Practical Uses of Health Equity in Disease Control

Naman Shah, March 26, 2011Sujal Parikh Memorial Symposium

Why this topic? Equity and social justice as the basis of public health

“The raison d'être [reason for being] of public health is social justice.”

- William Foege

“To declare that social justice is the foundation of public health is to call upon and nurture that invincible human spirit that led so many of us to enter the field of public health in the first place: a spirit that has a compelling desire to make the world a better place.”

- Nancy Krieger

1/5 Relevance of equity to public health

Health disparities

• Positive social determinants of health (environment, education, etc) concentrated in upper socioeconomic groups

• In developing and developed countries: Greater access to and awareness of health

services in better-off socioeconomic groups Distribution of public goods tend to benefit

the better-off (e.g. vaccines, bed nets, drugs)

Mortality of children under 5 per 1000 live births by level of household wealth in five countries, 1998-2004

WHO commission on macroeconomics and health 2008

• The poor, or those who may need the intervention the most, may not receive it

• Disparity itself, independent of the absence of the intervention, leads to deprivation

• Direct additional effects on health from deprivation for everyone

Inequity and deprivation

2/5 Defining health equity

Inequality versus inequity

• Inequality Difference in health outcomes between

groups of people

• Inequity Inequality that in addition is considered

unfair/ unjust and avoidable

Horizontal versus vertical equity

• Horizontal Equal treatment of equals Everyone benefits, what we usually think of E.g. Free access to vaccine for all children

• Vertical Unequal, but fair, treatment of unequals Positive discrimination E.g. Free access to vaccine for poor children

Relative versus AbsoluteEquity versus Efficiency

Relative improvement(Equity)

+ —

Absolute improvement

(Efficiency)

+ BestOften happens

—

Not pursued deliberately

Worst

National average and relative gap in DPT3 coverage among children aged 12–23

months for selected countries

Source: Delamonica et al. 2005

3/5 Measuring health equity

Choosing the group(s) of interestfor measuring equity

E.g. For immunization:• Interest in physical access to the service

Wealth Geography Urban/rural

• Interest in vulnerable populations Wealth Gender Ethnicity Occupation

Measuring equity in different stages of the logic model

• Input Funding allocation by group (Is the planning

equitable?)

• Process Qualitative, not commonly evaluated

• Output Vaccination coverage by group (Is the

program equitable?)

• Outcome Disease incidence/outbreaks by group (Is the

result equitable?)

Full immunization coverage among children 12-23 months in Indonesia and Philippines,

1991-98

Country Year

Coverage by wealth quintile

Total

Ratio(q5/q1)1 2 3 4 5

Indonesia 1991 39 47 55 67 77 56 2.0

1997 52 58 63 68 82 64 1.6

Philippines

1993 70 80 84 86 88 80 1.2

1998 58 68 75 79 82 70 1.4Opposite trend in relative equity of immunization coverage between the two countries clearly indicated by the ratio

Delamonica et al 2005

Concentration curve of full immunization coverage, rural and urban India, 1992-9

• The dashed line indicates perfect equality

• Equity of immunization by socioeconomic group higher in urban India

• Equity in urban India improved between the surveys

Gaudin et al 2006

4/5 Improving program strategy with equity

Strategies to improve equity in program design

• Targeting* Deliberately reaching certain populations

• Participatory approaches* Community involvement in designing,

implementing, and monitoring the program

• Social protection once ill Insurance to prevent poverty from health care costs

• Distributional focus* Equity as a program principle and monitoring

indicator

*more relevant for immunization programs

Targeting (or not) interventions

• Targeted: identification of groups for receiving the intervention Select Screen Deliver to targets

• Universal: providing the intervention to the entire population Don’t select Don’t screen Deliver to everyone

Targeted versus universal coverage strategies

Targeted

Universal

Efficiency

Benefit to poor Direct Delayed

Ease of operation

Less More

Sustainability

Fiscal expense Lower Higher

Political appeal Narrow Broad

No criteria used to target is perfect: Coverage and leakage vary

• Individual factors E.g. wealth Direct to intended recipients Operationally difficult, most direct

• Generic factors E.g. geography Groups in which intended recipients concentrate Operationally easier, less direct

• By disease E.g. rabies Diseases which mostly affect intended recipients Operationally easier, less direct

Strategies can complement and form different stages of a long-term

process

Evolution of hepatitis B vaccination in China : Inequity > Pro-poor > Universal coverage

Dates Description of eventsSurveyYear

Coverage by region

Eastern CentralWestern E/W

1992 - 2002

Charges for vaccine and user fee for immunization

1999 91.3 74.6 47.0 1.9

2002 - 2005

GAVI project in center and west - vaccine made free, small user fee

2004 94.1 91.8 68.0 1.4

2005 - onUniversal coverage in EPI with free vaccine and no user fee

2006 97.5 97.8 91.0 1.1

Data from Cui F et al. Unpublished (Central and Western provinces are poorer than the

East)

DPT3/DPT1 coverage among children in India by different

approaches, 1979-87Approach Period Dose1 Dose3 3/1 %

Siblings of school children on school premises

1979 385 346 90

Health facility under 5 clinics 1980-83

2423 1436 59

Community based under 5 clinics

1983 563 502 89

Door to door with community leaders

1981-83

2760 2277 83

Door to door without community participation

1984-86

3085 2066 67

Door to door with school children participation

1987 625 534 85

Kowli et al. 1990More children and better follow-up with participatory approaches

Limitations of participation

• Naïve application of “participation,” “social capital,” and “empowerment” is endemic

• Can raise undue expectations• Participation is not a goal in itself but a

means • Participation should have a clear

purpose• Applying a standard participation

strategy is not necessarily worthwhile

Focus on equity

• State equity as a guiding principle / goal

• Require equity as a monitoring indicator

Need for improved focus: Explicit use of equity in immunization among global

agencies

AgencyStated goal or

principle

In monitoring

or evaluation

GAVI Yes No

UNICEF/WHO

Yes No

US CDC No No

World Bank No NoBased on informal survey of websites and strategic plans, 6/2010

5/5 Uses with immunization

Immunization as a broader health service indicator: Possible with equity criteria

• System failure Measure never immunized

• System quality Measure DPT3 coverage or DPT3 - DPT1

gap • Marker for primary health system

Never immunized by wealth and gender among children in rural/urban India,

1992-99

Gaudin et al. 2006

Less overall failure and rural/urban gapBut still higher for rural, poor, and for females

Are vertical programs more inequitable? Not always!

• Given low baseline coverage Equity improves with gains in coverage

• Eg. supplementary immunization activities (mass campaigns) Might not be regular/sustainable But better coverage among rich and poor And better equity than routine activities

Routine and SIA measles coverage and equity among children 9–23 months, Kenya, 2002

Vijayaraghavan et al. 2007White=routine, black=SIASIA outperforms in coverage and equity

Take home points

1. Inequity is inequality that is unjust/unfair and remediable

2. Equity is a prime concern in public health3. Measure equity 4. Evaluate equity to guide program

strategy and assessment

A talisman for equity

"Whenever you are in doubt, or when the self becomes too much with you, apply the following test. Recall the face of the poorest and the weakest person whom you may have seen, and ask yourself, if the step you contemplate is going to be of any use to them. Will they gain anything by it? Will it restore them to a control over their own life and destiny? In other words, will it lead to swaraj [freedom] for the hungry and spiritually starving millions?

Then you will find your doubts and your self melt away."

- Mahatma Gandhi

Acknowledgements

• Sujal Parikh• WHO China EPI Team

Yvan Hutin Zuo Shuyan An Zhijie Lisa Cairns

Resources

• WHO Equity and Health Systems • International Society for Equity in

Health• EQUIDAD - PAHO equity email list• Annotated bibliography on equity in

health• WHO guide for mid-level immunization

managers to improve participation