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PubMed1999

Evaluating health service equity at a primary care clinic in Chilimarca, Bolivia.

Policy makers and health planners generally support the concept of equitable health care. A focus on who can use a health service, or its potential access, will not necessarily lead to equitable care if people are not willing to avail themselves of the health services offered. Because equity is difficult to operationalize, outcome-based indicators such as the actual utilization of services are advocated as a means to measure equal access. This paper evaluates the utility of linking the concept of equity with a temporal and spatial analysis of clinic users at a micro scale, supplemented by a community survey. Various spatial scales were employed in the analysis. Utilization of the primary care clinic in Chilimarca, Bolivia varied considerably during the first 25 months of operation. Spatially, utilization shifted away from the targeted service area. Within the targeted service area, usage was concentrated in a few blocks of the community and generally diminished with increasing distance from the clinic. The survey further revealed place of origin, length of residence, and language spoken at home as variables differentiating users from non-users. Failure to include the spatial dimension of utilization would lead to different conclusions if only aggregate data were employed. Spatial analysis of output measures is imperfect and does not necessarily deal with all of the access issues related to acceptability. They do, however, begin to isolate areas of a defined geographic area where further investigation would assist in ascertaining, and subsequently addressing, potential problems related to equal access.

Bolivia↗

PubMed2003

Restructuring the health system: experiences of advocates for gender equity in Bangladesh.

This paper illustrates how advocates for gender equity succeeded in influencing the restructuring of the health system in Bangladesh in the mid-1990s but failed to influence its implementation. Using published and unpublished documents and personal interviews, it traces the changing fortunes of health sector reforms and reform advocates from 1995 to 2002 and analyses the major challenges and strategies involved. It explores the gains advocates for gender equity made in the design of the reforms and also their limitations to counter some of the inherent risks. The paper highlights the gaps between the design and implementation of reforms. It argues that the key factor for success during the design of reforms was the participation of civil society, which enabled a large number of women, particularly poor women, to engage with the design of reforms. During the implementation phase, however, reforms became a government-donor driven programme disconnected from civil society and space for women's voices became limited. When a new government assumed power in 2001, opponents of reform succeeded in halting the restructuring of the health system, in part because civil society was no longer engaged with the reform process and registered little protest.

Bangladesh↗

PubMed2000

Regional equity in childhood health--register-based follow-up of the Finnish 1987 birth cohort.

Our objective was to investigate regional health differences among Finnish children using a population-based longitudinal register data. All live births born in 1987 were included in the study (N=59,546) and followed-up until the age of seven years. Statistically significant regional variation was found for all health indicators but diabetes. Background variables, such as maternal age and social class, explained only the difference in mortality. Various indicators gave different geographical patterns. Regional equity in childhood health has not been achieved in Finland. Existing health registers were feasible in studying regional variation in health, but a set of comprehensive morbidity indicators - preferably derived from different data sources - should be developed to monitor equity in health.

Child↗

PubMed1990

The economic efficiency and equity of abortion.

"This essay...examines the abortion option [using] two standard economic welfare criteria, efficiency and equity, to evaluate different distributions of property rights." The author critically examines a 1971 article by Judith Jarvis Thomson concerning fetal personhood and the maternal right to privacy. He asserts that "the efficiency of different output allocations and even output and wealth as such are neither ethically neutral nor ordinally invariant but depend on the range of property rights and distributions, wealth-constrained valuations, and populations considered. The results suggest that, insofar as claims of efficiency and equity are met or accepted as appropriate, economic criteria may affect the constitution of justice and behavior as legal and normative constraints."

Abortion, Induced↗

PubMed2002

Equity and resource allocation in health care: dialogue between Islam and Christianity.

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community in terms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services.

Christianity↗

PubMed2004

Genetic equity.

This paper proposes, elaborates and defends a principle of genetic equity. In doing so it articulates, explains and justifies what might be meant by the concept of 'human dignity' in a way that is clear, defensible and consistent with, but by no means the same as, the plethora of appeals to human dignity found in contemporary bioethics, and more particularly in international instruments on bioethics. We propose the following principle of genetic equity: humans are born equal; they are entitled to freedom from discrimination and equality of opportunity to flourish; genetic information may not be used to limit that equality.

Bioethics↗

PubMed1998

Equity and rationing in the NHS: past to present.

AIM: This paper explores the historical and political basis of equity and rationing in the British National Health Service (NHS). BACKGROUND: Rationing has always featured in the NHS as an implicit, rather than explicit process. Recent healthcare reforms have highlighted the inequity of healthcare provision in the UK and made the rationing debate more explicit. ORIGINS OF INFORMATION: Information is drawn from a variety of sources which include research studies, review articles and books, policy documents and personal experience of working in the NHS. KEY ISSUES: The search for efficiency in the new NHS is in conflict with the principle of equity and the most vulnerable groups in society are being denied access to healthcare. Decisions about rationing are currently made at a local rather than a national level resulting in variability of health service provision, an inconsistency which will continue with the development of primary care groups. CONCLUSIONS: Rationing of healthcare resources is thought to be inevitable as demands for healthcare increase in a funds-limited service. Rationing of resources is a political problem that requires some form of guidance from central government.

Decision Making, Organizational↗

PubMed2000

Pay equity and nursing in Ontario: ten years later.

'Nurses have never been compensated in accordance with their central role in health care' (Schreiber 1994), reflecting the generalized and well-documented under-valuing of the work of women (Schreiber 1993). Pay equity legislation, passed in Ontario, Canada in 1987, designed to correct gender wage discrimination, created great optimism that the under-valuing of nurses' work might be ending. Nonetheless, this has not been the case, as the social, political, and economic climate has not kept pace with the speed and enormity of social change necessary to enact the intent of the legislation. Indeed, gains in nurses' wages have been directly offset by significant lay-offs. In this paper, we examine the issues surrounding the implementation of pay equity legislation in Ontario, Canada, along with analysis and implications of these issues, drawn from 10 years of experience. In addition, we highlight lessons that can be learned from the Ontario experience.

Economics, Nursing↗

PubMed1975

Rights and health care--beyond equity and efficiency.

Economic analysis in general has difficulty accommodating the concept of rights. The economic analysis of health care in particular proposes triage as the model of a rational delivery system, with no place for traditional ethical limits and obligations. Familiar arguments based on resource constraints do not prove that rights cannot reasonably be recognized. Nor are rights in general and rights in medical care in particular adequately respected by attending to considerations of just distribution or equity. Rights in medical care are different from rights to medical care, and must be respected in any decent, advanced society. That such rights may be overridden in emergencies does not mean that respect for rights is not a constraint upon the pursuit of equity and efficiency.

Administrative Personnel↗

PubMed2006

Equity, by what measure?

Equity has in many instances been framed around the notion of fairness. But the metric used to determine what is fair leaves some people at a disadvantage because the things that they value are not always taken properly into account. If I value mangoes and you value oranges is a measure of fairness based on how many oranges I seek appropriate? If I am expected to give up my love of mangoes in order to get ahead is that fair? The debate about judging equity - about measuring fairness - needs to find the conceptual and methodological space to allow the voices and claims of the other to be heard.

Australia↗

PubMed1999

Free choice, equity, and care: the moral foundations of health care.

The aims of this paper are threefold. The first aim is to provide a critique of the reform proposal of the Harvard School of Public Health for Hong Kong's health care system through privatization of the public sector services. The second aim is to argue for the duty of society to guarantee every member equal access to a basic level of health care based on the values of equity, care and free choice. The third aim is to explore some suggestions about delivery structures and financial arrangements of a dual sector health care system which will better enable society to provide a basic level of health care that is sustainable and affordable, while being at the same time consistent with the values of care, equity and free choice.

Advisory Committees↗

PubMed2004

BRAC initiative towards promoting gender and social equity in health: a longitudinal study of child growth in Matlab, Bangladesh.

OBJECTIVE: To explore the effect of BRAC (formerly Bangladesh Rural Advancement Committee) initiatives towards promoting gender and social equity in health among children of poor mothers who are BRAC members. DESIGN: A cohort of 576 children from the prospective study of a BRAC- International Centre for Diarrhoeal Disease Research, Bangladesh joint research project was analysed. Data were collected three times during 1995-1996 with approximately 4-month intervals. Stunting, defined as height-for-age below minus two standard deviations from the reference median, was the outcome health measure. The study children were stratified into three groups according to their mother's social and BRAC membership status: poor and BRAC member (BM), poor non-member (TG) and non-poor non-member (NTG). SETTING: Matlab, rural area of Bangladesh. SUBJECTS: Children aged 6-72 months. RESULTS: The overall prevalence of stunting was 76%; the highest prevalence was found among TG (84.6%) children and no significant difference was observed between BM and NTG children (67.3% and 69.4%, respectively). In all groups, a significantly larger proportion of girls was stunted compared with boys in the first round. Group-level analysis showed that stunting decreased among all children except BM boys at the end of third round, with the largest decline among BM girls. In contrast, stunting prevalence increased among BM boys. A similar trend was found in the individual-level analysis, where a larger proportion of BM girls recovered from stunting compared with other groups and no recovery was observed among BM boys. At the end of the third round, the nutritional status of BM girls was almost equal to that of the BM boys, while gender inequity remained large among TG and NTG children. CONCLUSION: The BRAC initiative appeared to contribute to a significant equity gain in health for girls, as well as to decreased differences in ill health between the poor and the non-poor.

Bangladesh↗

PubMed1999

Data needs in studies on equity in health and access to care--ethical considerations.

In order to study equity in health and access to care in an appropriate way, data are needed on an individual level and must include information about health, mortality, morbidity, utilization of care, age, sex, residential area, family situation and the social and economic circumstances of each individual. These data must be collected at several points of time during a life cycle. This is a demanding task requiring many resources and methodological and ethical considerations. The ethical and political trade-off is between our demand for knowledge and a fair distribution of resources in order to achieve equity in health and access to care and the need to administrate sensitive data without threatening personal integrity. In presenting results from Swedish studies, it is argued that the benefits of using registers for this kind of epidemiological research by far outweigh the risk of using registers.

Data Interpretation, Statistical↗

PubMed1999

Equity in health and health care reforms.

In planning healthcare reforms increasing attention has been focused on the issue of equity. Inequities in the provision of healthcare exist even in relatively egalitarian societies. Poverty is still one of the major contributors to ill health and there are many powerful influences in society that continue to thwart the goal of a maximally equitable system for the provision of healthcare. The principles of equity in a healthcare system have been well articulated in recent years. It is incumbent on healthcare professionals who understand the issues to join the efforts towards a more humane and equitable healthcare system in their societies.

Health Care Reform↗

PubMedDate not supplied

Gender equity in health care: the case of Swedish diabetes care.

To explore the issue of gender equity in diabetes care in Sweden and to develop strategies for monitoring gender equity in health care, population-based studies and statistics published since 1990 were reviewed that contained gender-specific data on health care utilization, glycemic control, patient satisfaction, health-related quality of life, and mortality from diabetes. The review shows that diabetic women in Sweden report more frequent outpatient contacts, less patient satisfaction, and a lower health-related quality of life than diabetic men. No gender differences were found in the level of glycemic control. Young and middle-aged men with diabetes have a high excess all-cause mortality as compared with nondiabetic men. A trend toward stronger social gradient in mortality among women than men with diabetes was observed in a large nationwide study.

Diabetes Mellitus, Type 1↗

PubMed1990

The relationship of intergenerational reciprocity of aid to the morale of older parents: equity and exchange theory comparisons.

Information concerning the relationship of intergenerational helping to older adult well-being is ambiguous. Intergenerational reciprocity was investigated using two competing theoretical perspectives, social exchange and equity propositions. Social exchange propositions predict a linear relationship between intergenerational aid and older parent morale, with higher morale positively related to giving or receiving more intergenerational help. Equity propositions predict that the intergenerational aid, morale relationship will be curvilinear, with higher older parent morale related to balanced exchanges of intergenerational aid. Neither theoretical perspective was supported by the data. Intergenerational aid was not useful in explaining variance in older parent morale regardless of the operational definition of intergenerational aid. These results provide support for earlier studies that conclude the amount of help exchanged within families does not affect the well-being of older family members.

Aged↗

PubMed1997

Gender and equity in health sector reform programmes: a review.

This paper reviews current literature and debates about Health Sector Reform (HSR) in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. Any analysis of equity must therefore include a consideration of gender issues. Two main approaches to thinking about gender issues in health care are distinguished--a 'women's health' approach, and a 'gender inequality' approach. The framework developed by Cassels (1995), highlighting six main components of HSR, is used to try to pinpoint the implications of HSR in relation to both of these approaches. This review makes no claim to sociological or geographical comprehensiveness. It attempts instead to provide an analysis of the gender and women's health issues most likely to be associated with each of the major elements of HSR and to outline an agenda for further research. It points out that there is a severe paucity of information on the actual impact of HSR from a gender point of view and in relation to substantive forms of vulnerability (e.g. particular categories of women, specific age groups). The use of generic categories, such as 'the poor' or 'very poor', leads to insufficient disaggregation of the impact of changes in the terms on which health care is provided. This suggests the need for more carefully focused data collection and empirical research.

Cost-Benefit Analysis↗

PubMed1999

Unofficial fees in Bangladesh: price, equity and institutional issues.

The widespread collection of unofficial fees at health facilities is a common form of rent-seeking behaviour in Bangladesh. Typically, unofficial fees come in the form of cash payments for the performance of required services, for direct purchase of drugs and medical-surgical requisites, and for service access. Using observational and interview methods, this study explores linkages between official and unofficial fees at three Bangladesh health facility levels; primary care Thana Health Complexes, secondary or district hospitals, and medical college hospitals. The study estimates payment levels for different income classes and different payor types at these facilities, thereby highlighting potential equity, price and institutional questions associated with unofficial fees. Not only does the practice have clear income and equity effects, there also appear to be direct effects upon patient satisfaction, perception of quality, and the ability to pay for health services. The article concludes with a discussion of 'rent capture' processes at Bangladesh facilities and the effect of unofficial fees in six areas of health sector reform: displaced official policies, reduced merit goods production, upward income redistribution, distorted human resource development, growth of facility inefficiency, and obstruction of market reforms.

Bangladesh↗