An overview of tools to guide equity focused health systems

What tools do we have to guide an equity-focused approach to health systems strengthening?

We briefly mentioned these at the start. Remember when we defined the concept of equity within health systems earlier this week, we highlighted that equity could be measured both in terms of the financing of health services, and in the delivery of services, that is the distribution of outputs. While there are many methods of doing an equity analysis, we highlight common methods used to do an equity analysis of health financing strategies and available on-line tools to measure equity in the delivery of services and outcomes.

Financing incidence analysis and benefit incidence analysis are commonly used to measure health system equity related to distribution of finances. Financing incidence analysis, also known as progressivity analysis, measures the extent to which contributions to healthcare spending are in line with ability to pay. It addresses the question of which health financing strategies place greater burden on the poor, or in other words, which are regressive (if the rich pay a lower proportion of their income than the poor) and which are progressive (rich pay a higher proportion of their income than the poor).

Benefit incidence analysis (BIA) allows us to determine who, in terms of socioeconomic groups, receives what benefit from using health services, and whether this distribution of benefits is in line with needs. It is important to note that within BIA, benefits are typically expressed in monetary terms, and are calculated by multiplying utilisation rates of different types of health services by their unit costs.

For those of you interested in this, the World Bank has developed an on-line software platform called ADePT for conducting this analysis. The World Bank subsequently produced Health Equity and Financial Protection reports for many low and middle-income countries using ADePT.

The World Health Organization has an online software application – the Health Equity Assessment Tool, commonly abbreviated to HEAT – that facilitates the assessment of within-country health inequalities. The tool allows users to explore health outcomes by population group within a country through a variety of drivers of inequity such as place of residence, income, education, subnational region and sex. It also allows users to compare inequality over time and between countries. HEAT is a descriptive tool which illustrates the distribution of outcomes but says nothing about causes, nor can it be used to analyse a country’s health system. It is a useful place to start when looking at defining who the underserved populations might be in a country, whether the equity gaps have been reducing or increasing and to benchmark a country’s inequities with other countries.

Another on-line tool that goes a bit further in attempting to guide a more equity-focused approach to health systems strengthening is EQUIST – developed by UNICEF. EQUIST is based on UNICEF’s seven-step approach to health systems strengthening which guides program planners and policy makers to begin with identifying underserved groups and the factors underlying their (poor) health outcomes, identify health system bottlenecks constraining higher coverage, and devise context-specific solutions that will enable health systems to serve the disadvantaged better.

Let’s explore this approach in more detail in the following step.