Analysing health equity using household survey data: a guide to techniques and their implementation

In 1978 the Declaration of Alma-Alta highlighted the significance of equity as a principle of primary health care. Over the intervening 30 years, equity in health has been a growing concern to policy-makers in both developed and developing countries. It has become a key indicator in monitoring health system performance and social development. According to The world health report 2000, the goals of health systems are to improve equity in health and health levels; to ensure fair health financing; and to be responsive.1 Although definitions of equity and research approaches vary, it is commonly accepted that people should access health care based on their needs and pay for such care based on their financial abilities. This book provides a set of useful tools for measuring: equity in access to health service; financial contributions to health systems; and health outcomes. It complements work that WHO has been undertaking for many years on developing measures of equity in health, such as those relating to catastrophic health expenditures and fairness in financial contributions.2 The book focuses on income-rank-based measures derived from those used in public finance literature. The indices that it introduces consider the effect of income on: access to health care, the financial burden of paying for services, and improved health. The unique feature of the book is its practicality. Its 19 chapters are arranged by topic and are organized into three parts. Part I deals with data issues and the measurement of the key variables in health equity analysis; part II covers quantitative techniques for interpreting and presenting health equity data; and part III outlines the application of these techniques to the analysis of equity in health-care utilization and expenditure. Each chapter provides step-by-step details for researchers to apply the method being described to their own data. Many of the chapters include the Stata software code for estimating the indices of interest and provide examples of how to interpret the results. It functions as a useful textbook and practical guide for students and researchers working on equity in health, while also being an inspiring book for advanced researchers. The limitations of the current methods are discussed and the book includes outlines of research efforts that are under way to improve the methods. The authors of this book are highly respected researchers in the field of health equity. Adam Wagstaff and Eddy van Doorslaer are leaders of the ECuity Project being carried out in 15 OECD countries, and the methodology covered in the book has been applied and further developed in this project. The application of the methodology to developing countries began in the 1990s and it has been used in 15 Asia-Pacific countries and territories covered by the Equitap project, led by Eddy van Doorslaer and Owen O’Donnell. In addition to their many publications on equity in health, the authors of this book also have considerable teaching experience. The full text of the book can be downloaded free from the World Bank website (available at: www.worldbank.org/analyzinghealthequity), increasing its accessibility to researchers in developing countries. A series of lectures, presented as Microsoft Powerpoint slides, accompanies the book on a chapter-by-chapter basis and can also be downloaded from the same website, as can a set of Stata “do” and Microsoft Excel files. In summary, this is a very useful and practical book for students and researchers. I echo the authors in hoping that the book leads to more comprehensive monitoring of trends and evaluation of the impact of health sector reform through the equity lens. Also, I hope that it will stimulate further development of equity measures and encourage collection of better quality data. ■