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PubMed2006

Using the UK primary care Quality and Outcomes Framework to audit health care equity: preliminary data on diabetes management.

BACKGROUND: The incentivization of UK primary care through the Quality and Outcomes Framework (QOF) has released an unprecedented supply of data that in theory could aid health equity audit and reduce health inequalities. The current system allows for 'exception reporting' whereby patients can be excluded from calculation of payment for reasons such as failure to attend review. We speculated that such exclusions could be linked to socioeconomic deprivation. METHODS: We assessed 'exception reporting' rates for 15 diabetes indicators using 2004/05 QOF data for 49 general practitioner (GP) practices in Brighton and Hove and related it to a deprivation ranking for each practice. RESULTS: The standardized diabetes prevalence was 26% higher (P < 0.001) in the highest compared to the lowest quintile of deprivation. Correlations between 'exception reporting' and deprivation were seen for 10 of the 15 diabetes indicators (r = 0.20-0.41, P < 0.05). Practices with a more deprived patient population were more likely to report 'exceptions' for QOF indicators, although there was no such relationship with the achievement of QOF targets. CONCLUSIONS: Strategies to reduce health inequalities need to take into account that high levels of exception reporting, particularly in practices with deprived populations, may be disguising unmet need in those populations.

Appointments and Schedules↗

PubMed2000

Vertical equity in health care resource allocation.

This paper introduces this mini-series on vertical equity in health care. It reflects on the fact that by and large equity policies in health care have failed and that there is a need for positive discrimination to promote equity better in future. This positive discrimination is examined under the heading of 'vertical equity'. The paper considers Varian's notion of 'envy' as a basis for equity in health care but concludes that this is not a helpful route to go down. Better it would seem to pursue the idea from Sen of 'freedoms' and 'communitarian claims' (as raised previously by this author). While it is argued that procedural justice is to be preferred in the longer run as a basis for equity there are gains in adopting a short run goal of promoting distributive justice. Some preliminary evidence is presented on the weighting of health gains to reflect such vertical equity concerns.

Freedom↗

PubMed2006

Progressivity and horizontal equity in health care finance and delivery: what about Africa?

This paper applies concentration curves and indices, that have been previously used to analyze progressivity in health care finance and horizontal equity in health care delivery in developed countries, to a 1998-1999 household survey about health care expenditures and utilization carried out in four francophone West African capitals (Abidjan, Bamako, Conakry and Dakar). The paper also uses statistical inference for testing stochastic dominance relationship between curves, a technique already applied in the literature about equity in taxation, as the criterion for making rigorous inequality comparisons. In all four capitals, the results strongly suggest a regressive pattern of payments for health care, with lower income groups bearing an higher burden of health expenditures as a proportion of their income than do the higher income segments of the population. As soon as dominance between concentrations curves is statistically tested, results appear less conclusive, notably for the groups of population affected by severe morbidity, on the issue of horizontal inequity in health care delivery, which requires that persons with similar medical need be treated equally. Some recommendations are made for the use of equity measurements in access to care for future evaluations of the impact of health care reforms in Africa.

Africa, Western↗

PubMed1994

Would national health insurance improve equity and efficiency of health care in South Africa? Lessons from Asia and Latin America.

Arguments for and against national health insurance (NHI) for South Africa are illuminated by the experiences of other middle-income developing countries. In many Latin American and Asian countries the majority of their populations are covered by NHI, coverage having steadily increased over the last decade. Patterns of care under NHI tend to be inefficient--hospital-oriented, highly specialised and technical, with excessive investigation, surgery and medication, neglect of primary care and severe cost escalation. In some cases, however, urban primary care has been promoted through polyclinics and health maintenance organisations. Inequalities in funding, access and utilisation exist between the insured and uninsured, between strata of the insured, and between urban and rural areas. These inequalities have at times been ameliorated by expansion of coverage, subsidisation of poorer beneficiaries and initiation of programmes that extend care to rural areas. NHI can improve or impair efficiency and equity in health care, depending on structures and processes of revenue generation, payment and organisation of care. These depend in turn on how those likely to lose or gain from each option exercise their collective power.

Asia↗

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↗

PubMed2002

The Asian Voice in building equity in health for development - from the Asian Forum for Health Research, Manila, February 2000.

The Asian Forum for Health Research convened in Manila, the Philippines, in February 2000 to determine how best to create a new paradigm for health research in Asia. The forum was organized as an 'open university of research for equity in health development' to define the new paradigm and to identify methods for building a dynamic and collaborative architecture to more effectively link the nations and region of Asia with global stakeholders in health research. It was also to: determine Asian actions required to enhance leadership functions for innovative health research management; develop and disseminate tools and methodologies needed to accomplish essential tasks; establish collaborative networks within developing countries/regions to ensure efforts are not duplicated and international inputs are not monopolized; and use new information and communication technologies to integrate the process and contents of health research with equity in health development. Results of the forum's review of issues were presented and discussed at the International Conference on Health Research for Development, held in October 2000 in Bangkok, Thailand.

Asia↗

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

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↗

PubMed2005

Global health and equity: part 2: exploring solutions.

The Millennium Development Goals set an agenda for advancing global health in the 21st century. Nurses have a pivotal role to play in the pursuit of global health and equity, including achieving the goals, but their capacity to contribute has been largely untapped. In this article, the authors examine strategies to mitigate inequities in global health within an international development framework, threats to achieving equity in health and the implications of these issues for nurses and nursing.

Global Health↗

PubMed2006

Equity in resource allocation for health: a comparative study of the Ashanti and Northern Regions of Ghana.

Debate over the equitable allocation of financial resources in the health sector has focused overwhelmingly on allocation from national to regional levels. More equitable allocation of such resources within regions has been virtually ignored, creating a vacuum in knowledge regarding how resources are allocated intra-regionally and their potential influence on promoting health equity. In this paper, we report an empirical study examining progress towards equity in intra-regional resource allocation in the Ashanti and Northern regions of Ghana. Relative deprivation across the 31 districts of the two regions was measured as a proxy of health needs. The result was used to develop an equity-adjusted share index (EAS) applied as a yardstick against which progress towards equity was assessed. The study found a significant correlation between districts' share of donor pooled funds (DPF) and the EAS in the Northern region for three of the 4 years investigated. In Ashanti region, a worsening trend in relation to equity in DPF allocation was discovered. The proportion of variance in the share of DPF that could be explained by the EAS reduced incrementally from 56% in 1999 to less than 1% in 2002. The study highlights the need for more emphasis on intra-regional equity in resource allocation in Ghana.

Ghana↗

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↗

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↗

PubMed1994

Case-based telematic systems towards equity in health care. Introduction to the symposium.

The theme of this International Symposium, co-sponsored by EFMI (the European Federation for Medical Informatics) and WHO-Eur (the European Office of the World Health Organisation) is made of four components: (1) an ethical principle: equity in health care, that aims to social justice; (2) measurements of equity that should be case-based/population related; (3) communication of this information at a wide scale, using telematics, e.g. integrated computer systems at distance; (4) actions to improve health care and equity in its delivery by using resource management tools and developing quality of care. The combination of these four elements is recommended as a coherent scheme for future actions of public authorities in health care. They were therefore associated in the somewhat complex title of the symposium. A special attention is given to the present degree of availability of a large number of case based/population related data sources in Europe, as well as on the need to develop generic models in telematics, rather than too strict standards at the user level. These information systems can be made easily accessible to clinicians and epidemiologists as an aid to their decision making in the European region.

Computer Communication Networks↗

PubMed1983

Equity in health care: confronting the confusion.

Despite general agreement that equity is part of the objective of the UK National Health Service (as indeed it is in other health services), there is little consensus on what is meant by equity in health care. This paper suggests seven possible definitions of equity not with the intention of trying to decide which is in any sense best but rather simply to try to reduce some of the confusion surrounding the concept of equity. These definitions include equality of expenditure per capita; equality of inputs per capita; equality of input for equal need; equality of access for equal need; equality of utilisation for equal need; equality of marginal met need; and equality of health. The paper then takes a closer look at some of the issues surrounding these definitions. The difference between equity by access and by utilisation lies in separating supply and demand (or need) issues. Thus equality of access is about equal opportunity: the question of whether or not the opportunity is exercised is not relevant to equity defined in terms of access. Utilisation is a function of both supply and demand. If access, a supply side phenomenon, is equalised, unless demand is the same, utilisation will not be equalised.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Expenditures↗

PubMed2005

Gender equity in health care in Sweden--minor improvements since the 1990s.

A report by the Swedish National Committee on Gender Disparities in Patient Care (1996) identified many shortcomings in the ability of the health sector to gear patient management and treatment to the specific needs of men and women. To promote gender equity in health care, the Committee presented several proposals relating to research, education, monitoring, and evaluation of health services and the responsibilities of health authorities. In 2002, the Swedish Government authorised the National Board of Health and Welfare to review and analyse gender equity trends in health care. Data from, e.g. the national quality registers, epidemiological health data registers, population surveys, and Patient Trust Boards were compiled to identify gender disparities in the quality and accessibility of health services. The curricula of medical universities and the policies of major research funds were reviewed, as were developments in major fields of health research. The National Board found that many of the gender disparities identified in the 1990s still exist, e.g. access to advanced evidence-based technologies such as coronary interventions. As previously, women account for around 60%, and men for 40%, of complaints, e.g. to the Patients' Advisory Committees. Many of the proposals of the National Committee have not been fully implemented by the national authorities or the county councils. We conclude that promoting gender equity in health care is an important but difficult task for health authorities. To make health services more gender sensitive a combination of strategies, including enforcement by guidelines and regulations, may be needed.

Female↗

PubMed2004

[Twelve years after the Bamako initiative: facts and political implications for equity in health services accessibility for indigent Africans].

Launched in 1988, the Bamako Initiative was considered as a policy aimed at revitalizing the primary health care strategy while strengthening equity in access to health care. A decade later, two research initiatives conducted in Mali and Uganda, and later in Burkina Faso, concluded that a) this policy did very little to improve or increase access to health care among the most deprived and excluded vulnerable population groups, b) this policy only served to marginalize certain population groups already disenfranchised due to the emphasis on financial sustainability and viability of health care organisations, and c) the exemption mechanisms for alleviating the burden of payment and financial barriers for the poorest represent a technically feasible solution, while one not socially advocated. The current state of affairs requires that in order to give impetus to the principles of equity and the initial goals of the Bamako Initiative, African states should implement incentives, NGOs should consider planning as a tool for social change and donors need to ensure investments which are centred upon and prioritize principles of equity.

Africa↗

PubMed1983

Health systems as defences against the consequences of poverty: equity in health as social justice.

The main development problems in the Third World are known to be gross socioeconomic inequality, widespread poor health status accompanied by high fertility and infant mortality rates, low life expectancy, mass illiteracy and mass poverty. In most of these countries governments invest a great deal of scarce resources toward the consequences of poverty rather than it causes. The paucity of resources for such social services is exacerbated by continuously increasing demands and needs which have to be satisfied. Unmet needs tend to cause apathy in the population. For purposes of controlling poverty and its consequences, these must be clearly formulated and relevant policies, a commitment to implement such policies, adequate administrative capacity and reasonably adequate resources. In the case of the health services system, the same requirements apply. Above all, the health system has to be directed toward the greatest needs of the population. This must involve policy makers, implementors and the consumer community. This paper argues that health systems cannot be an effective weapon against the consequences of poverty unless the above kinds of policy exist and are implemented.

Africa↗

PubMed2005

Is promotion of physical activity a wise use of societal resources? Issues of cost-effectiveness and equity in health.

Physical activity creates health benefits, and society makes large contributions in order to promote physical activity within the population. However, the cost-effectiveness and equity-in-health effect of these efforts is seldom evaluated. A model for economic evaluation of community-promoted physical activity has been constructed based on referenced works on the health effects of physical activity, standard methods of economic evaluation, and targets for equity in health. This model was then used to assess published evaluations. A search for programs of community-promoted physical activity aimed to promote health or prevent illness found only eight economic evaluations. Three were based on models, and five evaluated actual interventions. Almost every aspect of the model proposed in this article is included in some of the earlier studies, but several important aspects were excluded in each previous study. A cost-effectiveness analysis of community-promoted physical activity is possible, but adequate knowledge of the components of cost-effectiveness and equity-in-health effect are still limited. The most important determinants of cost-effectiveness are adherence to new habits, experience and value of time spent on physical activity, and selection of the target group.

Attitude to Health↗