2. Dr. Shahram Yazdani Health Equity Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 02

3. Dr. Shahram Yazdani The Right to Health The International Declaration of Human Rights “Everyone has a right to a standard of living adequate for the health and well being of his family including food, clothing, housing and medical care”

4. Dr. Shahram Yazdani Global Disparities in Life Expectancy

5. Dr. Shahram Yazdani Inequity within Countries African American age adjusted death rates exceeded those for whites  By 77% in stroke  By 47% for heart disease  By 34% for cancer  By 655% for HIV infection

6. Dr. Shahram Yazdani Relation of socioeconomic conditions and ill health Cumulative % of the population Cumulative % of ill-health 100 0 0

7. Dr. Shahram Yazdani Relation of socioeconomic conditions and ill health Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health Perfect Equity Condition

8. Dr. Shahram Yazdani Relation of socioeconomic conditions and health expenditures Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people Cumulative % of expenditures 100 0 40% of ill health

9. Dr. Shahram Yazdani Relation of socioeconomic conditions and health expenditures Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people Cumulative % of expenditures 100 0 40% of expenditures 40% of ill health Perfect Equity Condition

10. Dr. Shahram Yazdani Burden of Disease Concentration Index Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health Cumulative % of expenditures 100 0 40% of expenditures 40% of ill health

11. Dr. Shahram Yazdani Burden of Disease Concentration Index Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health 65% of ill health!!! Cumulative % of expenditures 100 0 40% of expenditures Inequity Condition

12. Dr. Shahram Yazdani Burden of Health Expenditure Concentration Index Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health 65% of ill health!!! Cumulative % of expenditures 100 0 40% of expenditures

13. Dr. Shahram Yazdani Burden of Health Expenditure Concentration Index Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health 65% of ill health!!! 15% of expenditures Cumulative % of expenditures 100 0 40% of expenditures Inequity Condition

14. Dr. Shahram Yazdani The Paradox of Less Expenditure for Those with Ill-Health Cumulative % of the population Cumulative % of ill-health 100 0 0 40% or people 40% of ill health 65% of ill health!!! 15% of expenditures Cumulative % of expenditures 100 0 40% of expenditures

15. Dr. Shahram Yazdani Equity vs. Equality It is important to distinguish between equality and equity: Equality – concerned with equal shares Equity – about fairness and it may be fair to be unequal  This usually incorporates the concept of “Minimum Social Acceptable Level” (MSAL)

16. Dr. Shahram Yazdani Defining Equity in the UK NHS Beveridge (1942) argued for a health service which would provide treatment “ to every citizen without exception, without remuneration limit and without an economic barrier at any point to delay recourse to it ”

17. Dr. Shahram Yazdani Definition of Health Equity: Different Approaches Access to Healthcare (Equal or MSAL) Delivery/Utilization of Healthcare (Equal or MSAL) Financial Contribution (in Relation to Ability to Pay) Opportunity to be Healthy (Equal or MSAL) Health Outcomes (Equal or MSAL)

18. Dr. Shahram Yazdani Equality of Access Access to health care may have instrumental value to promoting better outcomes but it may also be valued in its own right as contributing towards procedural justice

19. Dr. Shahram Yazdani Equality of Use There are many problems with this principle: Not everybody responds to treatment in the same way It requires that there are no differences in quality. It ignores differences in individual preferences over health and health care And it cannot be used as a proxy for equality of access or equality of outcomes

20. Dr. Shahram Yazdani Equity in Delivery Horizontal equity  Health care delivery system is horizontally equitable if all people with equal need for health care are equally likely to obtain the same type of health care.  “Equal treatment of equals” Vertical equity  “A health care delivery system is vertically equitable if people with greater need for health care are more likely to obtain care than those with a lower need.”  “More health care for those with more need”

21. Dr. Shahram Yazdani Are Equity and Equality Synonymous? Some think that: “Inequity will not necessarily arise as a result of differences in consumption levels among individuals, but will always be present when consumption by any one individual or group is below a minimum socially acceptable” = HEALTH CARE MINIMUM SOCIALLY ACCEPTABLE = EQUITY GAP

22. Dr. Shahram Yazdani Are Equity and Equality Synonymous? In other words, some think that: As long as everybody has access to a minimum health benefits package, there is equity. If some have access to more than the minimum, there is inequality, but the system is still equitable. = HEALTH CARE MINIMUM SOCIALLY ACCEPTABLE = CONSUMPTION ABOVE MINIMUM

23. Dr. Shahram Yazdani Equity in Financing Horizontal equity  Horizontal equity in financing is when people with equal ability to pay make equal payments for health care  “Equal payments by equals” Vertical equity  A health system is vertically equitable when payment and ability to pay are positively correlated  “Greater ability to pay  higher payment”  “Smaller ability to pay  lower payment”  To some, a financing system is considered to be vertically equitable if those with greater ability to pay contribute a greater share of their income to pay for health care (“progressive” financing.)

24. Dr. Shahram Yazdani Assessing Vertical Equity in Finance 1. Regressive: The poor pay a higher percentage of their income than the rich 2. Proportional: Rich and poor pay the same percentage of their income 3. Progressive: Rich pay a higher proportion of their income than do the poor

25. Dr. Shahram Yazdani Income Financial Contribution 0 Proportional Contribution

26. Dr. Shahram Yazdani Income Financial Contribution 0 Regressive Contribution

27. Dr. Shahram Yazdani Income Financial Contribution 0 Progressive Contribution

28. Dr. Shahram Yazdani Social Health Insurance If you work for a company that provides health insurance benefits, you (and your employer) typically contribute the same % share of your wage or salary. For example, if the employee contribution rate is 3% both the low wage janitor and the high wage boss will be “taxed” 3% of their earnings.

29. Dr. Shahram Yazdani Annual Income Tax (a “Direct Tax”) There tends to be exemption from income tax for very low household income, whereas income tax rates climb with levels of household income and then become relatively high for highest income households.

30. Dr. Shahram Yazdani User Fees (or Out-of-Pocket Payments) Both poor and rich tend to be charged the same amount for a health service, regardless of ability to pay. This applies especially to drugs, whereas exemptions may be in place with respect to out-patient and in-patient services.

31. Dr. Shahram Yazdani Average Progressivity of Components of Health Care Financing (Kakwani Progressivity Indexes) Revenue SourceIndex (N=13) Direct taxes.169 Indirect taxes-.064 Social Insurance.054 Private Insurance-.005 Out-of-Pocket-.222

32. Dr. Shahram Yazdani Progressivity Components of Health Care Financing (Kakwani Progressivity Indexes) Country Direct Taxes Indirect Taxes Social Insurance Private Insurance Out-of- Pocket Denmark (1987).062-.113.000.031-.265 Finland (1990).128-.097.090.000-.246 France (1989).000.094-.186-.228 Germany (1988).251-.092-.081.093-.103 Ireland (1987).267---.126-.021-.147 Italy (1991).161-.112.112.177-.077 Netherlands (1992).200.089-.129.083-.038 Portugal (1990).218-.035.185.137-.242 Spain (1990).214-.152.050-.012-.212 Sweden (1992).053-.083.010----.240 Switzerland (1992).172-.072.038-.270-.403 United Kingdom (1992).284-.152.187.077-.223 United States (1987).192-.065.019-.175-.461

33. Dr. Shahram Yazdani Equity in Delivery and Finance does not Guarantee Equity in Health Socioeconomic Factors Have Crucial Role in Health Equity Health Needs More Radical policies for Redistribution of Wealth These Policies Should Ensure a Baseline Level of Welfare (and not merely health) for all Citizens

34. Dr. Shahram Yazdani Equity in Health Delivery in relation to health need Financing in relation to ability to pay

35. Dr. Shahram Yazdani Equality of Opportunity Equality of opportunity of having a healthy life

36. Dr. Shahram Yazdani Equality of Health This is concerned with distributive justice and represents a consequentialist view in which the only concern is with the distribution of health It has been criticised on the grounds that it is paternalistic and ignores individual choice and differences in preferences But Culyer and Wagstaff (1993) argue that “There is a danger in straining out the gnat of offending personal liberty that one swallows the camel of enduring and outrageous inequalities of health.”

37. Dr. Shahram Yazdani