This paper describes approaches to the measurement and explanation of income-related inequality and inequity in health care financing, health care utilisation and health and considers the applicability and the feasibility of these methods in low income countries. Results from a comparative study of fourteen Asian countries are used to illustrate the main issues. The empirical analyses demonstrate that, in low-income countries, the better-off tend to pay more for health care, both absolutely and in relative terms. But they also consume more health care. Assessing the distributional performance of health systems in low income settings therefore requires examination of finance and utilisation simultaneously.
Monitoring equity and research policy
Measurement and explanation of inequality in health and health care in low-income settings
Van Doorslaer E, O\\\'Donnell O: World Institute for Development Economic Research (WIDER)
Measuring adult mortality using sibling survival: A new analytical method and new results for 44 countries
Obermeyer Z, Rajaratnam JK, Park CH, Gakidou E, Hogan MC et al: Public Library of Science Medicine 7(4), 13 April 2010
This study presents the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. It applies the method to generate estimates of and trends in adult mortality for 44 countries with District Health Survey sibling survival data. Findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, estimates here show the risk of adult death between the ages of 15 and 60 to be about 20–35% for females and 25–45% for males in sub-Saharan African populations largely unaffected by HIV. In southern African countries, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at the age of fifteen will be dead by age 60, as will six out of ten women. The results of this study represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The study recommends that governments use the CSS method for more accurate tracking of adult mortality rates.
Measuring and correcting biased child mortality statistics in countries with generalised epidemics of HIV infection
Hallett TB, Gregson S, Kurwa F, Garnett GP, Dube S, Chawira G et al: Bulletin of the World Health Organization 88(10): 761–768, October 2010
In countries with generalized epidemics of human immunodeficiency virus (HIV) infection, standard statistics based on fertility history may misrepresent progress towards this target owing to the correlation between deaths among mothers and early childhood deaths from acquired immunodeficiency syndrome. To empirically estimate this bias, this study collected child mortality data and fertility history, including births to deceased women, through prospective household surveys in eastern Zimbabwe during 1998–2005. According to the empirical data, standard cross-sectional survey statistics underestimated true infant and under-5 mortality by 6.7% and 9.8%, respectively. These estimates were in agreement with the output from the model, in which the bias varied according to the magnitude and stage of the epidemic of HIV infection and background mortality rates. The bias was greater the longer the period elapsed before the survey and in later stages of the epidemic. Bias could substantially distort the measured effect of interventions to reduce non-HIV-related mortality and of programmes to prevent mother-to-child transmission, especially when trends are based on data from a single survey. A mathematical model with a user-friendly interface is available to correct for this bias when measuring progress towards Millennium Development Goal 4 in countries with generalised epidemics of HIV infection.
Measuring global health inequity
Reidpath DD and Allotey P: International Journal for Equity in Health 6(16), 30 October 2007
Notions of equity are fundamental to, and drive much of the current thinking about global health. Health inequity, however, is usually measured using health inequality as a proxy - implicitly conflating equity and equality. Unfortunately measures of global health inequality do not take account of the health inequity associated with the additional, and unfair, encumbrances that poor health status confers on economically deprived populations. Using global health data from the World Health Organization's 14 mortality sub-regions, a measure of global health inequality (based on a decomposition of the Pietra Ratio) is contrasted with a new measure of global health inequity. The inequity measure weights the inequality data by regional economic capacity (GNP per capita). The least healthy global sub-region is shown to be around four times worse off under a health inequity analysis than would be revealed under a straight health inequality analysis. In contrast the healthiest sub-region is shown to be about four times better off. The inequity of poor health experienced by poorer regions around the world is significantly worse than a simple analysis of health inequality reveals.
Measuring health inequality and health opportunity
Zheng B: World Institute for Development Economic Research (WIDER)
The paper considers the measurement of health inequality and health opportunity with categorical data of health status. A society’s health opportunity is represented by an income-health matrix that relates socioeconomic class with health status; each row of the matrix corresponds to a socioeconomic class and contains the respective probability distribution of health. The income-health matrix resembles the transition matrix used in measuring income mobility and, hence, approaches developed there can be adapted to measuring health opportunity.
Measuring health inequities in low and middle income countries for the development of observatories on inequities and social determinants of health
Guerra G; Borde E; Salgado de Snyder V: International Journal for Equity in Health 15(9), January 2016,
Almost seven years after the publication of the final report of the World Health Organisation’s Commission on Social Determinants of Health (CSDH), its third recommendation has not been attended to properly. Measuring health inequities (HI) within countries and globally, in order to develop and evaluate evidence-based policies and actions aimed at the social determinants of health (SDH), is still a pending task in most low and middle income countries (LMIC) in the Latin American region. In this paper the authors discuss methodological and conceptual issues to measure HI in LMIC and suggest a three-stage methodology for the creation of observatories on health inequities (OHI) and social determinants of health, based on the experience of the Brazilian Observatory on Health Inequities. The authors describe the three stages and discuss the replicability of this methodology in other Latin American countries. The authors also carried out a search of suitable national information systems to feed an OHI in Mexico, along with an outline of the institutional infrastructure to sustain it. When implementing the methodology for an OHI in LMIC such as Mexico, the authors found that having strong infrastructure of information systems for measuring HI is required, but not sufficient to build an OHI. Adequate funding and intersectoral network collaborations lead by a group of experts is a requirement for the consolidation and sustainability of an OHI in LMIC.
Measuring impact in the Millennium Development Goal era and beyond: A new approach to large-scale effectiveness evaluations
Victora CG, Black RE, Boerma JT and Bryce J: The Lancet 377(9759): 85–95, 1 January 2011
Evaluation of large-scale programmes and initiatives aimed at improvement of health in countries of low- and middle-income needs a new approach, according to this article. Traditional designs, which compare areas with and without a given programme, are no longer relevant at a time when many programmes are being scaled up in virtually every district in the world. The authors propose an evolution in evaluation design: a national platform approach that uses the district as the unit of design and analysis, is based on continuous monitoring of different levels of indicators and gathers additional data before, during, and after the period to be assessed by multiple methods. The approach uses several analytical techniques to deal with various data gaps and biases and includes interim and summative evaluation analyses. It is intended to promote country ownership, transparency and coordination of external funding, while providing a rigorous comparison of the cost-effectiveness of different scale-up approaches.
Measuring inequality: Tools and an illustration
Williams RFG, Doessel DP: International Journal for Equity in Health 5: 5, 22 May 2006
This paper examines an aspect of the problem of measuring inequality in health services. The measures that are commonly applied can be misleading because such measures obscure the difficulty in obtaining a complete ranking of distributions. The nature of the social welfare function underlying these measures is important. The overall object is to demonstrate that varying implications for the welfare of society result from inequality measures.
Measuring progress towards universal health coverage: national and subnational analysis in Ethiopia
Eregata G; Hailu A; Memirie S; Norheim O: BMJ Global Health 4:e001843 1-9, 2019
his study aimed to estimate the 2015 national and subnational universal health coverage service coverage (UHC) status for Ethiopia. The UHC service coverage index was constructed from indicators of four major categories using survey data and administrative data. The overall Ethiopian UHC service coverage for 2015 was 34.3%, ranging from 52.2% in Addis Ababa city to 10% in the Afar region. The coverage for non-communicable diseases, reproductive, maternal, neonatal and child health and infectious diseases were 35%, 37.5% and 52.8%, respectively. The national UHC service capacity and access coverage was only 20% with large variations across regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region. The 2015 overall UHC service coverage for Ethiopia was low compared with most of the other countries in the region. There was a substantial variation among regions. The authors argue that Ethiopia should rapidly scale up promotive, preventive and curative health services through increasing investment in primary healthcare if it aims to reach the UHC service coverage goals, and to narrow the gap across regions, such as through redistribution of the health workforce, increasing resources allocated to health and providing focused technical and financial support to low-performing regions.
Measuring Regional Policy Change and pro-Poor Health Policy Success: A PRARI Toolkit of Indicators for the Southern African Development Community
Amaya A; Choge I; De Lombaerde P; et al.,: UNU CRIS, Open University, December 2015
Developed collaboratively with actors in the region, this toolkit is a guide to the implementation of an indicator system to measure regional policy change and pro-poor regional health policy successes targeted at the pilot areas of HIV/AIDS, TB and malaria in the SADC context. The toolkit also aims to capture the limitations the health sectors in many countries may have in addressing structural issues that make the poor more vulnerable or at risk.