1. International Health Policy Program -Thailand Using STATA 10.0 for Health Equity Analysis Rachid Janta Vuthiphan Wongmongkol 4/12/2008 IHPP Meeting Room

2. International Health Policy Program -Thailand Outline of presentation Lecture Session – Definition of Health Equity – Difference of Health Inequity and Health Inequality – Determinants and Dimensions of health equity – Health Financing and data sources – Lorenz Curve – Gini coefficient Technical Session – basic technique on how to using STATA for equity analyses

3. International Health Policy Program -Thailand Definition of Health Equity The International Society for Equity in Health (ISEqH) defined equity in health as “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically”

4. International Health Policy Program -Thailand Difference of inequity and inequality Health inequalities are differences in health that are “avoidable,” “unjust, and unfair” Whitehead 1990

5. International Health Policy Program -Thailand Determinants of Health Inqualities Seven Determinants of Health Inequalities 1. Natural, biological variation 2. Differential health-damaging behavior that is freely chosen 3. Differential health-promoting behavior that is freely chosen 4. Differential health-damaging or health-promoting behavior, where choices are restricted 5. Differential exposure to unhealthy, stressful conditions (home, work, etc…) 6. Inadequate access to basic social and essential health services 7. Health-related social mobility Generally perceived as unavoidable or fair Generally perceived as avoidable or unfair

6. International Health Policy Program -Thailand Example of Inequality An old man has OP visit 10 time/year VS A young man has OP visit 3 time/year Should this be considered as; - inequality? - equity?

7. International Health Policy Program -Thailand Inequality of Physician Distribution Worldwide

8. International Health Policy Program -Thailand

9. Vertical and horizontal equity Horizontal equity applies to people in the same status or situation, and people who are alike should be treated in the same fashion, – in other words, equal treatment for equal need. Vertical equity focuses on the difference between individuals or groups of people, and people who are unlike in relevant respects (e.g. income, health needs), and states that the differences should be treated differently in a just way.

10. International Health Policy Program -Thailand Dimensions and Determinants of Health Equity Health financing Healthcare utilization Quality & responsive- ness Health status Health risk Geographic Region Urban vs. Rural Demographic Gender Age group Social Education Occupation Economic Income Wealth index

11. International Health Policy Program -Thailand Data requirements for health equity analysis Health Utilization Living standards (ordinal) Living standards (cardinal) Unit subsidies User payments Back-ground vbls Health inequality Equity in utilization Multivariate analysis Or Benefit-incidence analysis ( ) Health financing Progressivity Catastrophic payments Poverty impact

12. International Health Policy Program -Thailand Lorenz Curve Lorenz curve is a graphical representation of the proportionality of a distribution (the cumulative percentage of the values). It was developed by Max O. Lorenz in 1905 for representing income distribution.

13. International Health Policy Program -Thailand Lorenz Curve

14. International Health Policy Program -Thailand Gini Coefficient Note: Gini Coefficient is a tool for measuring inequality of income. The value of Gini coefficient ranges from 0 to 1. A low Gini coefficient indicates more equal income or wealth distribution, while a high Gini coefficient demonstrates more unequal distribution.

15. International Health Policy Program -Thailand Gini Coefficient

16. International Health Policy Program -Thailand The Kakwani index is defined as twice the area between the concentration curve of health payment and the Lorenz curve of household income. The value of the Kakwani index ranges from -2 to 1. A negative Kakwani index value indicates the regressive nature of health care payments. In contrast, a positive value indicates the progressive nature of health care payments.

17. International Health Policy Program -Thailand The concentration curve and index The concentration curve graphs on the x-axis the cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable. The concentration index is a means of quantifying the degree of income-related inequality within a specific health variable, for example, health service use, and government health subsidies.

18. International Health Policy Program -Thailand The concentration index is defined as twice the area between the concentration curve and the line of equality (the 45- degree line running from the bottom-left corner to the top-right). In the case where there is no income-related inequality, the concentration index is zero. The index takes a negative value when the concentration curve lies above the 45-degree line of equality, indicating disproportionate concentration of health service use or other health variables among the poor, and a positive value when it lies below the 45-degree line of equality.

19. Selected concentration curves of ambulatory service use among different types of health facilities in 2003

20. International Health Policy Program -Thailand Household equivalence scale Equivalence scale (e h ) = (A h + 0.5K h ) 0.75, where A (K) is the no. of adults (kids) in the household OECD-modified equivalence scale Oecdscale = 1 +(hhsize-1 - kids)* 0.5 + (kids*0.3)

21. The incidence of catastrophic health payments in 2000 and 2002 20002002% change Q1 (poorest) 9.975.61- 44 % Q25.415.02- 7 % Q34.824.810 % Q43.793.985 % Q5 (richest) 4.263.41- 20 % All quintiles6.114.65- 24 % Note: Catastrophic health expenditure refers to household out-of-pocket payments for health over 10% of household income or expenditure

22. International Health Policy Program -Thailand Resources WBI “OVWL” book – http://siteresources.world bank.org/INTPAH/Resour ces/Publications/459843- 1195594469249/HealthEq uityFINAL.pdf http://siteresources.world bank.org/INTPAH/Resour ces/Publications/459843- 1195594469249/HealthEq uityFINAL.pdf