2006/08/29 09:30 Ashok Agarwal, "Equity in Health Services: Issues and Challenges", SEM 2006, HUT

Services Engineering and Management Summer School, Helsinki University of Technology, August 28-September 2

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Ashok Agarwal, Insittute of Health Management Research, India

Introduction by Paul Lillrank

  • Extreme differences between Finland and India, good for academics
  • Possible for them to jump into higher level of technology, avoiding some of the blind spots of early adopters

[Ashok Agarwal]

Bring the science of management to health care

  • Like many other countries, health care is managed by doctors


  • Equity
  • How to measure it
  • Comparison of developed and developing coutnries
  • Millenium goals
  • Indicators of goals

Difficulty between defining equity, versus equality

  • Equality: compare various attributes of a country or person, in a semblance
    • Different background, financial, social
    • Hence provision of services is equally spread out
    • Equality is value-free
  • Equity means social justice
    • Several disparities in wealth, health care, democratic freedoms
    • Can understand inequities in wealth, from inheritance, and some people work harder than others
    • Everyone should have equal access to health, though
    • Health equity is multidimension, includes all of the other special acts in living
    • No matter where they're living, health level, age group

Bring health differentials as low as possible

Dimensions of equity in three parts:

  • Economic equity
  • Provision
  • Health outcomes

There's horizontal equity and vertical equity

  • Horizontal:  people who have the same neeed receive same services
  • Vertical:  people with more needs get more services

Extreme poverty: World Bank defines as less then $1 per day

  • However, different purchasing powers
    • One other way: caloric intake
    • People of different age groups, of different sexes, have different values of intake without malnutrion
    • 2000 calories per day
  • Also define poverty as resources, and access to services

Ten richest countries in the world

  • Do they have the best health status?
  • Do they provide equal health care?

Consider a world where they talk instead about taking care of their babies

  • More linked to public health than to engineering
  • Number of deaths of infants, under age of one year
  • Talks to nutrition status of the woman, health care of the woman while pregnant, health care, ... health status of the child when born

Lowest infant mortality rate:

  • Only 2 of 10 richest countries on the list

Range of infant mortality rates around the world

  • Countries more than 150/1000 live births
  • Singapore lowest at about 2

Expenditure health in different countries in the world, both public and private sector

  • Low income, middle income, and high income countries
  • Low income countries spend less per capita
  • India about 5%, low
  • Developed countries spend about 10%, and the U.S. is spending about 1/6 of GDP

Absolute numbers in spending:

  • Low income countries spend about $20 to $30 per person per year
  • Middle income countries spend about $200
  • High income countries spend about $3000
  • U.S. spends about $6000 per capita per year

India: typical example of a undeveloped country

  • Public health care only 30%
  • 82% is private, out of pocket
  • Have just started private health care
  • Rich people can get either free or fee services

Low income countries have low life expectancy

  • Sri Lanka an exception, infant mortality rate is relatively low
  • South Africa is an exception: apartheid, high infant mortality rate

1987:  Millenium Development Goals

  • Set up by U.N. and World Bank
  • Aim for 2015
  • Goals not equally spread out
  • Defines according to each country, each region in each country, based on 1990: environment, health care
  • #1 target: eradicate extreme poverty and hunger
    • Medicine won't improve everything
  • #2: achieve universal primary health care
    • Educated women have better health
  • #3: gender equiality
  • #4: reduce child morality
  • #5: improve maternal health

Why is goal setting important?

  • According to each countries' relevance
  • Important to mobilize world resources
  • Goals allow U.N. system to monitor progress
  • Last time: eradication of smallpox, a disease know for 5000 years that was highly contagious
  • In the 1970s, joint work, countries came together to say to eradicate one disease in the century
  • Up to $10000 reward in each country, to find an incidence of smallpox

Where are we?

  • On poverty, we're nowhere, because we don't know how to measure it
    • In India, have a different definition of poverty
    • Haven't been able to measure over the past 6 or 7 years
    • Wealth is increasing globally, but in only certain classes of people
    • Many countries in Africa, GDP sometimes goes down
  • HIV/AIDS: nothing has been achieved in 2005, because the goal is different, to halt new cases
  • Safe water, somewhat better, one of the most basic for health care

Goal to reduce child mortality

  • 2015 goal
  • Smallpox was eradicated in 9.5 years, without today's technology
  • Indicators:
    • Under 5 mortality rate, reduce by 2/3
    • Infant mortality rate
    • Measles
  • Under five rate in high-income countires < 5 per 1000 live births, and >100 in low income

In India, 26 million births per year:  5 Finlands

  • Highest proportion of global annual live births, but also highest proportion of neonatal deaths
  • Deaths less than 4 weeks are mostly related to mother's health status, or delivery conditions
  • Under-5 mortality rate is coming down

India's population is 1.1 billion

  • Diverse
  • Each state, 60 billion to 150 billion
  • In south, Kerala is poor, yet lowest infant mortality rate
  • Orissa, another poor state on the east, has highest infant mortality rate (similar to Africa), yet bad infant mortality rate
  • 100 years ago, Kerala had a policy of educating masses, families working together
  • Kerala has infant mortality rate, comparable to the U.S.
  • Kerala has electricity rate of 90%, Orissa has about 40%
  • Punjab, Delhi have higher mortality rates, and the ratio of men to women is high, biologically incorrect

If trend continues, won't make 2015 goal, but India can take steps

Goal 6: Improve maternal health, target, reduce by 3/4 by maternal mortality ratio

  • Indicators:
    • Maternal mortality rate
    • Proportion of births attended by skill health personnel
  • Death of the woman while pregnant, or within 6 weeks of termination of pregnancy
  • In India, preparing adolescents, a lot of women get pregnant at 18 or 19

Differential in maternal mortality health: 1100 per 100,000 live births in sub-Saharan Africa, compared to 12 in industrialized countries

  • In sub-Saharan Africa, a woman will be pregnant 5 or 6 times in her lifetime

Skilled birth attendants at time of childbirth

  • About half of children in the world at born at home
  • Chances of a child or mother getting infected is very high
  • In poor India, 10% have access to nurse or doctor, whereas in rich India, 90%

Goal 7:  Combat HIV/AIDS, malaria and other communicable diseases

  • Use of condoms
  • Knowledge of women
  • In 2005, global 1% with HIV, but about 6% in sub-Saharan

Limitations to achieving Millenium Development Goals

  • Difficult in countries that aren't well-defined, e.g. wars
  • Poorer people have to pay out of pocket expenses more often
  • When a poor person has to go to a hospital, 25% will have to dispossess something

Prescription to remove inequity?

  • Wish there was something, no standard prescription, has to vary country by country
  • Regions in mountain, by sea, inequal distribution of resources

What needs to be done?

  • Firstly, need resource allocation related to social and health needs
    • Some have other priorities, e.g. war
  • Education
  • People will live near jobs, health care has to go where people are
    • New technology can be distributed
  • Must be someone who looks at quality of care at national and regional levels.
  • Lots of centres provide free services, but people don't go there
    • Don't understand why
    • In fact, people go to public sector, spending a lot of money, to get the same services
    • Often, go to illegal doctors, quacks
    • In India, one major factor: unreliability, never find a doctor or nurse there or clean facilities
    • People would rather go to a private practitioner who will serve quickly

Most data not collected in a way that is useful

  • Lots of data, not churned out into information used in policy

How to monitor and evaluate health equity?

  • One research says: guided by values
  • You collect data, make it information, but must use it to provide care to the population
  • Hard to measure equity directly


  • More resources must be provided to health care, particularly in developing countries
  • Resources not just money, also trained manpower and infrastructure
    • Often find the building good, and doctors and nurses are there, but aren't trained well
  • Should be a pro-poor approach
  • Public funding should be distributed according to distribution of people, where they need it, even in special needs
  • Public/private partnership is difficult, defined differently
  • Instances where government are providing health care at high cost, and outcomes are quite low
  • There are cases where government could outsource to private, at same or lower cost
    • Instances in Cambodia and India, no cost to patients, health care is better
  • Health financing models, either by government or by companies, and others can't get it
    • Micro-health insurance
    • India is experimenting with community health insurance, e.g. 1 million people with access to a designated health system

Generic/research questions:

  • Is the equity definition correct?
  • Found more than a dozen definitions, most often defined as what is inequal (in health care needs, expenditures)
    • Equity to reduce disparities: people with more needs should get more resources
  • Who provides? government, people, private sector, NGOs?
  • Why is quality in health care intangible?


Equity.  Horizontal, same care to same needs. Can this definition of equity really work in a wealthy society? Curve flattens out at $700-$800 per person, then spending more money doesn't improve health. Amartya Sen 1995 and Robert Fogel 1993 have different views.  Fogel says in U.S., main obstacle is the concept of equity.

  • Definition of equity is not standard
  • There's 5000 ways to lose weight
  • Sen: equity is not in a narrow sense, it's multidimensional.
    • Ability of the people to access health care, or any other public good
    • Thus inequitable

Fogel says there's also moral behaviour, not just determined by body or environment, but by also how you choose to live your health.  If this is ignored, then the consequence is health totalarianism. In Nordics, this isn't far away. An issue of individual freedoms.

  • Living the life you want to live is a small decision
  • In poor countries, government resources are very limited

Obesity a bigger problem than malnutrition, increasing most in developing countries with bad foods. Should be addressed on a U.N. level. U.S. health care, diabetes at age 20 requires being on machines, cost of life.

  • Obesity is behaviour.

How much education about obesity?

  • Agree, more education should be on health behaviour.
  • Newfound wealth is in a certain class of people.

International problem.  Smallpox eradicated because all countries came together. Some issues difficult not just internationally, but within a country. e.g. polio vaccination, outbreaks in India.

  • Diversity, 6 billion people around the world
  • In 1970s, diversity, 4 billion people, but the whole world came together to talk about one problem, smallpox.
  • This wasn't about control, it was eradication.
  • Uniform will, manageable input.  Countries came together.

Politics and religion. A lot of health resistance is by religion communities. Mullahs. Person who wanted to set up a condom factory in Bangladesh, said that privately would support it, but not publically.

Management view.  What kind of health care service providing system, service production system could tackle this? Probably not the same as in the rich world. No alternative health production system, so that poor countries have to wait for GDP to grow.  Average return per user, e.g. building a mobile cell phone for under $20, or Negroponte computer < $100, lean production.

Jakur artificial knee, made of aluminum.

  • Health care is limited by doctors.
  • Doctors use medicines and technologies, which increase cost of health care.
  • Artificial limb is provided free to people. Cost is less than $1000.
  • Eye care, cataract surgery.
    • Do this on a camp basis, instead of at hospital at $200 to $1000, do it at $10 per person.
    • Infection rate and complication rate is as low as a hospital.
  • Can bring the cost down, but need to take it out of doctor's purview.

Who is responsible for ensuring health care? A lot of stakeholders.  People. Education.

  • Everyone has to pitch in.
  • Kerala, brought in the right time, 100 years ago, whereas in other states only 10 years ago.

From political theory, government is responsible to ensure equity of people.  Can't ask private sector to do this. Businesses tend to segment markets. Asking them to give up this fundamental principle is not sustainable.

In Finland, it has been NGOs. Service that public sector is offering, has been first developed by NGOs. When the knowledge has been gained, public sector takes them, and the NGO focuses elsewhere. Health clinics on maternal care.

  • Am an NGO.
  • They don't necessarily belief in government.

Governance doesn't come up with something new.  NGO doesn't have the rights to make it universal.

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2006/08/29 09:30 Ashok Agarwal, "Equity in Health Services: Issues and Challenges"