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PubMed2004

A nonparametric elicitation of the equity-efficiency trade-off in cost-utility analysis.

We performed an empirical elicitation of the equity-efficiency trade-off in cost-utility analysis using the rank-dependent quality-adjusted life-year (QALY) model, a model that includes as special cases many of the social welfare functions that have been proposed in the literature. Our elicitation method corrects for utility curvature and, therefore, our estimated equity weights are not affected by diminishing marginal utility. We observed a preference for equality in the allocation of health. The data suggest that the elicited equity weights were jointly determined by preferences for equality and by insensitivity to group size. A procedure is proposed to correct the equity weights for insensitivity to group size. Finally, we give an illustration how our method can be implemented in health policy.

Adolescent↗

PubMed2000

Measuring equity in access to health care.

This article develops and uses methodologies to: (1) measure equity in the distribution of access to health services; and (2) measure the impact of health insurance programs on equity. The article proposes two egalitarian-based indicators for measuring equity in terms of access to health care--a concentration coefficient derived from the Gini coefficient, and the Atkinson distributional measure and also employs a weighted Utilitarian social welfare function to measure overall levels of access. The article defines access as the use of health care by individuals with a need for care; need is measured as self-reported morbidity. The setting for the empirical application is the country of Ecuador. The Ecuador Social Security Institute runs a General Health Insurance (GHI) program, whose affiliates are primarily workers in the formal sector of the economy. The principal data source is the 1995 Ecuador Living Standards Measurement Survey. The study uses a microeconomic health care demand model and bivariate probit estimation techniques to measure the impact of insurance on health service use for each quintile of adjusted per-capita household expenditure. The study also predicts health care use and program impact for each quintile under a series of simulation scenarios corresponding to proposed expansion of eligibility for the GHI program. The GHI program increases overall access to health care, but has a negative impact on equity in the distribution of health services. The benefits of the program, calculated as its marginal impact on the probability of using of health care, have a strongly regressive distribution. Expanding eligibility to the self-employed makes the benefit more equitably distributed (but still inequitable), and increases overall social welfare considerably. Expanding eligibility to the dependents of the insured person has similar effects, although less important in magnitude.

Ecuador↗

PubMed2001

Equity of access to health care services: theory and evidence from the UK.

The pursuit of equity of access to health care is a central objective of many health care systems. This paper first sets out a general theoretical framework within which equity of access can be examined. It then applies the framework by examining the extent to which research evidence has been able to detect systematic inequities of access in UK, where equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity between socio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored in each of five service areas: general practitioner consultations; acute hospital care; mental health services; preventative medicine and health promotion; and long-term health care. The paper concludes that there appear to be important inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate, making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turn limits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings.

Health Services Accessibility↗

PubMed2002

Equity in health care access to: assessing the urban health insurance reform in China.

This study evaluates changes in access to health care in response to the pilot experiment of urban health insurance reform in China. The pilot reform began in Zhenjiang and Jiujiang cities in 1994, followed by an expansion to 57 other cities in 1996, and finally to a nationwide campaign in the end of 1998. Specifically, this study examines the pre- and post-reform changes in the likelihood of obtaining various health care services across sub-population groups with different socioeconomic status and health conditions, in an attempt to shed light on the impact of reform on both vertical and horizontal equity measures in health care utilization. Empirical estimates were obtained in an econometric model using data from the annual surveys conducted in Zhenjiang City from 1994 through 1996. The main findings are as follows. Before the insurance reform, the likelihood of obtaining basic care at outpatient setting was much higher for those with higher income, education, and job status at work, indicating a significant measure of horizontal inequity against the lower socioeconomic groups. On the other hand, there was no evidence suggesting vertical inequity against people of chronic disease conditions in access to care at various settings. After the reform, the new insurance plan led to a significant increase in outpatient care utilization by the lower socioeconomic groups, making a great contribution to achieving horizontal equity in access to basic care. The new plan also has maintained the measure of vertical equity in the use of all types of care. Despite reform, people with poor socioeconomic status continue to be disadvantaged in accessing expensive and advanced diagnostic technologies. In conclusion, the reform model has demonstrated promising advantages over pre-reform insurance programs in many aspects, especially in the improvement of equity in access to basic care provided at outpatient settings. It also appears to be more efficient overall in allocating health care resources by substituting outpatient care for more expensive care at emergency or inpatient settings.

Adult↗

PubMed2005

Which delivery systems reach the poor? A review of equity of coverage of ever-treated nets, never-treated nets, and immunisation to reduce child mortality in Africa.

Insecticide-treated nets (ITNs) and childhood vaccination are two of the most powerful interventions available to prevent childhood mortality in Africa, but ITN coverage is still very low. Current debates about how to increase ITN coverage are concerned with the roles of different supply and delivery systems, in particular whether or not commercial net markets have any useful role. Here, we review data available on coverage and equity of coverage of three interventions to prevent childhood mortality. We compiled and analysed data from nationally representative surveys in 26 African countries to compare equity of coverage of (1) the Expanded Programme on Immunisation (EPI), (2) any net, (3) ever-treated nets (ie, ITNs), and (4) never-treated nets (ie, untreated nets; UTNs). We assumed that ever-treated net coverage mostly reflects the activities of public-health programmes and projects, and that never-treated net coverage mostly reflects the activity of local unsubsidised commercial markets. We discuss the validity, limitations, and possible biases of these assumptions. We estimate that 87% of the 8.4 million children protected by nets used UTNs. We used the concentration index (CI) to assess equity of coverage of the interventions. The data shows that never-treated net coverage is surprisingly equitable: overall, and despite substantial regional variations, it is comparable in equity to EPI (median CI(UTN)=0.166, CI(EPI)=0.075; p=0.3). In almost all countries, coverage of ITNs is strongly concentrated in the least poor households, and significantly more inequitable than both UTNs (median CI(ITN)=0.435, mean CI(UTN)=0.158; p<0.001) and EPI (median CI(ITN)=0.435, CI(EPI)=0.075; p<0.001). These results suggest that the public-health value of commercial net markets has been greatly underestimated, and that these markets have so far contributed more to equitable and sustainable coverage of mosquito nets, and hence to the prevention of malaria in Africa, than have the ITNs delivered by public-health systems and projects.

Africa↗

PubMed2003

Effects of attachment styles on the experience of equity in heterosexual couples relationships.

Employing one correlational and two experimental studies, this paper examines the influence of attachment styles (secure, anxious, avoidant) on a person's experience of equity in intimate relationships. While one experimental study employed a priming technique to stimulate the different attachment styles, the other involved vignettes describing fictitious characters with typical attachment styles. As the specific hypotheses about the single equity components have been developed on the basis of the attachment theory, the equity ratio itself and the four equity components (own outcome, own input, partner's outcome, partner's input) are analyzed as dependent variables. While partners with a secure attachment style tend to describe their relationship as equitable (i.e., they give and take extensively), partners who feel anxious about their relationship generally see themselves as being in an inequitable, disadvantaged position (i.e., they receive little from their partner). The hypothesis that avoidant partners would feel advantaged as they were less committed was only supported by the correlational study. Against expectations, the results of both experiments indicate that avoidant partners generally see themselves (or see avoidant vignettes) as being treated equitably, but that there is less emotional exchange than is the case with secure partners. Avoidant partners give and take less than secure ones.

Adult↗

PubMed2002

Parental investment: how an equity motive can produce inequality.

The equity heuristic is a decision rule specifying that parents should attempt to subdivide resources more or less equally among their children. This investment rule coincides with the prescription from optimality models in economics and biology in cases in which expected future return for each offspring is equal. In this article, the authors present a counterintuitive implication of the equity heuristic: Whereas an equity motive produces a fair distribution at any given point in time, it yields a cumulative distribution of investments that is unequal. The authors test this analytical observation against evidence reported in studies exploring parental investment and show how the equity heuristic can provide an explanation of why the literature reports a diversity of birth order effects with respect to parental resource allocation.

Birth Order↗

PubMed2002

Vertical equity in service provision: a model for the Irish public health nursing service.

AIMS: This paper analyses the policy and conceptual basis of public health nursing service provision in the Republic of Ireland and situates it within an international context. It draws on the principles of horizontal and vertical equity in proposing a new model of public health nursing service provision. It gives the reader an understanding of a model of service delivery underpinned by the principle of vertical equity. BACKGROUND ISSUES: The Public Health Nurse in the Republic of Ireland has a wide remit encompassing primary, secondary and tertiary care at the level of the individual, family and community. The changing sociological and demographic nature of society in Ireland has impacted on a service that has largely remained unchanged since 1966. Since 1997 four review bodies have provided recommendations that are incompatible with each other. There remains a need to find a solution to the overwhelming demands placed on the public health nursing service in the Republic of Ireland. KEY ISSUES: The public health nursing service goes beyond the provision of a purely clinical nursing service. Communities differ in demography, epidemiology, environment, history, composition, support and most importantly needs. Using three exemplars a new model for the public health nursing service is explicated. This model has as its main focus the needs of the community it serves. CONCLUSIONS: A service underpinned by the principle of vertical equity can be used to deliver locally based, needs driven public health nursing services. The application of such a model would make the public health nursing service more flexible and responsive to local need. Public health nursing composition and provision must be determined using the principal of vertical equity determined by the needs of the community it serves.

Community Health Nursing↗

PubMed1999

Inequalities in health--future threats to equity.

In discussions about equity there is a tendency to focus on the inequalities in health status that appear to be the result of the material and immaterial consequences of a lower income, professional or social status in society. If we look at publications such as the Black Report in the UK or Ongelijke gezondheid in The Netherlands, we have to accept that despite our universal access to healthcare and the existence in many Western countries of social security measures that preclude 'real' poverty, considerable differences in health continue to exist between socioeconomic groups. This is corroborated for many other European countries in the research carried out by a concerted action led by Mackenbach. These inequalities in health have been referred to in many countries as inequities, meaning that society finds them unjust and expects them to be 'avoidable' or amenable to policy interventions. However, the research on the causal networks underlying the occurrence and the avoidability of inequalities in health remains sparse and intervention studies seem to focus on policy measures that can be evaluated, but which will most likely have a limited impact on the inequalities measured at the population level. Thus the research community leaves policymakers with very little evidence on which to build policy initiatives that are nevertheless requested by many governments. The third element, which needs to be addressed in this context, is the ominous inequality in access to healthcare. Since the debate on equity in health has rightly been initiated in the context of a broader, more intersectoral approach to health policy, very little attention has been paid, so far, to the issue of universal access to quality healthcare services. This is because in the second half of this century most Western (European) countries have created a healthcare system with universal access, financed either through taxation or through social insurance schemes. It is these financing systems that will be threatened in the years to come by the considerable demographic shift occasioned by the ageing of the post-war baby boom and the incentives for risk selection that have been introduced in many systems as part of the 'market' mechanisms. The benefits of these incentives have clearly been a greater efficiency at the patient or service level, but there is still the question of whether it will be a more efficient system also at a population level if equity considerations continue to require a system of universal access to all the healthcare technology that will become available in the coming years. The other side of the coin of risk solidarity is the delimitation of the collective responsibility, thus of a basic benefit package. It is important to realize that equity has been a fundamental underlying value that has led to the creation of the healthcare systems as we know them but which may have become so accepted that it is no longer carefully considered when looking at issues of rationing or health reforms.

Forecasting↗

PubMed1996

Racial differences in home ownership and home equity among preretirement-aged households.

This article measures the racial disparities in home ownership and home equity among preretirement-aged households. It computes the proportion of the racial gap explained by discrimination in housing and credit markets. Maximum likelihood and nonlinear least squares estimates are obtained for models of home ownership probabilities and home equity, conditional on home ownership, yielding computations for expected home equity for black and white households. The results reveal an average discriminatory gap in expected home equity as a percent of the actual gap of 55%. In the top third of the family income distribution, the measured discriminatory gap is 82%; in the middle third it is 83%; in the lowest third it is 62%.

Black or African American↗

PubMed2000

Voluntary siting and equity: the MRS facility experience in Native America.

This article focuses on aspects of intragenerational and intergenerational equity in the context of a unique policy experiment: the effort of the U.S. government to site a monitored, retrievable storage (MRS) facility for high-level civilian nuclear waste. This process and its outcomes are examined from both normative and subjective perspectives. While the MRS siting process was designed to be equitable, its eventual focus on Native American communities raises profound questions about environmental justice, as well as procedural, outcome, and intergenerational equity in cross-cultural contexts. The diverse reactions among Native American tribes demonstrate that translating theoretical concepts of equity into practice is an extraordinarily complex exercise. The MRS siting process, instead of being a bold policy experiment that promoted equity, emerges substantially flawed after its implementation in the Native American context.

Journal Article↗

PubMed2003

PER pressure: New Jersey's "Population Emissions Ratio" environmental equity screening model.

In recent years, much attention has focused on how to incorporate environmental equity considerations into government permitting programs for environmentally regulated facilities. On February 4, 2002, the New Jersey Department of Environmental Protection (NJDEP) became the first state environmental agency to propose a broad legally binding rule intended to guard against environmental inequity in its permitting decisions. The proposed rule centered on an innovative computerized environmental equity (EE) screening model that used "Population Emissions Ratios" to identify small geographic areas in which environmental equity concerns might exist and to simulate the effect on statewide environmental equity of increasing environmental risks in small geographic areas. The NJDEP's model examined an extensive array of ethnic groups, included a variety of environmental risks, evaluated most of those risks in terms of human health, and used an innovative simulation process designed to identify permitting decisions that would worsen statewide environmental inequity. The results of the NJDEP's efforts, however, pose substantial concerns. For example, some key provisions of the NJDEP's model were inadequately explained and some were illogical and would bias its results. The model might be susceptible to generating implausible results due to small, meaningless, and/or essentially random fluctuations in its data inputs. The model used relatively large geographic areas as the units of analysis and interpolated results between them, rather than using smaller geographic areas and avoiding interpolation errors. Finally, the environmental risks evaluated by the model were both arguably over- and underinclusive. Thus, the NJDEP's efforts, although noteworthy, raised more issues than they settled.

Environment↗

PubMed2006

Health disparities and health equity: concepts and measurement.

There is little consensus about the meaning of the terms "health disparities," "health inequalities," or "health equity." The definitions can have important practical consequences, determining the measurements that are monitored by governments and international agencies and the activities that will be supported by resources earmarked to address health disparities/inequalities or health equity. This paper aims to clarify the concepts of health disparities/inequalities (used interchangeably here) and health equity, focusing on the implications of different definitions for measurement and hence for accountability. Health disparities/inequalities do not refer to all differences in health. A health disparity/inequality is a particular type of difference in health (or in the most important influences on health that could potentially be shaped by policies); it is a difference in which disadvantaged social groups-such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination-systematically experience worse health or greater health risks than more advantaged social groups. ("Social advantage" refers to one's relative position in a social hierarchy determined by wealth, power, and/or prestige.) Health disparities/inequalities include differences between the most advantaged group in a given category-e.g., the wealthiest, the most powerful racial/ethnic group-and all others, not only between the best- and worst-off groups. Pursuing health equity means pursuing the elimination of such health disparities/inequalities.

Delivery of Health Care↗

PubMed2002

Annotated Bibliography on Equity in Health, 1980-2001.

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.

Journal Article↗

PubMed2002

Mapping environmental injustices: pitfalls and potential of geographic information systems in assessing environmental health and equity.

Geographic Information Systems (GIS) have been used increasingly to map instances of environmental injustice, the disproportionate exposure of certain populations to environmental hazards. Some of the technical and analytic difficulties of mapping environmental injustice are outlined in this article, along with suggestions for using GIS to better assess and predict environmental health and equity. I examine 13 GIS-based environmental equity studies conducted within the past decade and use a study of noxious land use locations in the Bronx, New York, to illustrate and evaluate the differences in two common methods of determining exposure extent and the characteristics of proximate populations. Unresolved issues in mapping environmental equity and health include lack of comprehensive hazards databases; the inadequacy of current exposure indices; the need to develop realistic methodologies for determining the geographic extent of exposure and the characteristics of the affected populations; and the paucity and insufficiency of health assessment data. GIS have great potential to help us understand the spatial relationship between pollution and health. Refinements in exposure indices; the use of dispersion modeling and advanced proximity analysis; the application of neighborhood-scale analysis; and the consideration of other factors such as zoning and planning policies will enable more conclusive findings. The environmental equity studies reviewed in this article found a disproportionate environmental burden based on race and/or income. It is critical now to demonstrate correspondence between environmental burdens and adverse health impacts--to show the disproportionate effects of pollution rather than just the disproportionate distribution of pollution sources.

Environmental Exposure↗

PubMed2005

[Equity in health according to reports by the Brazilian National Health Conferences since enactment of the 1988 Federal Constitution].

Based on a literature review and taking into account a concept of equity and its application to the field of public health, this article discusses the meaning ascribed to the term "equity" and its variations in the reports by the 9th, 10th, and 11th National Health Conferences in Brazil. Qualitative methods and content analysis were used to evaluate the approach to equity in two products the Conferences intended to formulate: analysis and presentation of the country's health profile and guidelines for public health policies. Little progress in understanding the issue of equity in health was observed; the predominant discourse was vague or excessively broad. The proposals were generic and nonspecific, failing to define the target problems and social groups.

Brazil↗

PubMed2001

Zoning, equity, and public health.

Zoning, the most prevalent land use planning tool in the United States, has substantial implications for equity and public health. Zoning determines where various categories of land use may go, thereby influencing the location of resulting environmental and health impacts. Industrially zoned areas permit noxious land uses and typically carry higher environmental burdens than other areas. Using New York City as a case study, the author shows that industrial zones have large residential populations within them or nearby. Noxious uses tend to be concentrated in poor and minority industrial neighborhoods because more affluent industrial areas and those with lower minority populations are rezoned for other uses, and industrial zones in poorer neighborhoods are expanded. Zoning policies, therefore, can have adverse impacts on public health and equity. The location of noxious uses and the pollution they generate have ramifications for global public health and equity; these uses have been concentrated in the world's poorer places as well as in poorer places within more affluent countries. Planners, policymakers, and public health professionals must collaborate on a worldwide basis to address these equity, health, and land use planning problems.

Global Health↗

PubMed2001

Health for All in the Twenty-First Century, World Health Organization renewal, and equity in health: a commentary.

Health for All in the Twenty-first Century is the document presenting the global health policy adopted by the World Health Organization (WHO) in 1998, which reaffirms and updates the vision of Alma-Ata. This article provides a synopsis of the document and a commentary, concentrating on the issue of equity, which is central to WHO policy, and discussing cultural differences that underpin the notion of equity. The meaning of "equity" implies measurement, and the authors develop an approach to definitions of social strata and data issues that are used to quantify health differences. Finally, they discuss the way in which policies invoking equity are implemented into programs and present a rights-based approach as a case study of one way in which policy is being translated into action.

Health Plan Implementation↗