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PubMed2002

[Intergenerational equity is more than pension financing].

Public old age pensions--often termed the "generational contract"--are part of a broader system of exchange among generations which must be assessed in its entirety when issues of generational equity are at stake. The paper discusses the elements of this exchange system on the basis of the German Aging Survey, a large representative survey of the German population aged 40-85. Its empirical foci are two domains that are usually neglected in the public discourse on generational equity: the productive activities of the elderly and the transfers between generations in the family. The results demonstrate that the elderly contribute substantially more to societal welfare than has become visible so far.

Adult↗

PubMed1992

Equity in the delivery of health care: some international comparisons.

This paper presents the results of an eight-country comparative study of equity in the delivery of health care. Equity is taken to mean that persons in equal need of health care should be treated the same, irrespective of their income. Two methods are used to investigate inequity: an index of inequity based on standardized expenditure shares, and a regression-based test. The results suggest that inequity exists in most of the eight countries, but there is no simple one-to-one correspondence between a country's delivery system and the degree to which persons in equal need are treated the same.

Cross-Cultural Comparison↗

PubMed1995

The pursuit of equity: a health sector case study from Vietnam.

The health care system in Vietnam has long been cited as an example of primary health care that has worked well. The achievements of the system during the past decades have indeed been impressive, but the changing economic situation in Vietnam has consequences for all public sector activities, including health care. Liberalization of economic policies has encouraged private medical practice and free trade in medicines and drugs, while financial support for the state health system is decreasing. Equity has always been an important goal for the vietnamese health system, but it becomes harder and harder to realize under the new conditions of financing. The restrictions in centralized planning and funding brought about by recent changes also reveal weak points in the system, from planning to training to management at the different levels. This situation is discussed and issues concerning policy, legislation and human resources are highlighted in terms of their effect on equity.

Financing, Government↗

PubMed1986

Reforming Medicare: the limited framework of political discourse on equity and economy.

Medicare, the major program that organizes the delivery and financing of health care for the elderly in the United States, is being rapidly and significantly changed in order to bring Federal expenditures for health care under control. Questions of 'equity', 'justice' and 'access to health care' (that have long been associated with liberal ideology) have lost discursive currency within the realm of acceptable political debate that now focuses on 'economy' and the restoration of 'competitive market forces' to the health care industry (a point of view associated with conservative ideology). Pluralistic analyses of American health care policy most often focus on the differences between liberals and conservatives and could only explain the current bipartisan effort to reorganize Medicare as a defeat for liberals and as a vindication for the conservative perspective during a period of economic crisis. This essay develops the alternative point of view that American political debate on health care, among and between liberals and conservatives, has always taken place within a space bracketed by well defined limits established by widespread support for the market model of health care. The strength and dominance of this model that organizes and supports the private production of health care for profit is far more important in explaining the continuity in American health care policy over time and the recent policy adjustments than any examination of ideological differences between political conservatives and liberals. After analyzing the limited framework of debate structured by the market model of health care, this paper critically examines the recent changes in Medicare and challenges the market model on empirical grounds. Finally, the author returns to a discussion of the implications of these changes for equity and justice.

Aged↗

PubMed1991

Challenges to equity in health and health care: a Zimbabwean case study.

The current economic crisis in Africa has posed a serious challenge to policies of comprehensive and equitable health care. This paper examines the extent to which the Zimbabwe government has achieved the policy of "Equity in Health" it adopted at independence in 1980, that is provision of health care according to need. The paper identifies groups with the highest level of health needs in terms of both health status and economic factors which increase the risk of ill health. It describes a series of changes within the health sector in support of resource redistribution towards health needs, including a shift in the budget allocation towards preventive care, expansion of rural infrastructures, increased coverage of primary health care, introduction of free health services for those earning below Z$150 a month in 1980, increased manpower deployment in the public sector and the reorientation of medical training towards the health needs of the majority. The implementation of equity policies in health have however been challenged by several trends and features of the health care system, these becoming more pronounced in the economic stagnation period after 1983. These include the reduction in allocations to local authorities, increasing the pressure for fees, the static nominal level of the free health care limit despite inflation, the continued concentration of financial, higher cost manpower and other resources within urban, central and private sector health care and the lack of effective functioning of the referral system, with high cost central quaternary facilities being used as primary or secondary level care by nearby urban residents. While primary health care expansion has clearly been one of the success stories of Zimbabwe's health care post 1980, the paper notes plateauing coverage, with evidence of lack of coverage in more high risk, socio-economically marginal communities. Measures to address these continuing inequalities are discussed. Their implementation is seen to be dependent on increasing the capacity and organisation of the poor to more strongly influence policy and resource distribution in the health sector.

Financial Management↗

PubMed1994

Child health: equity in the non-industrialized countries.

Significant improvements have been made in infant and child survival globally in recent decades. In spite of a substantial literature describing achievements to date and strategies for continuation of this progress, there has been relatively little attention directed toward the issue of equity in global child health outcomes. This paper briefly reviews global improvements in child health outcomes over the past four decades, but then provides evidence that there has been substantial variation in these improvements, both between nations and within non-industrialized nations. The identifying characteristics of high risk populations are summarized. The specific diseases and disease complexes associated with mortality in populations with different mortality rates are presented as background to a discussion of the anticipated increase in 'effort' (both personnel and material resources) that will be necessary for sustained improvement in child survival. In this context, the Acquired Immunodeficiency Syndrome is likely to further increase disparities in health outcomes. Finally, prospects for increased equity in the future are discussed.

Child↗

PubMed2004

Equity in resource allocation in the Irish health service. A policy Delphi study.

Resource allocation in the Irish health service, based on historical allocations with incremental increases, is widely believed to be inequitable. Using a three-round policy Delphi survey, which seeks to explore both consensus and disagreement surrounding policy issues, the views of 52 senior health service personnel were sought in order to determine ways to improve equity in resource allocation. Panelists provided several reasons why the current method of resource allocation is inequitable and several suggestions for improving equity. The level of consensus on views was determined by calculating the percentage of ratings in each category based on a series of rating scales. The main suggestion centred around the development and implementation of a needs based resource allocation formula. Panelists reached a high consensus in favour of this but only reached a low consensus as to its feasibility. Potential obstacles identified included methodological difficulties, insufficient resources and resistance from potential losers. These findings highlight concerns about the lack of transparency in the resource allocation process and openness to the development of a more equitable needs based resource allocation model, a move which is becoming more common internationally. Feasibility concerns should not preclude an attempt to begin this process.

Delphi Technique↗

PubMed2006

What is driving the EU Burden-sharing Agreement: efficiency or equity?

Under the Kyoto Protocol the European Union agreed to reduce emissions of greenhouse gases by 8 percent. The Burden-Sharing Agreement (BSA) redistributes the reduction target among the member states. The purpose of this paper is to evaluate the BSA. To determine if cost efficiency was considered, marginal abatement costs (MACs) are first calculated based on an estimation of the directional output distance function using country production data for 1990-2000. MACs, together with equity indicators, are then regressed on the emission change targets. The main conclusion is that both efficiency and equity were important aspects considered in the settlement.

Air Pollution↗

PubMed2004

Equity weights in the allocation of health care: the rank-dependent QALY model.

This paper introduces the rank-dependent quality-adjusted life-years (QALY) model, a new method to aggregate QALYs in economic evaluations of health care. The rank-dependent QALY model permits the formalization of influential concepts of equity in the allocation of health care, such as the fair innings approach, and it includes as special cases many of the social welfare functions that have been proposed in the literature. An important advantage of the rank-dependent QALY model is that it offers a straightforward procedure to estimate equity weights for QALYs. We characterize the rank-dependent QALY model and argue that its central condition has normative appeal.

Empirical Research↗

PubMed2005

User charges and priority setting in health care: balancing equity and efficiency.

User charges are the major source of finance for many health care systems. However, traditional approaches to health care priority setting, such as cost-effectiveness analysis, usually assume there are no user charges and therefore may ignore important implications for equity and efficiency. This paper therefore develops a rudimentary model of priority setting in which the fixed health care budget can be augmented by user charges. The paper uses methods analogous to models of optimal commodity taxation to develop a set of rules for the inclusion of a health technology in the subsidized health care package, and the calculation of its associated copayment rate. The results indicate that optimal levels of subsidy depend on the cost-effectiveness of the intervention, its price elasticity of demand, the epidemiology of the associated disease, and the policy maker's attitude towards equity. The model has important implications for policy making in three domains: health care priority setting, evaluation of health care technologies, and charging policy.

Delivery of Health Care↗

PubMed2005

Efficiency is a legitimate consideration in equitable distribution of cadaveric transplants: development of an efficiency-equality model of equity.

It is proposed that equity is a trade-off, or compromise, between equality and efficiency. The kidney transplant allocation algorithm currently used in the United Kingdom (NAT) was tested in the efficiency-equity model. In an exercise of 2000 past UK donors and a dynamic waiting list of 5000 potential recipients, 4000 transplants were allocated according either by NAT, by equal allocation (EQ) (a lottery), or by efficiency (EF). Diabetic recipients received 7.4% of transplants in NAT, 8.6% in EQ, and 0% in EF; paediatric recipients received 6.8% in NAT, 0.6% in EQ, and 0.7% in EF model. For HLA matching, there were 77.9% favourable or 000 matches in NAT, 3.0% in EQ, and 53.1% in EF. Predicted survival showed better outcomes in EF versus NAT (P < .0001) and in NAT versus EQ (P = .05). The NAT allocation system favours paediatric recipients and does not deny diabetics the chance of a transplant, broadly in line with published public and professional opinions. The NAT scheme achieves better HLA matching than the EF model, and this suggests that the rationale for allocation based primarily on HLA matching could be reexamined.

Algorithms↗

PubMed2006

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India.

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.

Delivery of Health Care↗

PubMed1997

In search of human dignity: gender equity, reproductive health and healthy aging.

This paper analyzes the nine pillars of human dignity (sufficient food, potable water, shelter, sanitation, health services, healthy environment, education, employment and personal security), which humankind tries to establish by following nine approaches to reality (scientific, cultural, religious, ethical, economical, ecological, socio-critical, philosophical and political) in a world drastically changed by nine revolutions (demographic, scientific, technological, communication, global identity, environmental, contraceptive, reproductive health and gender equity). The author's generation participated in these revolutions and contributed to the global intellectual process by which gender equity and reproductive health assumed a central role in world affairs. A rapidly aging world population constitutes another major challenge. Its likely impact on the very fundaments of our future social, economical, health and even political infrastructures is--as yet--incompletely comprehended by the international community. The International Federation of Gynecology and Obstetrics (FIGO) has and will continue to have an indispensable role in assisting humankind to reach its ultimate goal : human dignity.

Aging↗

PubMed2003

Applying an equity lens to child health and mortality: more of the same is not enough.

Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidized health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.

Child↗

PubMed1997

Progressivity, horizontal equity and reranking in health care finance: a decomposition analysis for The Netherlands.

This paper employs the method of Aronson et al. (1994) to decompose the redistributive effect of the Dutch health care financing system into three components: a progressivity component, a classical horizontal equity component and a reranking component. Results are presented for the health care financing system as a whole, as well as for its constituent parts. A final section sets out to uncover the relative importance (in terms of their effects on progressivity, horizontal equity and reranking) of the key institutional features of one component of the Dutch system-the AWBZ social insurance scheme.

European Union↗

PubMed2001

Equity in health in unequal societies: meeting health needs in contexts of social change.

The paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. Discourses on equity in health are presently dominated by a debate between 'European' and 'American' models of health delivery. This has led to a focus on ideal outcomes rather than practical options for organising and financing health services in poor countries undergoing rapid change. The paper argues for a more explicit acknowledgement of the dynamic character of health development and the political nature of the negotiations regarding the use of government powers. Unregulated markets for health care are neither equitable nor efficient. Government must play a role in supporting the organisation of health services used by different social groups. Countries with low levels of inequality may be able to provide universal access to relatively sophisticated health services. Otherwise, governments need to operate within a segmented system. This means the negotiation of strategies to reduce the burden of sickness and premature death, whilst meeting the needs of different social groups. The discussion is organised in terms of the powers of government to require individuals and institutions to transfer resources for social uses, enforce regulations and generate and disseminate information. The paper concludes that governments committed to equity-enhancing health development need to increase their capacity to facilitate coalition building and manage change. It proposes an international public health legal framework that might include a definition of minimum standards for certain health services, to be underwritten by national and international financial commitments.

Developing Countries↗

PubMed2000

Gender equity in health: debates and dilemmas.

Gender equity is increasingly cited as a goal of health policy but there is considerable confusion about what this could mean either in theory or in practice. If policies for the promotion of gender equity are to be realisable their goal must be the equitable distribution of health related resources. This requires careful identification of the similarities and differences in the health needs of men and women. It also necessitates an analysis of the gendered obstacles that currently prevent men and women from realising their potential for health. This article explores the impact of gender divisions on the health and the health care of both women and men and draws out some of the policy implications of this analysis. It outlines a three point agenda for change. This includes policies to ensure universal access to reproductive health care, to reduce gender inequalities in access to resources and to relax the constraints of rigidly defined gender roles. The article concludes with a brief overview of the practical and political dilemmas that the implementation of such policies would impose.

Adult↗

PubMed1997

Ethnicity, equity and the use of health services in the British NHS.

This paper addresses the extent to which equity of treatment is received by people of different ethnic groups from the British National Health Service. Using data from the General Household Surveys of 1984-91 it examines the use of general practitioner, outpatient services using three different methods to adjust for need and for other possible confounding variables. The results do not suggest there is any gross pattern of inequity between ethnic groups, except perhaps with respect to the Chinese population which displays consistently low levels of utilisation. However, while use of GP services by minority ethnic groups is in general as high or higher than the white population, use of outpatient service is low. Some of the results also suggest that there may be important ethnic differences underlying the broader finding of equity. For example, females of Pakistani origin report low levels of GP use. More generally, excess use of GP services among several minority ethnic groups appears to be associated with need, while people from most minority ethnic groups who do not report illness display especially low use of outpatient services relative to the corresponding group in the white population. The paper examines the implications of these findings.

Adolescent↗