (facilities, personnel,
expenditures, technology)
 Financial contributions
 Determinants of health (water &
sanitation, housing, education, etc.)
 Consequences of ill health (social,
financial)
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 The ambitious definition maintains that
equity in health care is achieved when equal
health status has been
attained(whitehead,1992)
 In practice this is unrealistic goal for most
services, because health care is only one of
many factors that contribute to health
differences in a country and acting in
isolation would not be able to bring about
the required improvement in community
health status

34
Why equitable distribution?
 House hold economic status, ethnic
difference, education of women,
access to and use of health services
were found to be associated with,
morbidity, mortality and health
outcomes(WHO,2000)

35
36
Smoking is more common among
the less educated in India
(Men, Chennai

70
60
Smoking Prevalence (%)

50
40
30
20
10
0
Illiterate <6 yrs 6-12 yrs >12 yrs
 Source: Gajalakshmi, CK et al. Patterns of
Tobacco Use and Health Consequences,
Background Paper for “Curbing the Epidemic:
Governments and the Economics of Tobacco
Control, World Bank, 1999.

37
 Public and private health services are
used equally, but mainly by wealthier
groups.

 Data from 2000 show that Ethiopian

households seek care in about 41
percent of illness cases. While the poor
to rich ratio for incidence of illness is
1.0, the poor/rich ratio for seeking care
is 0.68, ranging from 0.54 in Afar to
1.12 in Tigray.
 Although females report higher levels of
morbidity, they are less likely to seek
care as compared to males.(WB,2004)

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Operationalising
the definition of equity

 Equity in access to health services

(access in accordance to need)
 Equity in financing health care
(paying according to ability…)
 Equity in health outcomes
 Equity in the distribution of other
determinants
(education, political participation, living
conditions, etc.)

41
 The problem of equity in the health care
system of Ethiopia are:
 1.intra-regional and inter-regional
distribution of the existing health facility
 2.inadequate number of health facility in
terms of population served
 3.Wide variation in terms of average
traveling distance
 4. Utilization

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Operationalising
the definition of equity...

 Gilson argued that if health care is not

used by those individuals most in need it
will not promote equitable moves towards
health(1989).
 Equity in health care is therefore, to be

1.equal access to available care for equal

needs,
2.equal utilization for equal needs
3.equal quality of care for all

47
Access
 There are three key elements to defining
access. Firstly, drawing on Donabedian’s7
concept, access is the “degree of fit”
between the health system and those it
serves;
 a dynamic process of interaction between
health system (or supply-side) issues and
individual or household (or demand-side)
issues.
 Secondly, access has a number of
dimensions:

48
Access cont’d
 Availability (sometimes referred to as
physical access) refers to whether or not
the appropriate health services are in the
right place and at the right time.

 Affordability (sometimes referred to as

financial access)
refers to the “degree of fit” between the
cost of health care and individuals’
ability-to-pay.
 Acceptability (sometimes referred to as
“cultural” access) is the social and cultural
distance between health care systems
and their users.
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Access cont’d
 availability includes the location of
services, hours during which care is
provided and the type, range, quantity
and quality of services, each considered
relative to the health needs of the
population served.
 The range of services is in turn influenced
by the type of staff working in that facility
and the scope of practice of each category
of health worker, which in turn, are
influenced by human resource policies,
and so on.

50
Access cont’d
 Thirdly, the concept of access is distinct
from that of utilization.
 Access is the opportunity or freedom to
use a
health service while
 utilization is when an empowered
individual makes an explicit and informed
decision to exercise his/her freedom to
use health care.
 The definition of access is summarized in
the next frame work .

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An access framework

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An access framework
acceptability outlines three central
elements:
1. The fit between lay and
professional health beliefs
2. Patient-provider engagement and
dialogue
3. The ways in which health care
organizational arrangements
influence patient responses to
services
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An access framework
 The impacts of acceptability problems are,
finally, seen in population level health
inequities. Acceptability problems are
 linked, for example, to: patient
unwillingness to reveal past medical history,
making diagnosis and treatment difficult;
 lower rates of referral to secondary and
tertiary care, and lower rates of intervention
relative to need; or facility by passing
 limited patient adherence to advice or
treatment,

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 Measuring equity
 What?
 employment, housing, risk factors,…
 Health status,
 Access & Utilisation
 Resources (human, infra-structure,
equipment,..)
 Finance (who pays: ‘incidence’;
distribution: progressive/regressive)
 Over what population groups?
Age, Sex, Ethnic, Area (rural/urban),
Income
 Is it fair?

56
summary
 “Equity refers to differences that are
unnecessary or reducible and are unfair and
unjust. The concept of fairness obviously involves
a moral judgement
 and is, therefore, intrinsically difficult. As is the
case with health outcomes, similarly the
inequities in health determinants are those that
should not exist.
 Every person should, in terms of equity, have the
opportunity to access those sanitary and social
measures necessary to protect, promote and
maintain or recover health.”
 George Alleyne

57
summary
 Equity is a question of values, and closely
associated with the concept of social
justice,
 When applied to health, equity has been
most often linked to the reduction of
inequalities.
 Thus, one of the most widely cited
definition of health inequity is that it
“refers to differences in health… which…
are considered unfair and unjust.”

58
Summary
 In similar vein, health equity
indicated that” equity requires
reducing unfair disparities…” and
that” pursuing equity in health and
health care development means
trying to reduce unfair and un
necessary social gaps in health and
health care….”(WHO/Euro document)

59
References
1.Mills.A, Gilson.L (1988).Health economics
for Developing countries: A survival
Kit,HEEP working paper, health economics
and financing program.
2.Barker.K (1996).The health care policy
process, sage publications, London.
3.WHO(2000).Inequalities in
Health,Bulletin,78(1), 2000 PP1-152
4.WB(2004).Ethiopia country status report
on health and poverty, the World Bank
Africa region. PPX-XIII

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References…
5.Office of Health Economics (OHE), the
economics of health care 12 Whitehall,
London SW1A 2DY
6.MOH(2005/2006).Health and Health related
indicators, Addis Ababa, Ethiopia
7.Central statistics Agency(2006).Ethiopian
Demographic and Health survey
EDHS(2005).Addis Ababa, Ethiopia
8.Feldstein.P.J(2005).Health Care
Economics,6th ed,delmar,USA.

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Group exercise
 Present your proposal outcome in
plenary after 30 minutes

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Group exercise cont’d
 Resource allocation may be based
on consideration of equality of
expenditure, of inputs or of access.
 This will have different results, and
thus different implications for policy
 therefore propose resource
allocation modalities in Ethiopian
health care

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Thank you !!!

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