Gordon A. Carmichael

Measuring and Decomposing Inequity in Self-Reported Morbidity and Self-Assessed Health in Thailand

BackgroundIn recent years, interest in the study of inequalities in health has not stopped at quantifying their magnitude; explaining the sources of inequalities has also become of great importance. This paper measures socioeconomic inequalities in self-reported morbidity and self-assessed health in Thailand, and the contributions of different population subgroups to those inequalities.MethodsThe Health and Welfare Survey 2003 conducted by the Thai National Statistical Office with 37,202 adult respondents is used for the analysis. The health outcomes of interest derive from three self-reported morbidity and two self-assessed health questions. Socioeconomic status is measured by adult-equivalent monthly income per household member. The concentration index (CI) of ill health is used as a measure of socioeconomic health inequalities, and is subsequently decomposed into contributing factors.ResultsThe CIs reveal inequality gradients disadvantageous to the poor for both self-reported morbidity and self-assessed health in Thailand. The magnitudes of these inequalities were higher for the self-assessed health outcomes than for the self-reported morbidity outcomes. Age and sex played significant roles in accounting for the inequality in reported chronic illness (33.7 percent of the total inequality observed), hospital admission (27.8 percent), and self-assessed deterioration of health compared to a year ago (31.9 percent). The effect of being female and aged 60 years or older was by far the strongest demographic determinant of inequality across all five types of health outcome. Having a low socioeconomic status as measured by income quintile, education and work status were the main contributors disadvantaging the poor in self-rated health compared to a year ago (47.1 percent) and self-assessed health compared to peers (47.4 percent). Residence in the rural Northeast and rural North were the main regional contributors to inequality in self-reported recent and chronic illness, while residence in the rural Northeast was the major contributor to the tendency of the poor to report lower levels of self-assessed health compared to peers.ConclusionThe findings confirm that substantial socioeconomic inequalities in health as measured by self-reported morbidity and self-assessed health exist in Thailand. Decomposition analysis shows that inequalities in health status are associated with particular demographic, socioeconomic and geographic population subgroups. Vulnerable subgroups which are prone to both ill health and relative poverty warrant targeted policy attention.

Consensual partnering in the more developed countries.

An especially spectacular demographic trend in the more developed countries since the mid-1960s has been the increasing frequency with which couples have cohabited without being formally married. This paper summarizes evidence that exists for the emergence of this phenomenon in different countries, and reviews the substantial literature it has generated. The latter part of the paper is organized under the following headings: ‘The international nature of the phenomenon’; ‘Reasons for the rise in consensual partnering’; ‘Who cohabits?’; ‘‘The nature of consensual unions’; ‘Union conversion to marriage and dissolution’; ‘The rise of consensual partnering and the retreat from marriage’; ‘The impact of premarital cohabitation on marital stability’; ‘Childbearing in consensual unions’; and ‘Consensual partnering following marital breakdown’. The view is expressed that research to date often has avoided confronting the diversity of meanings consensual unions have for those who live in them.

Health payment-induced poverty under China’s New Cooperative Medical Scheme in rural Shandong

OBJECTIVE To measure the incidence and severity of health payment-induced poverty of rural households under the New Cooperative Medical Scheme (NCMS) in rural Shandong, China. METHOD We collected primary data from a household survey to identify catastrophic health payments and measure associated health payment-induced poverty in a county of Shandong province. From a stratified random cluster sample of 3101 households, 375 households that might be at risk of catastrophic payments were identified and interviewed. A validity test of the screening method was conducted, from which we obtained the adjusted total number of households with catastrophic payments in the sample of 3101. The health payment-induced poverty incidence and severity were compared without and with NCMS reimbursements. RESULTS Before the NCMS intervention, 5.06% of the sample households fell below the national poverty line due to health payments in 2004, compared with 4.03% after reimbursements. With NCMS reimbursements, the health payment-induced poverty gap of those households still remaining below the Chinese national poverty line dropped by 19.2% to an average of 977.2 Yuan. CONCLUSION Out-of-pocket health payments remain a severe burden for rural households. Financial protection from the NCMS was limited.

Decomposing Socioeconomic Inequality for Binary Health Outcomes: An Improved Estimation that Does not Vary by Choice of Reference Group

BackgroundDecomposition of concentration indices yields useful information regarding the relative importance of various determinants of inequitable health outcomes. But the two estimation approaches to decomposition in current use are not suitable for binary outcomes.FindingsThe paper compares three estimation approaches for decomposition of inequality concentration indices: Ordinary Least Squares (OLS), probit, and the Generalized Linear Model (GLM) binomial distribution and identity link. Data are from the Thai Health and Welfare Survey 2003. The OLS estimates do not take into account the binary nature of the outcome and the probit estimates depend on the choice of reference groups, whereas the GLM binomial identity approach has neither of these problems.ConclusionsThe GLM with binomial distribution and identity link allows the inequality decomposition model to hold, and produces valid estimates of determinants that do not vary according to choice of reference groups. This GLM approach is readily available in standard statistical packages.

Explanation of inequality in utilization of ambulatory care before and after universal health insurance in Thailand.

Thailand implemented a Universal Coverage Scheme (UCS) of national health insurance in April 2001 to finance equitable access to health care. This paper compares inequalities in health service use before and after the UCS, and analyses the trend and determinants of inequality. The national Health and Welfare Surveys of 2001 and 2005 are used for this study. The concentration index for use of ambulatory care among the population reporting a recent illness is used as a measure of health inequality, decomposed into contributing demographic, socio-economic, geographic and health insurance determinants. As a result of the UCS, the uninsured group fell from 24% in 2001 to 3% in 2005 and health service patterns changed. Use of public primary health care facilities such as health centres became more concentrated among the poor, while use of provincial/general hospitals became more concentrated among the better-off. Decomposition analysis shows that the increasingly common use of health centres among the poor in 2005 was substantially associated with those with lower income, residence in the rural northeast and the introduction of the UCS. The increasing use of provincial/general hospitals and private clinics among the better-off in 2005 was substantially associated with the government and private employee insurance schemes. Although the UCS scheme has achieved its objective in increasing insurance coverage and utilization of primary health services, our findings point to the need for future policies to focus on the quality of this primary care and equitable referrals to secondary and tertiary health facilities when required.

Sexual perceptions and practices of young people in Northern Thailand.

This study draws together survey and qualitative data on sexual practices among more than 1750 young Northern Thai people aged 17–20 years. The survey data indicate that sexually active young people frequently engage in, or are subjected to, risk-taking behaviours that may expose them to sexually transmitted infections and unwanted pregnancies. These include having multiple sexual partners and quite frequent partner turnover. High percentages also engage in unprotected sexual intercourse with various types of sexual partner (steady, casual and paid), and young women especially had often experienced sexual coercion. Qualitative data revealed a mixture of perceptions and practices affecting sexual intercourse among the young, such as having unplanned sex, engaging in sexual relations to display love or cement committed relationships, and having serial relationships, both monogamous and non-monogamous. We conclude that condom use should be a central focus of activities aimed at preventing adverse sexual health outcomes, but that new intervention approaches to encourage use of other contraceptives are also needed. Changes in sexual norms among young people also need to be acknowledged and accepted by older Thai generations in order for programmes and interventions to combat negative sexual and reproductive health consequences to be more effective.

Has universal health insurance reduced socioeconomic inequalities in urban and rural health service use in Thailand

This study analyses urban and rural health service use before and after the introduction of the Universal Coverage Scheme (UCS). Using data from the Thai national health surveys of 2001 and 2005, the study utilises age–sex adjusted concentration indices to measure within-area differences in use of health services among populations distinguished by socioeconomic status. Between 2001 and 2005, the UCS substantially reduced Thailand’s uninsured population (from 42.5% to 7.0% in urban areas and from 24.9% to 2.7% in rural areas). The implementation of the UCS changed patterns of health services use, particularly for rural people and the urban poor, by placing greater emphasis on primary healthcare. Relevant policy recommendations should focus on continued improvement of primary health services, and ensuring adequate and timely referrals to secondary and tertiary health services when the need arises.

A Cohort Analysis of Marriage and Informal Cohabitation among Australian Men

Australias postwar marriage boom lasted until the early 1970s, since when ages at marriage have risen and a growing minority of young people have avoided marrying. This paper focuses on the retreat from marriage and the accompanying increase in consensual part nering. Multi-state life tables constructed for five-year age cohorts using marriage/relationship histories from a 1986 nationally repre sentative sample of 2 104 males aged 20-59 are used to explore three issues: the extent of the retreat from marriage; the extent of the more or less concurrent increase in informal cohabitation; and the extent to which the latter trend may have offset the former.

Tracking and Decomposing Health and Disease Inequality in Thailand

Purpose In middle-income countries, interest in the study of inequalities in health has focused on aggregate types of health outcomes, like rates of mortality. This work moves beyond such measures to focus on disease-specific health outcomes with the use of national health survey data. Methods Cross-sectional data from the national Health and Welfare Survey 2003, covering 52,030 adult aged 15 or older, were analyzed. The health outcomes were the 20 most commonly reported diseases. The age-sex adjusted concentration index (C∗) of ill health was used as a measure of socioeconomic health inequality (values ranging from −1 to +1). A negative (or positive) concentration index shows that a disease was more concentrated among the less well off (or better off). Crude concentration indices (C) for four of the most common diseases were also decomposed to quantify determinants of inequalities. Results Several diseases, such as malaria (C∗ = −0.462), goiter (C∗ = −0.352), kidney stone (C∗ = −0.261), and tuberculosis (C∗ = −0.233), were strongly concentrated among those with lower incomes, whereas allergic conditions (C∗ = 0.174) and migraine (C∗ = 0.085) were disproportionately reported by the better off. Inequalities were found to be associated with older age, low education, and residence in the rural Northeast and rural North of Thailand. Conclusions Pro-equity health policy in Thailand and other middle-income countries with health surveys can now be informed by national data combining epidemiological, socioeconomic and health statistics in ways not previously possible.

Living together in Australia: Qualitative insights into a complex phenomenon

Abstract This paper mines data from in-depth interviews on family formation with 115 women, men and couples of family-forming age in eastern Australia to examine aspects of the complex phenomenon of living together unmarried. Sixty-five percent of interviews yielded evidence of one or more such relationships entered over approximately a 20-year period. Informants had rarely made considered ‘decisions’ to cohabit. Moving in had rather ‘just happened’, often after couples were ‘sort of’ living together anyway through regularly staying over with one another. What tended to be transitions rather than datable events were widely perceived to be ‘natural progressions’, and motives for them were typically more pragmatic than emotional. The notion of cohabitation as trial marriage did not resonate widely among cohabiters, but did appear to have aided increasing parental acceptance of the lifestyle. Non-cohabiters mostly cited religious beliefs, a desire not to offend parents or a view that by marrying directly they had shown greater commitment as reasons for not having lived together. Youthful entry to cohabiting relationships seems frequently to presage their dissolution as ‘growing up’ relationships in a climate that increasingly eschews serious family formation until some years later in life. Transitions to marriage, which remains a highly symbolic act of commitment despite being seen in some quarters as irrelevant, have a variety of triggers. Prominent among them are decisions to have children (notwithstanding widespread childbearing within cohabiting unions) and the age-old prerogative of a male to propose marriage as the mood takes him.