Quantitative M & E of Health Care Equity

Quantitative M & E

of Health Care Equity

Supon Limwattananon, MPHM, PhD

Analysis of Health Care Equity

• Progressivity (or regressivity) of health financing

• Benefit Incidence Analysis (BIA) of health care utilization and subsidy

• Impacts of OOP payments – Health catastrophe or catastrophic impact

– Post-OOP impoverishment or poverty impact

Data Sources

Source Sample size

Survey period Living standardConcept Period

HWS 2001

222,248 individuals

Apr. 2001 (one month)

Income (15 intervals)

Monthly average

HWS 2004

68,109 individuals

Apr. 2004 (one month)

Income (in-cash and

in-kind)

Monthly average

SES 2000

24,747 households

Jan. – Dec. 2000 (12 months)

Consumption expenditure

Prior month

SES 2002

34,785 households



Prior month

SES 2004

34,843 households



Prior month

Measures of Ability to Pay and Living Standards

Source: O’Donnell et al. (2005)

Data Sources

Source Health care utilization OOP health payment

Measurement unit

Recall period Recall period

HWS 2001

IP: Number of admissions

IP: Prior 12 months IP: Prior 12 months

HWS 2004

OP: Number of visitsIP: Number of admissions

OP: Prior 1 monthIP: Prior 12 months


SES 2000

N/A N/A Self med: Prior 1 month OP: Prior 1 monthIP: Prior 12 months

SES 2002(Health module)

OP: Number of visitsIP: Number of admissions


Self med: Prior 1 month OP: Prior 1 monthIP: Prior 12 months

SES 2004

N/A N/A Self med: Prior 1 month OP: Prior 1 monthIP: Prior 12 months

Amount of Rank Cumulative Amount of Cumulative wealth/ATP population (pi) health care (Yi) health care

Poorest $ 1 1% Y1 Y1/Y %

$$ 2 . Y2 (Y1+Y2)/Y %

. . 20% . .

. . . . .

. . 40% Y40 (Y1+Y2+… +Y40)/Y %

. . . . .

. . . . .

. . . . .

. . . . .

Richest $$$$$$$$$$$$ . 100% Y100 100%

(X-axis) (Y-axis)

Q1

Q5

Q2

Y = Y1+Y2+Y3+ … +Y100

Concentration Curve and Concentration Index

20

100

80

60

40

20 40 60 80 100

Population cumulative % (p) ranked by ATP

0

AT

P (

in c

um

ula

tive

%)

Lorenz curve for ability to pay (ATP)

L(p)

L(p) “Lorenz curve” for ATP (wealth or total consumption/income)

Area between the diagonal line and Lorenz curveGini coefficient =

Area under the diagonal line (or perfect equality line)

0 < GC < 1.0

Equality line

20

100

80

60

40

20 40 60 80 100


0

Hea

lth

car

e u

se (

in c

um

ula

tive

%)

Concentration curve for health care utilization

LH(p)

LH(p) Concentration curve for health care use

Concentration Index for health use has a negative sign: -1.0 < CI < 0

Health care is progressive in favor of the poor (pro-poor)

20

100

80

60

40

20 40 60 80 100


0

LH(p)

Concentration curve for health care utilization

Hea

lth

car

e u

se (

in c

um

ula

tive

%)

LH(p) Concentration curve for health care use

Concentration Index for health use has a positive sign: 0 < CI < 1.0

Health care is regressive against the poor (pro-rich)

Index for absolute equity

Concentration Index (CI) = 2 x Area between equality line and concentration curve

Area between equality line and Lorenz curveGini coeffcient (GC) =

Area under the equality line (diagonal line)

Index for relative equity (1977)

Kakwani Index (KI) = Concentration Index – Gini coefficient

20

100

80

60

40

20 40 60 80 100


0

AT

P &

hea

lth

car

e (i

n c

um

ula

tive

%

)

LH(p)

L(p)

In this case, Concentration Index for health care has a positive sign

but Kakwani Index has negative sign, CI < GC

The health care is pro-rich but it reduces the relative inequality

Lorenz curve for ATP and concentration curve for health care

20

100

80

60

40

20 40 60 80 100


0

AT

P &

hea

lth

car

e (i

n c

um

ula

tive

%

)

Lorenz curve for ATP and concentration curve for health care

LH(p)

L(p)

In this case, CI > GC

Both Concentration Index and Kakwani Index have positive signs,

The health care is pro-rich and increases the relative inequality

Health Care Financing

Sources of Funds1. Direct payments

• Household’s out-of-pocket (OOP) payments

2. Prepayments

• General government revenue• Taxation

• Direct tax

• Indirect tax

• Earmarked tax

• Contribution• Compulsory: Social health insurance

• Voluntary: Private insurance

Figure 2: Out-of-pocket (OOP) and general government revenues (GGR) as share of total expenditure on health

Bangladesh

China

Hong Kong

Indonesia

Japan

Korea Rep.

Kyrgyz Rep.

Nepal

Philippines Punjab

Sri Lanka

Taiwan

Thailand

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

OOP as % of TEH

GG

R a

s %

of T

EH



Figure 6: Concentration and Kakwani indices for total health financing

-0.1 0.0 0.1 0.2 0.3 0.4 0.5 0.6

Japan Taiwan

Korea Rep. Kyrgyz Rep.

China Punjab Nepal

Sri Lanka Philippines

Hong Kong Indonesia Thailand

Bangladesh

Concentration index Kakwani index

Concentration and Kakwani indices for OOP payments

-0.3 -0.2 -0.1 0.0 0.1 0.2 0.3 0.4 0.5 0.6

JapanTaiwan

Kyrgyz Rep.Punjab

Korea Rep.Nepal

Hong KongChina

Sri LankaThailand

IndonesiaBangladeshPhilippines

Concentration index Kakwani indexSource: O’Donnell et al. (2005)

Poorest quintile Richest quintile

Distribution of Taxation and ATP by Household Living Standards


Concentration and Kakwani indices of direct taxes

0.0 0.2 0.4 0.6 0.8 1.0

JapanNepal

IndonesiaTaiwan

Kyrgyz Rep.Korea Rep.

ChinaHong KongPhilippines

BangladeshThailand

Sri Lanka


Concentration and Kakwani indices of indirect taxes

-0.3 -0.2 -0.1 0.0 0.1 0.2 0.3 0.4 0.5 0.6

JapanTaiwanPunjabKyrgyz

IndonesiaKorea

Sri LankaBangladesPhilippines

NepalChinaHong

Thailand

Concentration index Kakwani index


Concentration and Kakwani indices for social insurance

-0.3 -0.2 -0.1 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

Korea Rep.

Taiwan

Japan

Kyrgyz Rep.

Thailand

Philippines

Indonesia

China


Equitable distribution of health care

Amount of health care received

• correlates highly with health needs

• is independent of things not related to health needs

A. Socio-economic status

– Ability to pay (wealth): consumption or expenditure, income, asset index

– Education or schooling

– Occupation

B. Geographical area

– Urban/rural, region/province

C. Demographic– Gender

– Ethnicity: language, tribal, religion, immigrant vs. native-born

Ref: Anderson R. Health service distribution and equity (1975)

Source: Gwatkin DR et al. Lancet (2004)

Maternal and Child Health Services(50 developing and transitional countries)

Source: Gwatkin DR et al. Lancet (2004)

Maternal and Child Health: Public / Private Services(50 developing and transitional countries)

Coverage in lowest wealth quintile Coverage ratio (highest : lowest wealth)

Source: Technical Note #13 (EQUITAP Project)

Health Care Utilization(OP Care, 2004)

Health centreDistrict hospital

Provincial hospital

Quintile 1 331. % 312. % 254. %

Quintile 2 257. % 257. % 193. %

Quintile 3 242. % 201. % 218. %

Quintile 4 120. % 158. % 159. %

Quintile 5 49. % 73. % 176. %

Concentration index -03144. -02843. -01477.

Standard error 00172. 00210. 00293.

Kakwani index -08598. -08286. -06868.

Standard error 00184. 00224. 00308.

District hospital Provincial hospital

Year 2001

Year 2004

Year 2001

Year 2004

Quintile 1 303. % 269. % 206. % 203. %

Quintile 2 266. % 250. % 178. % 188. %

Quintile 3 189. % 233. % 199. % 213. %

Quintile 4 160. % 161. % 241. % 227. %

Quintile 5 81. % 87. % 175. % 169. %

Concentration index

-0304.1 -02589.

-007.29

-011.49

Standard error0015.

4 00196.0011.

0

0018.7

Kakwani index-0832.

9 -08046.-059.48

-065.51

Standard error0015.

9 00209.0011.

5

0020.1

Health Care Utilization (IP Care, 2001 and 2004)

Subsidy to Health Care

Subsidy = Cost incurred in health care – OOP paid by individuals

Health Care Public Subsidy(OP Care, 2004)

Health centreDistrict hospital

Provincial hospital

Quintile 1 345. % 319. % 258. %

Quintile 2 259. % 258. % 192. %

Quintile 3 238. % 203. % 217. %

Quintile 4 115. % 146. % 153. %

Quintile 5 43. % 74. % 180. %

Concentration index -03326. -02921. -01496.

Standard error 00186. 00212. 00302.

Kakwani index -08787. -08367. -06888.

Standard error 00198. 00225. 00318.

Public Subsidy to OP Care -20040

.2.4

.6.8

1C

um

. p

rop

ort

ion

of pu

blic

su

bsi

dy

for

OP

0 .2 .4 .6 .8 1Cumulative proportion of persons: ranked from poor to rich

Lorenz curve Health centerDistrict hospital Provincial hospitalCumulative population proportion

Outpatient care: Public Hospitals

BIA of Public Subsidy to OP Care(2004)

0%

5%

10%

15%

20%

25%

30%

35%

40%

SSS CSMBS UCE UCP

Population Household income Health centreDistrict hospital Provincial hospital

0%

10%

20%

30%

40%

50%

60%

70%

80%

SSS CSMBS UCE UCP

Population Household income Health centreDistrict hospital Provincial hospital


Source: Limwattananon et al. (2005)

District hospital Provincial hospital

Year 2001

Year 2004

Year 2001

Year 2004

Quintile 1 312. % 274. % 221. % 209. %

Quintile 2 266. % 255. % 194. % 186. %

Quintile 3 187. % 227. % 204. % 218. %

Quintile 4 155. % 160. % 225. % 220. %

Quintile 5 79. % 84. % 156. % 166. %

Concentration index

-0313.0 -02666.

-011.04

-012.21

Standard error0016.

2 00201.0011.

7

0019.3

Kakwani index-0842.

1 -08125.-063.34

-066.26

Standard error0016.

7 00214.0012.

2

0020.7

Health Care Public Subsidy(IP Care, 2001 and 2004)

Public Subsidy to IP Care -20040

.2.4

.6.8

1C

um

. p

rop

ort

ion

of pu

blic

su

bsi

dy

for

IP

0 .2 .4 .6 .8 1Cumulative proportion of persons: ranked from poor to rich

Lorenz curve District hospitalProvincial hospital Cumulative population proportion

Inpatient care: Public Hospitals

BIA of Public Subsidy to IP Care(2004)


0%

5%

10%

15%

20%

25%

30%

35%

40%

SSS CSMBS UCE UCP

Population Household income District hospital Provincial hospital

0%

10%

20%

30%

40%

50%

60%

70%

80%

SSS CSMBS UCE UCP

Population Household income District hospital Provincial hospital


Equity in OOP health expenditure

Health is financed according to ability to pay (ATP)

1. Vertical equity

Those with unequal ATP pay unequally

(the rich pay more, the poor pay less)

2. Horizontal equity

Those with equal health needs pay equally

Those with equal ATP pay equally

Source: van Doorslaer et al. (2005)

Large share of out-of-pocket payments in total health funding

OOP as % of total health finance

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Vietnam

Nepal

Indonesia

Bangladesh

China

Korea, Rep.

India

Kyrgyz, Rep.

Sri Lanka

Philippines

Hong Kong

Thailand

Taiwan


Figure 1: Out-of-pocket (OOP) share of total expenditure on health (TEH) against national income (GNI per capita)

Thailand

Bangladesh China

Hong Kong

Indonesia

Japan

Korea Rep.

Kyrgyz Rep.

Nepal

Philippines

Punjab Sri Lanka

Taiwan

0%

10%

20%

30%

40%

50%

60%

70%

80%

5 6 7 8 9 10 11 12

log (GNI per capita)

OO

P a

s %

of

TH

E


Impacts of OOP Health Payments

• Catastrophic impact

• Poverty impact

Catastrophic Health Expenditures

Incidence of Catastrophic Expenditures


Cum % of pop, ranked by decreasing oops share

Pay

me

nts

as

sh

are

of

inc

om

e

0% 100%

Proportion Hcat

exceeding threshold

Total catastrophic ‘excess’ Gcat

zcat

Incidence of Catastrophic Expenditures%

Ho

use

ho

lds

exce

edin

g t

hre

sho

lds


Catastrophe vs. OOP Payments & Income


Catastrophe* vs. OOP Payments(OOP > 40% of Income net of needs, N=59 countries)

Source: Xu et al. Household catastrophic health expenditure: a multicountry analysis (Lancet 2003)

Distribution of Catastrophic Health Expenditure*

(OOP payments > 10% total consumption expenditure)

14.8% 10.2% 11.2%

24.5%

13.0% 17.1%

19.8%

21.9%19.6%

20.5%

24.6% 21.1%

20.5%30.3% 31.1%

Year 2000 Year 2002 Year 2004

Quintile 5

Quintile 4

Quintile 3

Quintile 2

Quintile 1


Incidence of Catastrophic Health Expenditure

All households SSS CSMBSLIC/VHC

UC

Year 2000

Quintile 1 40. % 2 .7 %

Quintile 2 6 .6 % 5 .3 %

Quintile 3 54. % 48. %

Quintile 4 56. % 69. %

Quintile 5 56. % 7 .1 %

All Quintiles 54. % N/A N/A 47. %

Year 2002

Quintile 1 17. % 00. % 05. % 17. %

Quintile 2 21. % 00. % 49. % 02. %

Quintile 3 36. % 07. % 46. % 38. %

Quintile 4 40. % 20. % 39. % 48. %

Quintile 5 50. % 34. % 35. % 61. %

All Quintiles 3 .3 % 2 .3 % 38. % 32. %

Year 2004

Quintile 1 16. % 00. % 16. % 16. %

Quintile 2 24. % 14. % 72. % 20. %

Quintile 3 2 .7 % 03. % 50. % 28. %

Quintile 4 29. % 11. % 35. % 3.3%

Quintile 5 43. % 25. % 46. % 52. %

All Quintiles 28. % 1 .5 % 45. % 26. %

0%

5%

10%

15%

20%

25%

30%

All 2000 All 2002 All 2004 LIC/VHC 2000 UC 2002 UC 2004

Self med. OP/no IP With IP

Catastrophic Incidence by Types of Health Care


Catastrophic Incidence by Levels of Health Care

0%

5%

10%

15%

20%

25%

30%

35%

40%


Public facility Health center District hospitalProvincial hospital Private hospital Private clinic

OP Care

0%

5%

10%

15%

20%

25%

30%

35%

40%


Public hospital District hospital Provincial hospitalPublic hospital, outside Private hospital

IP Care


Impoverishment as a Result of

OOP Payments for Health Care


A B

C

Hpre Hpost

Pre-payment parade

Post-payment parade

income

cum % of pop, ranked by income

poverty line zpov

Incidence of Poverty Impact (Pen Parade)


Poverty* Impact of OOP Health PaymentsPre-payment and post-payment consumption, Bangladesh 2000

0

2

4

6

8

10

12

14

16

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 5500 6000 6500 7000

HHs ranked by total consumption

HH

cons a

s m

ulti

ple

of pov li

ne P

L

Poverty line Post payment consumption Pre payment consumption

* US$1.08 = International poverty line

Poverty headcounts

$1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

$1 $2


Impoverishment vs. OOP Payments

Vietnam

Thailand

Sri Lanka

Philippines Nepal

Kyrgyz Rep

Indonesia

India

China

Bangladesh

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

0% 20% 40% 60% 80% 100%

OOP share of tot finance

Po

v im

pact

($2)


Vietnam

Thailand

Sri LankaPhilippines

Nepal

Kyrgyz Rep

IndonesiaIndia

China

Bangladesh

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5 6 6 7 7 8 8

log(GNI per capita)

Po

v h

ead

co

un

t ($

2)

Impoverishment vs. Income


Incidence of Impoverishment*(Total consumption expense – OOP health payment < National poverty lines)


UC

Year 2000 N/A N/A

Quintile 1 183. % 164. %

Quintile 2 15. % 14. %

Quintile 3 10. % 10. %

Quintile 4 08. % 08. %

Quintile 5 06. % 17. %

All Quintiles 44. % 58. %

Year 2002 Quintile 1 103. % 2 .4 % 9 .4 % 98. %

Quintile 2 05. % 00. % 01. % 06. %

Quintile 3 05. % 01. % 04. % 06. %

Quintile 4 06. % 00. % 02. % 08. %

Quintile 5 08. % 04. % 02. % 10. %

All Quintiles 25. % 02. % 06. % 31. %

Year 2004 Quintile 1 80. % 76. % 55. % 76. %

Quintile 2 03. % 02. % 14. % 02. %

Quintile 3 03. % 00. % 03. % 03. %

Quintile 4 03. % 00. % 02. % 03. %

Quintile 5 03. % 00. % 02. % 07. %

All Quintiles 18. % 01. % 06. % 22. %

Poverty Impact: Post-OOP Impoverishment(Headcounts of increased impoverishment due to OOP

payments)


UC

Year 2000 N/A N/A

Quintile 1 67. % 59. %

Quintile 2 15. % 14. %

Quintile 3 10. % 10. %

Quintile 4 08. % 08. %

Quintile 5 06. % 17. %


Year 2002 Quintile 1 20. % 00. % 27. % 19. %

Quintile 2 05. % 00. % 01. % 06. %

Quintile 3 05. % 01. % 04. % 06. %

Quintile 4 06. % 00. % 02. % 08. %

Quintile 5 08. % 04. % 02. % 10. %

All Quintiles 08. % 02. % 03. % 10. %

Year 2004 Quintile 1 16. % 00. % 10. % 15. %

Quintile 2 03. % 02. % 14. % 02. %

Quintile 3 03. % 00. % 03. % 03. %

Quintile 4 03. % 00. % 02. % 03. %

Quintile 5 03. % 00. % 02. % 07. %

All Quintiles 05. % 00. % 03. % 06. %


UC

Year 2000 N/A N/A

Quintile 1 14. % 12. %

Quintile 2 05. % 04. %

Quintile 3 04. % 05. %

Quintile 4 06. % 05. %

Quintile 5 06. % 16. %


Year 2002 Quintile 1 04. % 00. % 03. % 04. %

Quintile 2 02. % 00. % 01. % 03. %

Quintile 3 03. % 00. % 03. % 03. %

Quintile 4 04. % 00. % 01. % 06. %

Quintile 5 08. % 06. % 02. % 09. %

All Quintiles 04. % 03. % 02. % 04. %

Year 2004 Quintile 1 03. % 02. % 03. % 03. %

Quintile 2 01. % 00. % 01. % 01. %

Quintile 3 01. % 00. % 02. % 01. %

Quintile 4 02. % 00. % 01. % 02. %

Quintile 5 03. % 00. % 02. % 07. %

All Quintiles 02. % 00. % 01. % 02. %

Poverty Impact(Poverty Gaps as % of poverty line, in post-OOP impoverished

HH)

Poverty Incidence by Types of Health Care –All households


1.7%

3.8%

11.9

%

0.3%

1.7%

4.3%

0.3% 1.5% 2.

6%

0%1%2%3%4%5%6%7%8%9%

10%11%12%13%

No

use

Sel

f m

ed.

OP

/no

IP

With

IP

No

use

Sel

f m

ed.

OP

/no

IP

With

IP

No

use

Sel

f m

ed.

OP

/no

IP

With

IP

Year 2000 Year 2002 Year 2004

post-OOPimpoverished

pre-OOPimpoverished

Poverty Incidence by Types of Health Care –UC Beneficiaries


2.1%

4.8%

12.3

%

0.4%

2.0%

4.1%

0.3% 1.

7%

2.9%

0%1%2%3%4%5%6%7%8%9%

10%11%12%13%

Nouse

Selfmed.

OP/noIP

WithIP

Nouse

Selfmed.

OP/noIP

WithIP

Nouse

Selfmed.

OP/noIP

WithIP

Year 2000 (LIC/VHC) Year 2002 (UC) Year 2004 (UC)

post-OOPimpoverished

pre-OOPimpoverished

Poverty Impact by Levels of Health Care Service –OP care(Absolute Increase in Poverty Headcounts)


or UC

Year 2000 N/A N/A

Public facility 7.2% 10.7%

Private hospital 5.5% 8.8%

Private clinic 4.8% 7.9%

Year 2002

Health centre 1.4% 0.0% 0.0% 1.7%

District hospital 0.7% 0.0% 0.6% 0.8%

Provincial hospital 1.1% 0.0% 0.8% 1.7%

Private hospital 5.2% 4.2% 2.8% 6.4%

Private clinic 2.3% 0.0% 0.1% 3.1%

Year 2004 Health centre 0.3% 0.0% 0.0% 0.3%

District hospital 2.2% 0.0% 2.2% 1.9%

Provincial hospital 2.5% 0.0% 2.0% 3.1%

Private hospital 3.2% 1.5% 0.8% 5.7%

Private clinic 1.6% 0.1% 0.2% 2.0%

Poverty Impact by Levels of Health Care Service –IP care(Absolute Increase in Poverty Headcounts)

All households SSS CSMBS

LIC/VHC or UC

Year 2000 N/A N/A

Public hospital 109. % 94. %

Private hospital 110. % 205. %

Year 2002 District hospital 25. % 16. % 36. % 19. %

Provincial hospital 42. % 38. % 1 .5 % 39. %

Public hospital outside province 65. % 37. % 2 .3 % 52. %

Private hospital 85. % 00. % 09. % 123. %

Year 2004 District hospital 09. % 00. % 10. % 08. %

Provincial hospital 16. % 06. % 06. % 12. %

Public hospital outside province 64. % 00. % 11. % 92. %


Poverty Impact by Types and Levels of Health Care(Relative Increase in Poverty Headcounts)

OP care IP careAll

householdsLIC/VHC

or UCAll

householdsLIC/VHC

or UC

Year 2000 Public facility and

hospital 802. % 785. % 964. % 895. %


Private clinic 925. % 900. % N/A N/A

Year 2002 Health centre 514. % 563. % N/A N/A

District hospital 342. % 339. % 621. % 562. %


Public hospital outside province N/A N/A 1000. % 1000. %



Year 2004 Health centre 131. % 166. % N/A N/A

District hospital 678. % 625. % 289. % 254. %


Public hospital outside province N/A N/A 1000. % 1000. %



OOP Payments by Levels of Health Care Service –OP Care(Amount of Payments in Median Baht)

Not Impoverishe

d

Post-OOP Impoverishe

d

Pre-OOP impoverishe

d

Year 2000 Public facility and

hospital 210 800 80

Private hospital 750 2,000 N/A

Private clinic 240 500 200

Year 2002 Health centre 30 30 30

District hospital 30 30 30

Provincial hospital 120 600 60



Year 2004 Health centre 30 30 30

District hospital 30 60 30

Provincial hospital 60 1,275 30



Not Impoverished

Post-OOP Impoverished

Pre-OOP Impoverished

Year 2000 Public hospital 192 442 21

Private hospital 417 867 N/A

Year 2002 District hospital 3 114 2

Provincial hospital 108 1,500 3

Public hospital outside province 167 3,333 N/A


Year 2004 District hospital 5 125 2

Provincial hospital 30 250 3

Public hospital outside province 217 167 N/A


OOP Payments by Levels of Health Care Service –IP Care(Amount of Payments in Median Baht)

Quantitative M & E of Health Care Equity

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