Eddy van Doorslaer

On the measurement of inequalities in health

This paper offers a critical appraisal of the various methods employed to date to measure inequalities in health. It suggests that only two of these--the slope index of inequality and the concentration index--are likely to present an accurate picture of socioeconomic inequalities in health. The paper also presents several empirical examples to illustrate of the dangers of using other measures such as the range, the Lorenz curve and the index of dissimilarity.

Analyzing health equity using household survey data : a guide to techniques and their implementation

This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.

Socioeconomic inequalities in health: Measurement, computation, and statistical inference

This paper clarifies the relationship between two widely used indices of health inequality and explains why these are superior to others indices used in the literature. It also develops asymptotic estimators for their variances and clarifies the role that demographic standardization plays in the analysis of socioeconomic inequalities in health. Empirical illustrations are presented for Dutch health survey data.

On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam

The authors propose a method for decomposing inequalities in the health sector into their causes, by coupling the concentration index with a regression framework. They also show how changes in inequality over time, and differences across countries, can be decomposed into the following: Changes due to changing inequalities in the determinants of the variable of interest. Changes in the means of the determinants. Changes in the effects of the determinants o the variable of interest. The authors illustrate the method using data on child malnutrition in Vietnam. They find that inequalities in height-for-age in 1993 and 1998 are accounted for largely by inequalities in household consumption and by unobserved influences at the commune level. And they find that an increase in such inequalities is accounted for largely by changes in these two influences. In the case of household consumption, rising inequalities play a part, but more important have been the inequality-increasing effects of rising average consumption and the increased protective effect of consumption on nutritional status. In the case of unobserved commune-level influences, rising inequality and general improvements seem to have been roughly equally important in accounting for rising inequality in malnutrition.

Income-related inequalities in health: some international comparisons

This paper presents evidence on income-related inequalities in self-assessed health in nine industrialized countries. Health interview survey data were used to construct concentration curves of self-assessed health, measured as a latent variable. Inequalities in health favoured the higher income groups and were statistically significant in all countries. Inequalities were particularly high in the United States and the United Kingdom. Amongst other European countries, Sweden, Finland and the former East Germany had the lowest inequality. Across countries, a strong association was found between inequalities in health and inequalities in income.

Inequalities in access to medical care by income in developed countries

Background: Most of the member countries of the Organization for Economic Cooperation and Development (OECD) aim to ensure equitable access to health care. This is often interpreted as requiring that care be available on the basis of need and not willingness or ability to pay. We sought to examine equity in physician utilization in 21 OECD countries for the year 2000. Methods: Using data from national surveys or from the European Community Household Panel, we extracted the number of visits to a general practitioner or medical specialist over the previous 12 months. Visits were standardized for need differences using age, sex and reported health levels as proxies. We measured inequity in doctor utilization by income using concentration indices of the need-standardized use. Results: We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland. Interpretation: Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.

Equity in the delivery of health care in Europe and the US

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data.

BACKGROUND Conventional estimates of poverty do not take account of out-of-pocket payments to finance health care. We aimed to reassess measures of poverty in 11 low-to-middle income countries in Asia by calculating total household resources both with and without out-of-pocket payments for health care. METHODS We obtained data on payments for health care from nationally representative surveys, and subtracted these payments from total household resources. We then calculated the number of individuals with less than the internationally accepted threshold of absolute poverty (US1 dollar per head per day) after making health payments. We also assessed the effect of health-care payments on the poverty gap--the amount by which household resources fell short of the 1 dollar poverty line in these countries. FINDINGS Our estimate of the overall prevalence of absolute poverty in these countries was 14% higher than conventional estimates that do not take account of out-of-pocket payments for health care. We calculated that an additional 2.7% of the population under study (78 million people) ended up with less than 1 dollar per day after they had paid for health care. In Bangladesh, China, India, Nepal, and Vietnam, where more than 60% of health-care costs are paid out-of-pocket by households, our estimates of poverty were much higher than conventional figures, ranging from an additional 1.2% of the population in Vietnam to 3.8% in Bangladesh. INTERPRETATION Out-of-pocket health payments exacerbate poverty. Policies to reduce the number of Asians living on less than 1 dollar per day need to include measures to reduce such payments.

Equity in the finance of health care: some further international comparisons

This paper presents further international comparisons of progressivity of health care financing systems. The paper builds on the work of Wagstaff et al. [Wagstaff, A., van Doorslaer E., et al., 1992. Equity in the finance of health care: some international comparisons, Journal of Health Economics 11, pp. 361-387] but extends it in a number of directions: we modify the methodology used there and achieve a higher degree of cross-country comparability in variable definitions; we update and extend the cross-section of countries; and we present evidence on trends in financing mixes and progressivity.

Measuring and Testing for Inequity in the Delivery of Health Care

This paper compares two indices of horizontal inequity in the delivery of health care, the index proposed by Wagstaff, van Doorslaer, and Paci (1991), and another index derived in this paper. As well as discussing the computational aspects of these two indices, the paper also addresses the issue of statistical inference, comparing two estimators for the standard error of each index. The paper contains an empirical illustration of both sets of methods using data from the 1992 Dutch Health Interview Survey.