equity or equality md-mph, sdh course اسفند هشتاد و شش
TRANSCRIPT
Equity or Equality MD-MPH, SDH Course
اسفند هشتاد و شش
2
تاريخچه•تعريف: برابري يا عدالت•توزيع زماني و مكاني نابرابري•اندازه گيري نابرابري•
ضريب جيني––Concentration index
ابعاد نابرابري•
3
تاريخچه
1845 اولين نوشته هاي مربوط به عدالت به سال • باز مي گردد. Fredrick Engelsتوسط
تعلق سياسي و علمي به نابرابري 1980در سال •در سالمت و عوامل موثر بر آن افزايش مشهودي
داشت، و يكي از علل اصلي اين افزايش تعلق گزارشي با عنوان نابرابري در سالمت معروف
. بود "Black Report“به سازمان جهاني بهداشت توجه 1995در سال •
دولت ها و سازمان هاي جهاني را به اين موضوع .معطوف نمود
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تعريف
تفاوت در سالمتبي عدالتي در سالمت به معناي • غير ضروري و قابل اجتناباست به نحوي كه نه تنها
تلقي گرددناعادالنه و بي انصافانهباشد، بلكه و اختالفات سيستماتيكعدالت در سالمت به عدم وجود •
قابل اجتناب در يك يا چند بعد از سالمت در جوامع مختلف جغرافيايي، اجتماعي و دموگرافيكي اطالق
مي گردد. بي عدالتي در 1998سازمان جهاني بهداشت در سال •
ما وضعيت سلامت، عوامل خطر يا دسترسي به خدمات تندرستيسالمت را به شكل زير تعريف نمود: " نابرابري در بين افراد كه غير ضروري، قابل اجتناب و ناعادالنه
باشد" .
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مثال
ميزان سرطان ريه در افرادسيگاري بيش تر از •جامعه است.
سال بيش تر از 45-20خطر سكته قلبي در مردان •زنان در همين گروه سني است.
بيماري سل در قشر فقيرتر جامعه بيشتر است.• در افرادي كه رفتار پر خطر جنسي HIVشيوع •
دارند بيشتر است.افرادي كه به بيماري فنيل كتين اوري مبتال هستند، •
اميد به زندگي كوتاه تري دارند.
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رويكرد بين بخشيبرابري در سالمت مستلزم يك • شامل سياست هاي اجتماعياست كه تقريبا تمام
سياست هاي اقتصاديمحيط اجتماعي و فيزيكي، را در بر مي گيرد.سياست هاي آموزشيونيز
ارتقاي متوسط سطح سالمت لزوما با توزيع بهتر •سالمت، يعني عدالت، مربوط نيست. در نتيجه، سياست هايي كه متوسط سطح سالمت را ارتقا
مي بخشند، لزوما عدالت در سالمت را تامين نمي كنند و حتي مي توانند آن را كاهش دهند.
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تاريخچه•تعريف: برابري يا عدالت•توزيع زماني و مكاني نابرابري•اندازه گيري نابرابري•
ضريب جيني––Concentration index
ابعاد نابرابري•
8
Infant Mortality Rate
0
30
60
90
120
150
1980 1985 1990 1996
Bangladesh
India
Nepal
Pakistan
Sri Lanka
Half Full …
9
…Or Half Empty?
Infant Mortality Rate
0
20
40
60
80
100
120
Pakistan(1990/91)
Bangladesh(1996/97)
Nepal (1996)
India (1992/93)
Poorest 20%Richest 20%
10
Is it Getting Better?
Infant Mortality Rate
020406080
100120
Bang
lade
sh(1
996/
97)
Bang
lade
sh(2
004)
Nepa
l
(199
6)
Nepa
l(2
001)
Indi
a
(199
2/93
)
Indi
a (1
999)
Poorest 20%Richest 20%
11
How about in Africa?
0
20
40
60
80
100
120
140
Uganda SouthAfrica
Rwanda Nigeria
Poorest 20%
Richest 20%
12
Is Latin American any Different?
01020
3040
5060
7080
90
Bolivia Brazil Colom. Dom.Rep.
Poorest 20%
Richest 20%
13
Is East Asia any Different?
0
20
40
60
80
100
120
Vietnam Indonesia Cambodia Philipp.
Poorest 20%Richest 20%
14
How About the Middle East?
0
20
40
60
80
100
120
Morocco Egypt Yemen
Poorest 20%Richest 20%
15
INFANT MORTALITY RATESamong Lowest and Highest 20% of the Population
56 Low- and Middle-Income Countries
0
20
40
60
80
100
120
East Asia,Pacific (4
Countries)
Europe,Central Asia (6
Countries)
Latin America,Caribbean (9Countries)
Mid.East,N.Africa (4Countries)
South Asia (4Countries)
S.Sahara Africa(29 Countries)
Total (56Countries)
Lowest 20% of Population Highest 20% of Population
16
HOW ABOUT FERTILITY RATESamong Lowest and Highest 20% of the Population
56 Low- and Middle-Income Countries
0
1
2
3
4
5
6
7
East Asia,Pacific (4
Countries)
Europe, CentralAsia (6
Countries)
Latin America,Caribbean (9Countries)
Mid.East,N.Africa (4Countries)
South Asia (4Countries)
S.Sahara Africa(29 Countries)
Total (56Countries)
Lowest 20% of Population Highest 20% of Population
17
HOW ABOUT SEVERE STUNTINGamong Lowest and Highest 20% of the Population
56 Low- and Middle-Income Countries
0
5
10
15
20
25
30
35
Europe, CentralAsia (6 Countries)
Latin America,Caribbean (9Countries)
Mid.East, N.Africa(4 Countries)
South Asia (4Countries)
S.Sahara Africa (29Countries)
Total (56Countries)
Lowest 20% of Population Highest 20% of Population
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كدام را اندازه مي گيريم ؟ برابري يا عدالت•
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تاريخچه•تعريف: برابري يا عدالت•توزيع زماني و مكاني نابرابري•اندازه گيري نابرابري•
ضريب جيني––Concentration index
ابعاد نابرابري•
20
Lorenz Curve
• X: Cumulative percent of population ranked by income
• Y: Cumulative percent of income
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Discussion question
• Look at spreadsheet
– Graph cumulative distribution of income
22
Step 1: Income inequality
Cumulative proportion of population ranked by income
Cu
mu
lati
ve p
rop
ort
ion
of
inco
me
Diagonal: line of equality
Poorest Richest
Lorenz curve of income inequality
Gini coefficient: twice the area between the diagonal and the Lorenz curve
Range of Gini: 0-1
23
Cumulative distribution of income
0,00%
20,00%
40,00%
60,00%
80,00%
100,00%C
um
ula
tiv
e %
of
inc
om
e
cumulative % of population ranked by income
20% 100%80%60%40%
income
24
The Gini coefficient
• The diagonal reflects equal distribution of income
• The closer the Lorenz curve to the diagonal, the smaller the income inequality– When the Lorenz curve is close to the diagonal, the
area is small and the Gini coefficient is small – Small values of Gini indicate low inequality – The closer the Gini to 0, the less the inequality
• The further away the Lorenz curve from the diagonal, the greater the inequality
25
Step 2: Inequality in health care payments
Cumulative proportion of population ranked by income
Cu
mu
lati
ve p
rop
ort
ion
of
healt
h c
are
paym
en
ts
Diagonal: line of equality
Poorest Richest
Concentration curve of health care payments
Concentration index: Twice the area between the diagonal and the concentration curve
Range of CI: -1 & +1
26
Concentration curve and index
• Increasingly popular measure of inequality• Summary measure capturing experience of
entire population • Helpful for comparison with other countries • Data needs
– Approach (a)– Household health data and direct measure of
SES
• See handout
27
CI
• X: Cumulative percent of population ranked by income
• Y: Cumulative percent of diarrhea cases
28
Cumulative share of diarrhea
Cumulative share of diarrhea cases
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
cumulative % of population ranked by income
cu
mu
lati
ve
%
of
dia
rrh
ea
ca
se
s
100604020 80
29
Cumulative share of diarrhea (2)
Cumulative share of diarrhea cases
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
cumulative % of population ranked by income
cu
mu
lati
ve
%
of
dia
rrh
ea
ca
se
s
100604020 80
30
Cumulative share of diarrhea (3)
Cumulative share of diarrhea cases
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
cumulative % of population ranked by income
cu
mu
lati
ve
%
of
dia
rrh
ea
ca
se
s
100604020 80
31
Cumulative share of diarrhea (4)
Cumulative share of diarrhea cases
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
cumulative % of population ranked by income
cu
mu
lati
ve
%
of
dia
rrh
ea
ca
se
s
100604020 80
32
Illness concentration curve
Poorest 50% of population
75% of disease burden
Cu
mu
lati
ve p
rop
ort
ion
of
illn
ess
Inequality where the poor bear a greater share of illness than their share in the population
33
Illness concentration curve
Cumulative proportion of population ranked by socio-economic status
Cu
mu
lati
ve p
rop
ort
ion
of
illn
ess
Illness concentration curve
Diagonal: line of equality
Poorest Richest
34
Illness concentration curve
Poorest 50% of population
25% of disease burdenC
um
ula
tive p
rop
ort
ion
of
illn
ess
Inequality where the rich bear a greater share of illness than their share in the population
35
Turkey: distribution of IMR99.9
72.7 72.1
54.4
25.4
0102030405060708090
100
Poorest 2nd 3rd 4th Richest
Quintiles
IMR
Infa
nt
mort
alit
y r
ate
(per
1,0
00
LB
s)
Source: DHS, 1993 http://www.worldbank.org/poverty/health/data/turkey/turkey.pdf
36
Turkey: concentration curve of IMR
100
0
92.2
75.4
53.2
30.8
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
cumulative share of population ranked by assets
Cum
ula
tive s
hare
of
infa
nt
death
s
Source: DHS, 1993, author’s calculations
Concentration index = -0.19
37
Concentration index of IMR in 44 countries from DHS
-0.30
-0.25
-0.20
-0.15
-0.10
-0.05
0.00
0.05Br
azil
Boliv
ia
Dom
inic
an R
ep.
Indi
a
CAR
Kyrg
yzst
an
Para
guay
Yem
en
Gha
na
Beni
n
Nig
eria
Burk
ina
Faso
Hai
ti
Togo
Nam
ibia
Con
cen
trati
on
in
dex
Data source: http://www.worldbank.org/poverty/health/data/
38
Applying tools to health service use
• Concentration Curves apply to health services use:Q: If we draw a concentration curve for health service use that is pro rich, will the concentration curve be above or below the 45 degree line?
• Concentration index is negative if health services are pro poor and positive if they are pro-rich
39
• glcurve7 case, sortvar(income)
• Ineqerr case
• Lorenz income
• Inequal income
• ..\educational folder\Equity & quality\asd.dta
40
تاريخچه•تعريف: برابري يا عدالت•توزيع زماني و مكاني نابرابري•اندازه گيري نابرابري•
ضريب جيني––Concentration index
ابعاد نابرابري•
41
Dimensions To Inequality
• Outcomes, Outputs, Inputs1. Health Outcomes2. Financing Burden3. Service Use (Expenditures or Benefits)
• Dimensions1. Income 2. Residence (Geographic, Rural/Urban)3. Other Socio Economic Measures
42
1. Health Outcomes
• Mortality Measures (Infant 1Q0 , Child 5Q0, Adult 45Q15)
• Morbidity Measures (quality of life)
• Nutritional Outcomes (stunting, BMI)
• Population Outcomes (fertility rates)
43
2. Financial Burden• Direct out-of-pocket payments (drugs, co-
payments, fees, informal payment)
• Indirect out-of-pocket payments (time from work, transport)
• Private insurance premiums
• Tax Burden (direct tax, indirect tax, payroll tax)
44
3. Service Use (Expenditures or Benefits)
• Basic Utilization – Preventive care – Curative care (primary, outpatient
specialist, hospital)– Delivery related
45
Dimensions
• Income– Consumption-based– Income-based– Asset-based
• Residence– Geography (State, province, oblast, etc.)– Rural/Urban (within Urban—Slums)
46
Discussion question
• Identify important equity issues in Iran’s health system – What important outcomes, outputs, and inputs
are distributed inequitably?– What are the main dimensions of these
inequality?
• What are the main causes of these persistent inequalities?