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Inte
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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
Inte
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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
Inte
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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