HEALTH

EQUITY
Royasia Viki Ramadani, SKM, MSc
16-05-2020
 Health Equity

Equity is the absence of avoidable,

"Health equity” or “equity in health”
unfair, or remediable differences
implies that ideally everyone should
among groups of people, whether
have a fair opportunity to attain their
those groups are defined socially,
full health potential and that no one
economically, demographically or
should be disadvantaged from
geographically or by other means of
achieving this potential. (WHO)
stratification.
DISKUSI
(#1)
“Health is among the most important
conditions of human life and a critically
significant constituent of human capabilities
which we have reason to value”
(Sen 2002)—Nobel Price Winner –Welfare
Economics
Renungan/Diskusi (#2)
Mengapa?
Masyarakat (kita)/ (pengambil kebijakan) pada umumnya tidak peduli
jika ada:
• Kesenjangan atau perbedaan jumlah kepemilikan kendaraan
bermotor antara kaya dan miskin
• Masyarakat miskin memiliki jumlah baju/pakaian lebih sedikit
Namun
Masyarakat (Society) , peduli (concerned), jika hal tersebut dibawah
ini terjadi :
• Kematian anak dibawah 5 tahun lebih banyak terjadi pada keluarga
miskin
• Penyakit kronis dan mematikan lebih banyak terjadi pada kelompok
keluarga miskin
• Out of pocket spending lebih memiskinkan pada kelompok kelurga
miskin
• Penggunaan layanan kesehatan lebih susah diakses oleh masyarakat
miskin
 Equality

Diskusi Equity
(#3)
Disparity
Potret Disparitas Tenaga Kesehatan/Fasilitas
Kesehatan di Indonesia
POTRET DISPARITAS TENAGA
KESEHATAN/FASILITAS
KESEHATAN DI INDONESIA
MENGAPA ADA
KESENJANGAN???
SOCIAL DETERMINANT
OF HEALTH

(WHO FRAMEWORK)

“The social determinants of health (SDH) are the conditions in which people are
born, grow, work, live, and age, and the wider set of forces and systems shaping
the conditions of daily life”

The social determinants of health are mostly responsible for health inequities - the
unfair and avoidable differences in health status seen within and between countries
(Trend) Artikel tentang Equity
 Health outcomes

(Typical
research) in
Health care utilization

Health Subsidies received through the use of services

Equity
Payments people make for health care (directly through
out-of-pocket payments as well as indirectly through
insurance premiums, social insurance contributions, and
taxes)
Data Sources/Sumber Data
• Survey Data (household): i.e Demographic and Health Surveys
(DHS), Indonesian Family Life Survey (RAND), Susenas (BPS)
• Survey data (Exit poll) : i.e exit poll survey di RS untuk pasien BPJS
Kesehatan
• Administrative data : i.e. HIS
• Census data : i.e Data sensus BPS
Health Variables
• Health outcomes (i.e. angka kematian, angka kematian balita, angka
kematian ibu)
• Health related behavior (i.e. quality of life, hemoglobin status, lung
capacity, blood pressure, Body Mass Index)
• Morbidity (i.e. Dissability Adjusted Life Year, Quality Adjusted Life Year)
• Symptoms and impairments
• Functional disability
• Clinical diagnosis
• Functional disability
Living Standard (SES)
• Household Expenditure
• Income
• Composite Index (aggregating different component of consumption:
food consumption, non-food consumption) menggunakan PCA/Factor
Analysis)

*PCA : Principal Component Analysis

CONTOH
HEALTH EQUITY
RESEARCH
(BETWEEN COUNTRIES)

*Persistent Health Inequity

Between and within country
Contoh Health Inequity Within Country
[Adult Health in Northern Sweden ]
Measurement (Refreshment)

HEALTH VARIABLES LIVING STANDARDS

MEASUREMENT
 Displays the share of health accounted for by cumulative
proportions of individuals in the population ranked from
poorest to richest (Kakwani 1977; Kakwani et al. 1997;
Wagstaff et al. 1991).

Concentration The concentration curve can be used to examine

inequality not just in health outcomes but in any health
Curve sector (between countries, across time, across program)

The two key variables underlying the concentration

curve are the health variable, the distribution of which is
the subject of interest, and a variable capturing living
standards against which the distribution is to be
assessed.
 The first series graphs the line of
Concentration equality,
Curve
The x-values being the cumulative
percentage of the sample

The y-values being the cumulative

percentage of the health variable

Score x-axis and Y-axis range between 0-

100
CONTOH
(DATA ANGKA KEMATIAN BALITA DI INDIA)
 CONCENTRATION
CURVE
Angka kematian balita
terkonsentrasi pada kelompok
keluarga miskin

Angka kesenjangan untuk kematian

balita di Mali jauh lebih rendah
dibandingkan di India. Kesenjangan
di India jauh lebih tinggi, angka
kematian balita jauh lebih
terkonsentrasi pada penduduk
miskin di India dibandingkan di
Mali.
Contoh
(Apakah ada perbaikan dalam penanganan malnutrisi pada anak di
Vietnam? 1992/1993 vs 1997/98)

The inequality in child malnutrition

increased
somewhat in Vietnam between
1992/93 and 1997/98.
The Concentration Index
• Concentration curve dapat digunakan untuk mengidentifikasi
eksistensi health inequality pada health outcome, apakah lebih
baik/buruk antar negara atau antar tahun. NAMUN tidak memberikan
magnitude of inequality yang dapat dibandingkan antar period,
negara, regions, tahun.
• Rule of thumbs:
Index negative: pro-poor (diatas garis equality 45°)
Index positive: pro-rich (dibawah garis equality 45°)
Grafik Pro-poor (index
negative)

Jika outcome kesehatan

adalah “bad health”/”ill
health”: i.e. angka kematian,
angka kesakitan
Pro-rich (index
Maka ketika index positive)
negative

bahwa angka kematian terjadi

lebih tinggi pada kelompok
miskin
 HOW TO
SOLVE /
REDUCE
INEQUALITY
IN HEALTH?
HOW TO SOLVE / REDUCE
INEQUALITY IN HEALTH? (#2)
• Addressing Social Determinant of Health (i.e.Health System,
Universal Health Coverage)
Evaluasi
Kebijakan JKN
The JKN programme has increased the
utilisation of outpatient and inpatient care in
the contributory group. Those with subsidised
insurance have an increase in access to
inpatient facilities only, and this is of a
smaller magnitude. Hence, while JKN has
improved average utilisation, inequity in
access to both outpatient and inpatient care
may remain
“We find that access gaps have narrowed, driven by a weaker association between access and households' economic status. Urban areas see a
bigger reduction. Access to health services is generally greater, supported by increased participation of private providers under the new
regime. ”

Johar M, Soewondo P, Pujisubekti R, Satrio HK, Adji A. Inequality in access to health care, health insurance and
References (#1)

• https://www.who.int/sdhconfe
rence/resources/Conceptualfra
meworkforactiononSDH_eng.
pdf
• https://apps.who.int/iris/bitstr
eam/handle/10665/71116/80
%282%2997-105.pdf?sequen
ce=1&isAllowed=y
• https://openknowledge.world
bank.org/bitstream/handle/10
986/6896/424800ISBN97801
1OFFICIAL0USE0ONLY10.
pdf?sequence=1&isAllowed=
y
References (#2)
https://link.springer.com/content/pdf/10.1007/s00038-019-01215-2.pdf
https://www.sciencedirect.com/science/article/abs/pii/S0277953618304
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