Measurement and Explanation of Inequality in Health and Health Care in Low-Income Settings

This paper describes approaches to the measurement and explanation of income-related inequality and inequity in health care financing, health care utilization and health and considers the applicability and the feasibility of these methods in low-income countries. Results from a comparative study of 14 Asian countries are used to illustrate the main issues. The structure of health finance in low-income countries, in particular the heavy reliance on out-of-pocket payments, means that the equity issues in finance are quite different from those of concern in high-income countries. Primary concern is not with the distribution of contributions to pre-payment mechanisms but with the deterrent effect of payments on utilization and the distribution of uninsured payment risks. Measurement of inequity in utilization of health care in low-income countries is constrained by the lack of reliable measures of health that can be used to standardize for need. Nonetheless, sufficient is known of the distribution of need in many circumstances in order to make inferences about equity from inequality in health care use. The empirical analyses demonstrate that, in low-income countries, the better-off tend to pay more for health care, both absolutely and in relative terms. But they also consume more health care. Health care is financed is largely according to the benefit principle. Assessing the distributional performance of health systems in low-income settings therefore requires examination of finance and utilization simultaneously.health inequality, equity

Paying for health care : quantifying fairness, catastrophe, and impoverishment, with applications to Vietnam, 1993-98

The authors compare egalitarian concepts of fairness in health care payments (requiring that payments be linked to ability to pay) and minimum standards approaches (requiring that payments not exceed a prespecified share of prepayment income or not drive households into poverty). They develop indices for both sets of approaches. The authors compare the"agnostic"approach, which does not prespecify exactly how payments should be linked to ability to pay, with a recently proposed approach that requires payments to be proportional to ability to pay. They link the two approaches using results from the income redistribution literature on taxes and deductions, arguing that ability to pay can be thought of as prepayment income less deductions deemed necessary to ensure that a household reaches a minimum standard of living or food consumption. The authors show how both approaches can be enriched by distinguishing between vertical equity (or redistribution) and horizontal equity, and show how these can be quantified. They develop indices for"catastrophe"that capture the intensity of catastrophe as well as its incidence and also allow the analyst to capture the degree to which catastrophic payments occur disproportionately among poor households. Their measures of the poverty impact of health care payments also capture both intensity and incidence. To illustrate the arguments and methods, the authors use data on out-of-pocket health spending in Vietnam in 1993 and 1998-an interesting application, since 80 percent of health spending in that country was out-of-pocket in 1998. They find that out-of-pocket payments had a smaller disequalizing effect on income distribution in 1998 than 1993, whether income is measured as prepayment income or as ability to pay (that is, prepayment income less deductions, regardless of how deductions are defined). The underlying cause of the smaller disequalizing effect of out-of-pocket payments differs depending on whether the benchmark distribution is prepayment income or ability to pay. The authors find that the incidence and intensity of catastrophic payments-in terms of both prepayment income and ability to pay-declined between 1993 and 1998, and that both the incidence and the intensity of catastrophe became less concentrated among the poor. They also find that the incidence and intensity of the poverty impact of out-of-pocket payments diminished over the period. Finally, they find that the poverty impact of out-of-pocket payments is due primarily to poor people becoming even poorer rather than the nonpoor becoming poor and that in Vietnam in 1998 it was not expenses associated with inpatient care that increased poverty but nonhospital expenditures.Economic Theory&Research,Health Systems Development&Reform,Payment Systems&Infrastructure,Health Economics&Finance,Public Health Promotion,Health Economics&Finance,Health Systems Development&Reform,Payment Systems&Infrastructure,Health Monitoring&Evaluation,Economic Theory&Research

Inequality and polarisation in health systems’ responsiveness: a cross-country analysis

The World Health Report 2000 proposed three fundamental goals for health systems encompassing population health, health care finance and health systems responsiveness. The goals incorporate both an efficiency and equity dimension. While inequalities in population health and health care finance have motivated two important strands of research, inequalities in responsiveness have received less attention in health economics. This paper examines inequality and polarisation in responsiveness, bridging this gap in the literature and contributing towards an integrated analysis of health systems performance. It uses data from the World Health Survey to measure and compare inequalities in responsiveness across 25 European countries. In order to respect the inherently ordinal nature of the responsiveness data, median-based measures of inequality and polarisation are employed. The results suggest that, in the face of wide differences in the health systems analysed, there exists large variability in inequality in responsiveness across countries

The Indicative Power of A Key Word System. A Quantitative Analysis of the Key Words in the Translation Studies Bibliography

Over the last decades, Translation Studies has explicitly tried to develop and regard itself as an interdiscipline. This evolution, as well as this self-esteem, has not only widened the focus of the field, it has also created a sometimes unclear eclecticism of topics, influences and methods. Characteristic of a still not too well-established and not always acknowledged discipline, research in Translation Studies has been looking for common interests and common grounds with other disciplines in an ambitious, but often unstructured way.The new online Translation Studies Bibliography (TSB - first release October 2004), which concentrates on the last decade, is used here as a tool for the analysis of the multiplicity of influences. Expanded several times a year, the TSB offers more than 7,000 annotated entries and uses a sophisticated key word system. The quantitative analysis of these key words and their thematic fields indicate the priorities in the dissemination of TS research over the past decade. How does research on translation today reflect this assumption? Is research on literary translation still as widespread as it was in the eighties? What is the relationship between publications on the ‘cultural turn’ and those on the ‘power turn’? The results of this analysis may indicate emphases and research priorities for the next decade in Translation Studies.Dans son évolution des dernières décennies, la traductologie se veut explicitement interdisciplinaire, ce qui a permis à cette discipline — encore toute jeune — d’élargir son domaine de recherches. Mais cette tendance a également mené à un éclectisme dans les sujets traités, les méthodes appliquées, les influences subies. Comme toute discipline jeune à la recherche de reconnaissance, la traductologie a dirigé ses recherches vers des intérêts et des domaines communs à d’autres sciences déjà établies. Ceci s’est cependant souvent fait avec (trop) d’ambition et de façon (trop) peu structurée.Pour l’analyse de la diversité des influences, nous nous sommes basé sur les résultats obtenus grâce à la Translation Studies Bibliography (TSB — lancée pour la première fois en octobre 2004). Cette nouvelle base de données bibliographiques en ligne (mise à jour annuellement (au mois) regroupe les publications de la dernière décennie. Elle offre plus de 7000 entrées annotées que l’utilisateur peut consulter grâce à un système de mots-clé sophistiqué. L’analyse quantitative de ces mots-clé aussi bien que de leurs champs thématiques nous donne d’importantes indications quant aux priorités de recherche dans le domaine de la traductologie de la dernière décennie. Quel est, proportionnellement parlant, le rapport entre les recherches faites en traduction et celles faites en interprétation? La recherche en traduction littéraire est-elle toujours aussi répandue que dans les années 1980 ? Quelles relations les publications sur le ‘cultural turn’ et sur le ‘power turn’ entretiennent-elles

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.Environmental Economics&Policies,Public Health Promotion,Health Monitoring&Evaluation,Early Child and Children's Health,Disease Control&Prevention,Health Monitoring&Evaluation,Inequality,Regional Rural Development,Environmental Economics&Policies,Early Child and Children's Health

Improving maternal and child health in Pakistan: A programme evaluation using a difference in difference analysis

Introduction: Pakistan is a country with high maternal and infant mortality. Several large foreign funded projects were targeted at improving maternal, neonatal and child health. The Norway-Pakistan Partnership Initiative (NPPI) was one of these projects. This study aims to evaluate whether NPPI was successful in improving access and use of skilled maternal healthcare.Methods: We used data from three rounds (2009-2010, 2011-2012 and 2013-2014) of the Pakistan Social and Living Standards Measurement Survey (PSLM). A difference-in-difference regression framework was used to estimate the effectiveness of NPPI and its different programme components with respect to maternal healthcare seeking behaviour of pregnant women. Various parts of the PSLM were combined to examine the healthcare seeking behaviour response of pregnant women to exposure to NPPI.Results: Trends in maternal care seeking behaviour of pregnant women were similar in districts exposed to NPPI and control districts. Consequently, only a weak and insignificant impact of NPPI on maternal care seeking behaviour was found. However, women in districts which used vouchers or which implemented contracting were more likely to seek skilled assistance with their delivery.Conclusion: We conclude that the objective to improve access to and use of skilled care was not achieved by NPPI. The small effects identified for vouchers and contracts on skilled birth attendance hold some promise for further experimentatio

Fourth stable radical species in X-ray irradiated sucrose

C