Measuring Health Inequities within a Health Equity Gauge

1. Grupo de Análisis para el Desarrollo Measuring Health Inequities within a Health Equity Gauge Martín Valdivia Presented at the Global Equity Gauge Alliance (GEGA) Technical Workshop, February 10-16, 2002, Entebbe, Uganda

2. Measuring health inequity has several aspects • Selecting health-related variables (health status, access to quality health care, health-related expenditures) • Selecting indicators of SES (education, income, expenditures, wealth) • SES at individual or household-level? • Indicators of health inequity • Poor/rich ratio • relative gap • concentration index • regression-based indicators

3. Key message • Look at all inequity indicators and the whole distribution • None of them may be enough to capture the situation for all health-related indicators • Report confidently those inequities that are robust • Is all this really important?

4. Let me give you an example • Estimating health inequities in Peru • First, look at children’s chronic malnutrition: z-score for height for age • Rate of chronic malnutrition in Peru: 24% • Let’s look at their distribution by SES and place of residence (urban/rural) • Which group is more equitable • See the poor/rich ratio, CI, and relative gap

5. Urban vs Rural • Global health inequity is higher than within urban and rural areas. • Feature of deviation indicators • Warning: That is, significant component of inequities relate to differences between urban and rural areas. • There is less SES related health inequalities in rural areas. Is that population group better?

6. 0.59 0.53 How important are these urban-rural differences in inequity? • Poor/rich ratio would say they are large. Less true with relative gap • There is definitely less inequality in rural areas, but ...

7. 70 decil 1 60 50 40 Tasa de desnutrición 30 decil 1 decil 10 20 decil 10 10 0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 Promedio del ln del gasto per cápita Urbana Rural Chronic malnutrition rates: the whole distribution • Malnutrition rate in rural areas is 40% in rural areas, but it drops to 12% in urban areas • The issue is: rural kids face higher nutritional risk than their SES-equivalent urban counterparts.

8. What do we do? • We could use absolute differences between poorest and richest decile • It is 45.2 percentage points in rural areas • and only 26.7 points in urban areas • Rural areas are worse according to this indicator • problem is … we are trying to resolve with an inequality indicator an issue that has more to do with other aspects of the distribution • Another way is to use a regression-based approach • isolate “income” effect from related effects such as education, district marginality, etc • helps to identify effect of interventions on health status and in the income effect itself

9. Income effect in urban and rural areas • In urban areas, 38% of poor-rich nutritional differences are explained by income differences • That percentage is 63% in rural areas. • Conclusion 1: Rural safety nets are less efficient in isolating health from income differences and fluctuations • Conclusion 2: inequality indicators are not sufficient to describe overall health and nutritional differences between societies

10. Grupo de Análisis para el Desarrollo www.grade.org.pe