The meaning of equity in health systems strengthening

PETER ANNEAR: Our objective in this session is to define equity and to look at the key measures of inequity and then use these measures to identify vulnerable populations and the possible causes of their inequitable access to health services. Think about this graphic. There is clearly a difference in the absolute level for each person, but also in their relative social position. Absolute inequity is where someone falls below the minimum socially acceptable level. This is the equity gap. And this is mainly what we seek to address first. Relative inequity is simply being worse off than your peers. We can’t completely remove inequalities. So we define inequity as inequality that is avoidable or unfair and causes someone harm.

We study equity not simply because it’s an ethical issue, but because it has a cost in terms of poorer health outcomes and an economic cost in different ways, both direct and indirect– on the one hand, paying for health care, on the other, losing opportunities for employment and income earning and so on. There are, in fact, various ways to identify vulnerable populations– from the social determinants of health, which means the context in which the health system operates, to the social gradient, which indicates that the poor nearly always suffer worse outcomes than the rich. If we simply measure national averages, which is the blue line in this graph, we may mask real inequalities that are unfair.

Here in this graph, the poorest part of the population receive much less than the national average income, and the rich much more. That is a social gradient. And that’s the red line in this graph. This, in fact, was a real weakness in the Millennium Development Goal indicators. So equity is measured both in terms of the delivery of services– that is, the distribution of outputs– and in the financing of service delivery– that is, the payment for services. Equity may be horizontal. Or it may be vertical. In health service delivery, the equal treatment of equals is horizontal equity; that is, based on equal need for health care for those who are sick.

Providing more health care to those with more need is vertical equity. Frequently, for example, the poorest people have the highest level of sickness but receive proportionately the least care. And that’s not equitable. In health financing, equal payment by people with equal ability to pay is horizontal equity. Vertical equity in financing is when those with greater ability to pay actually pay more to receive care. Or more precisely, I think, those with little ability to pay are not required to pay. Take a look at this table. I want you to think for a moment. Which city experiences the greatest horizontal inequity in receiving care when needed? You might ask yourself these questions just to sort this out.

For which group in which city is the health need greatest? Which group in which city receives the least medical care? I’ll let you think about that for a moment.

Now, you probably realised the answer immediately. Bamako is the city we’re referring to. The way in which health is financed can be progressive. That is, those with more pay a greater percentage of their income. It may be proportional. Everybody pays the same percentage of their income. Or it may be regressive. The rich pay less than the poor as a percentage of their income. How would you describe in these terms user fees, social health insurance premiums, and income tax? I’ll give you a moment just to look at those numbers and think about that question. I think the answer might be quite apparent.

So how do we measure inequities? We can, in fact, measure inequities quite accurately– of course, as long as we have the data to do so. Now, if we divide the population into five equal parts, or income quintiles, then every part that is 20% of the population should in principle get 20% of the health benefit. We can do the same thing for payments. This graph here shows that the poor are treated inequitably. And this is one way to measure and report on inequity. This is benefit incidence analysis. And these are bar charts that describe the outcomes of our analysis. You can see the same data– essentially the same data– shown as a graph.

Now, this time, the red line indicates perfect equality. That is, each 20% of the population receives 20% of the benefit. The blue line shows that the poor receive much less than what they should. So here the blue line is called the “concentration curve.” And when we express this concentration curve as an equation in numbers, it becomes a concentration index. So it can either be a graph, or it can be a number. It’s the same thing. And the index tells us what the slope of the curve is and how severe the inequality is. So here we can see where the benefit is concentrated. That’s why it’s called the “concentration curve.”

And when it applies to income distribution, this is called the Lorenz curve. Here we can consider some of the elements of progressivity in government spending. Income distribution is shown here in this graph as the Lorenz curve. A tax that moves the Lorenz curve closer to the 45 degree line is progressive. You can then work out by looking at this graph what is proportional and what is regressive. There are, in fact, many different software programs that are available to make these calculations for you once you enter the data. EQUIST, in fact, has data already stored for 60 countries. It’s the Equitable Impact Sensitive Tool. And it’s been developed by UNICEF. HEAT is the Health Equity Assessment Tool.

That was developed by WHO to assess within country health inequalities. Another is called ADePT, developed by the World Bank to produce analytical reports related to equity. A further one is LiST. That’s used in UNICEF’s report Ending Child Deaths from Pneumonia and Diarrhoea. OneHealth is another, developed by WHO for national strategic health planning in low- and middle-income countries. We’ll look at some of these in later sections.