Attacking Inequality in the Health Sector: Operational Manual Version 1.0

Contents......Page 6
Foreword......Page 14
Preface......Page 16
Acknowledgments......Page 22
Abbreviations......Page 24
1. An Unacceptable Reality......Page 26
A Light at the End of the Tunnel: A New Way to Measure Inequalities......Page 27
Not a Pretty Picture......Page 29
Health Sector May Exacerbate Inequality......Page 33
Figure 1.6 Population-Weighted Regional Averages of Percentage of Fully Immunized Children from the Poorest and Wealthiest Quintiles......Page 40
Presenting Inequality Data......Page 42
Annex 1.1 Asset Index as a Measure of Relative Wealth......Page 49
Annex 1.2 Health, Nutrition, and Population Inequality Data......Page 54
Annex 1.3 Benefit Incidence Analysis......Page 97
Annex 1.4 Recommendations for Further Reading......Page 99
Notes......Page 101
Pathways to Good Health......Page 104
The Binding Constraints Faced by the Poor......Page 106
The Blind Spots of the Health Sector......Page 109
Health Sector Finance and the Poor......Page 112
Moving Forward......Page 118
Annex 2.1 Summary of the Multisectoral Determinants of Health......Page 119
Annex 2.2 Recommendations for Further Reading......Page 124
Notes......Page 126
The Views of Leaders from Low- and Middle-Income Countries......Page 128
The Dilemmas Posed by the Long List of Causes......Page 130
Listening Is Critical......Page 132
Table 3.1 Immunization Coverage of Children in India, by Wealth Quintile, 1992?93......Page 136
Advanced Analytical Techniques......Page 138
Eight Steps to Effective Use by the Poor......Page 141
Following the Money: Tools for Analyzing the Role of Resource Allocations and Financing in Inequality......Page 152
An Analytical Checklist......Page 164
Annex 3.1 Data Sources and Their Limitations......Page 166
Annex 3.2 Beneficiary Assessment......Page 173
Annex 3.3 Recommendations for Further Reading......Page 176
Notes......Page 179
4. A Menu of Pro-Poor Policies......Page 182
Recurring Themes......Page 183
Rules of Thumb......Page 185
Figure A4.1 Service Delivery Accountability Framework......Page 190
Annex 4.2 Recommendations for Further Reading......Page 195
Note......Page 197
Challenges......Page 198
Policy Change: Supplementing Universal Health Coverage......Page 201
Note......Page 203
Policy Change: Contracting with NGOs......Page 204
Table 6.1 Average Annual Recurrent Expenditure per Capita......Page 206
Note......Page 210
7. Cambodia: Health Equity Fund for the Poor......Page 212
Policy Change: The Health Equity Fund......Page 213
Findings......Page 218
Note......Page 220
8. Chile: Integrated Services Program for the Poor......Page 222
Policy Change: Chile Solidario......Page 223
Findings......Page 227
Note......Page 229
9. Colombia: Expanding Health Insurance for the Poor......Page 230
Policy Change: The 1993 Health Sector Reform......Page 231
Findings......Page 233
Note......Page 238
10. India: Community-Based Health Care Services......Page 240
Policy Change: The Self-Employed Women’s Association (SEWA)......Page 241
Findings......Page 243
Note......Page 246
Policy Change: The Health Card Program......Page 248
Figure 11.1 Outpatient Consultations, by Type of Provider......Page 249
Note......Page 252
12. Kenya: Expanding Immunization Reach through Campaigns......Page 254
Policy Change: Immunization Campaigns......Page 255
Findings......Page 256
Note......Page 259
13. The Kyrgyz Republic: Health Financing Reform and the Poor......Page 260
Policy Change: The Kyrgyz Health Finance Reforms (2001?05)......Page 261
Findings......Page 262
Note......Page 265
Policy Change: Conditional Cash Transfers in Health and Education......Page 266
Findings......Page 268
Note......Page 271
15. Mexico: Providing Subsidized Health Insurance to the Poor......Page 272
Policy Change: Subsidized Health Insurance for the Poor through Segura Popular......Page 273
Figure 15.1 Enrollment in Mexico’s Seguro Popular Program by Economic Level......Page 276
Note......Page 278
Policy Change: The Nepal Adolescent Project......Page 280
Figure 16.1 Delivery in a Medical Facility: First Pregnancy, Poor and Nonpoor Young Married Women, Nepal......Page 282
Note......Page 285
17. Rwanda: Community-Based Health Insurance......Page 286
Policy Change: Emergence of Community-Based Health Insurance Schemes......Page 287
Findings......Page 288
Note......Page 292
18. Tanzania: Social Marketing for Malaria Prevention......Page 294
Policy Change: The KINET Project......Page 295
Findings......Page 297
Table 18.1 Protective Efficacy of Insecticide-Treated and Untreated Nets in Kilombero and Ulanga Districts of Southwestern Tanzania, 1999......Page 300
19 Vigilance......Page 302
What to Monitor......Page 304
Figure 19.1 Three Classes of Health Services......Page 307
Annex 19.1 Recommendations for Further Reading......Page 310
Note......Page 312
References......Page 314
Index......Page 320
Figure 1.1 Regional Inequalities in Health Sector Outcomes......Page 30
Figure 1.2 Use of Basic Maternal and Child Health Services, Coverage Rates among the Poorest and Wealthiest 20 Percent of the Population in 56 Low- and Middle-Income Countries......Page 35
Figure 1.3 Inequalities in the Use of Basic Maternal and Child Health Services: Coverage Rate Ratios for the Wealthiest and Poorest 20 Percent, 56 Low- and Middle-Income Countries......Page 36
Box 1.2 Variations in Health Service Use in India......Page 37
Figure 1.5 Population-Weighted Regional Averages of Percentage of Deliveries for the Poorest and Wealthiest Quintiles That Were Attended by a Medically Trained Person......Page 39
Figure 1.7 Selected Benefit Incidence Findings for Public Spending on Health......Page 41
Figure 1.8 Wealth Gap for Full Immunization, India, 1998?99......Page 44
Figure 1.9 Odds Ratios for Infant Morality: The Likelihood of Infant Death in the Poorest Quintile of Families Relative to That in the Wealthiest Quintile, Rural and Urban India, 1998?99......Page 45
Figure 1.10 Inequality in Full Immunization, India, 1998?99......Page 46
Figure 1.12 Immunization Concentration Curves, Selected Indian States, 1998?99......Page 47
Table A1.2 Household Wealth Quintiles, Urban India, 1998?99......Page 53
Figure 2.1 Determinants of Health Outcomes: The PRSP Pathways Framework......Page 105
Figure 2.2 Eight Steps to Effective Use of Health Services by the Poor......Page 110
Figure 3.1 Physical Access and Regional Poverty Levels, Mauritania, 1999......Page 143
Figure 3.2 Regional Drug Affordability, Cameroon......Page 144
Figure 3.3 Perception of Quality, Cameroon......Page 146
Figure 3.4 Relevance of Services by Age, Mauritania and Benin, 1998......Page 147
Figure 3.5 Continuity of Immunizations, Mozambique, 1997......Page 149
Figure 3.6 Participation by Region, Mauritania, 2000......Page 151
Figure 3.7 Share of Public Subsidy for Curative Care by Income Group......Page 153
Figure 3.8 Subsidy Benefits Concentration Curve by Type of Care......Page 154
Figure 3.9 Subsidy Benefits Concentration Curve for Curative Care by Residence......Page 155
Figure 3.10 Benefit and Tax Incidence for the Health Sector in Canada......Page 159
Figure 4.1 Results from Studies Presented at RPP Conference......Page 184
Figure 5.1 Distribution of Wealth Status for Residents of Areas Covered by the Family Health Program (PSF)......Page 202
Figure 6.1 Changes in Concentration Indexes, 1997?2003......Page 209
Figure 7.1 Hospitalizations for HEF Beneficiaries and Nonbeneficiaries in the Four HEFs......Page 219
Figure 8.2 Estimated Chile Solidario Participants by Economic Group, 2006......Page 228
Figure 9.1 Population Who Paid for Inpatient Care in Public Hospitals by Income Level......Page 232
Figure 9.2 Insured Population, by Income Status......Page 234
Figure 9.3 Reasons for Not Seeking Health Care, 2003......Page 236
Figure 9.4 Impact of Institutional Delivery and Prenatal Care on Infant Mortality Rate......Page 237
Figure 10.1 Frequency Distribution of SEWA Reproductive Health Mobile Camp Users, Urban and Rural, by Deciles of the SES Index Score......Page 244
Figure 11.2 Health Card Ownership versus Use for Outpatient Treatment......Page 250
Figure 12.1 Percentage of Children Covered by Kenya’s 2002 Mass Campaign Who Had Not Previously Received Measles Immunization......Page 258
Figure 13.1 Effect of Reforms on Hospital Out-of-Pocket Payments, Conditional on Hospitalization......Page 263
Figure 14.1 PROGRESA/Oportunidades’s Success in Reaching the Poor......Page 269
Figure 17.1 Proportion of Sick Seeking Care from Modern Provider, by Income Quartile, 2000......Page 289
Figure 17.2 Out-of-Pocket Illness-Related Expenditures......Page 290
Figure 18.1 Household Net Ownership before and after Social Marketing Program, by Socioeconomic Status......Page 299
Figure 19.2 Tracking Drug Expenses in Africa in the 1980s......Page 309
Table 1.1 Health Services with the Largest Measure of Inequality......Page 34
Table A1.1 Assets and Factor Scores, Urban India, 1998?99......Page 50
Table A1.3 Infant Mortality Inequalities in Low- and Middle-Income Countries......Page 55
Table A1.4 Adolescent Fertility Inequalities in Low- and Middle-Income Countries......Page 61
Table A1.5 Severe Stunting Inequalities in Low- and Middle-Income Countries......Page 67
Table A1.6 Full Immunization Inequalities in Low- and Middle-Income Countries......Page 73
Table A1.7 Antenatal Care (Three or More Visits) Inequalities in Low- and Middle-Income Countries......Page 79
Table A1.8 Contraception (Women) Inequalities in Low- and Middle-Income Countries......Page 85
Table A1.9 Attended Delivery Inequalities in Low- and Middle-Income Countries......Page 91
Table A2.1 Potential for Multisectoral Synergies to Achieve the Millennium Development Goals for Health and Nutrition......Page 120
Table A3.1 Data Sources and Their Limitations......Page 169
Table 4.1 A Menu of Pro-Poor Policies......Page 186
Table 5.1 Prevalence of Incomplete Immunization among Children 12 Months and Older, by Wealth Quintiles, and Concentration Indexes......Page 199
Table 5.2 Proportion of Mothers Receiving Inadequate Antenatal Care, by Wealth Quintiles, and Concentration Indexes......Page 200
Table 6.2 Health Service Indicators: Definitions and Coverage Goals......Page 208
Table 7.1 Procedures and Criteria Used in Four HEFs to Identify the Poorest......Page 216
Table 9.1 Individuals Pushed below Poverty and Subsistence Lines by a Health Shock......Page 235
Table 10.1 The Three SEWA Health Services Covered by Reaching the Poor......Page 242
Table 11.1 Health Card Use......Page 251
Table 12.1 Measles Immunization Coverage in Kenya before and after the 2002 Catch-Up Campaign......Page 257
Box 1.1 Variations in Health and Fertility Outcomes in India......Page 32
Box 1.3 Benefit Incidence Analysis at the Subnational Level......Page 43
Box 2.1 Why Did Safar Banu Die?......Page 107
Box 3.1 Determining How Health-Financing Policy Choices Affect Inequality in Service Use......Page 157
Box 8.1 Illustrative Minimum Conditions to be Achieved by Chile Solidario Participants......Page 225