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Using health equity approaches for assessing equity in maternal and

child health care in Thailand

Phusit PrakongsaiKanjana TisayaticomSudarat Tuntivivat

International Health Policy Program (IHPP), Ministry of Public Health, Thailand

The 3rd Global Forum on Gender Statistics11-13 October 2010Manila, Philippines

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Outline of presentation

• Rationale of health equity approach• Data availability in Thailand• Concentration curve and concentration

index (CI)• Examples of assessing health equity in

selected Maternal and Child Health (MCH) indicators in Thailand

• Discussion and conclusions• The way forward

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Rationale• Improving health equity is a key outcome indicator

for assessing health system performance of a country WHO framework on health system performance assessment (HSPA)

• Determinants of health equity– By gender and sex-disaggregated analysis, – other determinants (socio-economic status, educational

level, residential areas, etc.)

• Various dimensions of health equity – Access to and utilization of health care, – health care financing,– Health status,– Health risk behaviors, etc.

• Available MCH data from MICS 2006 in Thailand and insertion of household asset variables for computing ‘wealth index’

Monitoring & Evaluation of health systems reform /strengtheningA general framework

Data sources

Indicatordomains

Analysis & synthesis

Communication & use

Administrative sourcesFinancial tracking system; NHADatabases and records: HR, infrastructure, medicines etc.Policy data

Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness

Clinical reporting systemsService readiness, quality, coverage, health status

Vital registration

Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems

Targeted and comprehensive reporting; Regular country review processes; Global reporting

Improved health outcomes

& equity

Social and financial risk protection

Responsiveness

Fina

ncin

gInfrastructure

/ ICT

Health workforce

Supply chain

Information

Interventionaccess & services

readiness

Interventionquality, safety and efficiency

Coverage of interventions

Prevalence risk behaviours &

factors

Gov

erna

nce

Inputs & processes Outputs Outcomes Impact

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Rationale• Improving health equity is a key outcome indicator

for assessing health system performance of a country WHO framework on health system performance assessment (HSPA)

• Determinants of health equity– By gender and sex-disaggregated analysis, – other determinants (socio-economic status, educational

level, residential areas, etc.)

• Various dimensions of health equity – Access to and utilization of health care, – health care financing,– Health status,– Health risk behaviors, etc.

• Available MCH data from MICS 2006 in Thailand and insertion of household asset variables for computing ‘wealth index’

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Dimensions and Determinants of Health Equity

Healthcare

utilization

Health financin

g

Quality & responsive

-ness

Health status

Government subsidy on health

Health risk

behavior

DemographicGender

Age group

GeographicRegion

Urban vs. Rural

SocialEducation

Occupation

EconomicIncome

Wealth index

Data availability for M&E system in Thailand (1)Data availability for M&E system in Thailand (1)Input Output Outcome Impact

HCF HRH Infra struct

ure

Gover

nance

Med/Health tech

HIS access

quality

safety

efficienc

y

Interven

coverage

Risk factor

s

H outco

me

Responsive

Equity

Finan prote

ction

Civil registration and vital statistics

Biennial SES

Biennial HWS

Census / SPC

NHES

MICS

Reproductive H survey

NHA

Note: SES = household socio-economic survey, HWS= Health and Welfare survey, NHES = National Health Examination survey, MICS = Multiple Indicator Cluster survey, NHA = National Health Accounts, HA = Hospital accreditation, SPC= Survey of Population Changes

Data availability for M&E system in Thailand (2)Data availability for M&E system in Thailand (2)

Input Output Outcome Impact

HCF HRH Infra structu

re

Gover

nance

Med/Health

tech

HIS access

quality

safety

efficiency

Interven coverage

Risk factors

H outco

me

Responsive

Equity Finan protect

ion

Facility-based report

H resource survey

HIS electronic IP database

Dis surveillance

Behavioral H survey

Sero-sentinelSurvey

Specific dis registration

Quality assurance (HA)

The concentration curve• The concentration curve graphs on the x-axis the

cumulative percentage of the sample ranked by living standards, beginning with the poorest, and on the y-axis the cumulative percentage of the health service use corresponding to each cumulative percentage of the distribution of the living standard variable.

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The concentration index

• is defined as twice the area between the concentration curve and the line of equality (the 45-degree line running from the bottom-left corner to the top-right).

• In the case where there is no income-related inequality, the concentration index is zero.

• The index takes a negative value when the concentration curve lies above the 45-degree line of equality, indicating disproportionate concentration of health service use or other health variables among the poor, and a positive value when it lies below the 45-degree line of equality.

• The index is bounded between -1 and +1

Selected concentration curves of ambulatory service use among different types of health facilities in 2003

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Concentration curves of selected MCH indicators in Thailand, MICS data 2005-

2006

Selected MCH indicators in Thailand from MICS data 2005-2006

Average prevalence or coverage

(%)

Relative risk between

urban and rural

Relative risk

between Q5:Q1

Concentration

index

Teenage pregnancy

37.3 0.76*** 0.51*** -0.1073

Family planning

72.6 0.92*** 0.99*** -0.0005

Prenatal care by skilled health workers

97.8 1.0006** 1.05*** 0.0078

Low birth weight

8.3 1.15*** 0.92*** 0.0367

Underweight children

9.3 0.52*** 0.24*** -0.2192

Stunting 11.9 0.66*** 0.34*** -0.1767

0

10

20

30

40

50

1 (poorest) 2 3 4 5 (richest)

Economic status quintile

Un

de

r 5

de

ath

s p

er

1,0

00

liv

e

bir

ths

1990 census 2000 census

RR = 2.8 (95% CI 2.5-3.0)

RR = 1.8 (95% CI 1.6-2.0)

55% (39%-68%) reduction

Error bars are 95% CIs

Source: Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez AD, Lim SS. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet 2007; 369:850-855

Child mortality by quintile of household economic status from 1990 and 2000

census

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Discussion and conclusion

• Most MCH services in Thailand are concentrated to the poor, and the poor can access to MCH care with no financial barrier.

• Major challenges in health inequity still remain in health outcomes, particularly teenage pregnancy and child malnourishment.

• Remaining gaps between the rich and the poor, and between urban and rural areas require policy interventions and multi-sectoral actions.

• This analytical approach shows possibility in using health inequity intra- and inter-groups for gender-based analysis.

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The way forward

• Including sex-aggregated and gender-based analyses in health-related M& E system.

• Insert a list of household assets and gender in the nationally representative household surveys which household income or expenditure is unavailable.

• Intra- and inter-group analyses in other dimensions of health equity e.g. health status, health risk behavior, disease burden, etc.

• Dissemination of key research findings and policy communication of gender-based health equity analysis.

• Establishment of Health Equity Monitoring Network (HEM-Net) for domestic and international networks.

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17

Thank you

for your

attentio

n