Calculated Concentration Index Research Articles

Концентрация на региональных рынках кредитования населения России в условиях роста цифровизации банковских услуг

Due to the dominance of the largest banks, the issue of increasing concentration and monopolisation of the Russian banking sector is discussed in regards to the competition in the industry. The Bank of Russia set the task to increase competition and reduce concentration in the financial sector, including at the regional level. This task can potentially be solved using new financial technologies, digital banking services and remote access technologies. The paper aims to assess the dynamics of concentration in local consumer loan markets in 2015–2021, as well as to answer how new financial technologies and digitalisation can increase competition in the banking sector at the regional level. The study calculated concentration indices and number of banks in consumer loan markets of Russian regions and the country as a whole. To this end, data from the website of the Bank of Russia, both for the retail loan market and the housing loan market, were analysed. The findings show that concentration indices did not decrease during this period. Simultaneously, the regional average number of banks issuing consumer loans decreased less than the total number of banks due to the entry of some banks into new regional markets. This means that the expansion of remaining banks to more regions, including through digitalisation and remote methods, has the potential to increase competition in the industry. However, at this point, only few consumer loans and deposits were provided by banks that do not have branches in a given region. Therefore, there is little evidence to suggest that new financial technologies are already increasing competition in the banking sector of Russian regions.

Socioeconomic inequalities in patient-reported outcome measures of Dutch primary hip and knee arthroplasty patients for osteoarthritis

To study socio-economic inequalities in patient-reported outcomes in primary hip and knee arthroplasty (THA/TKA) patients for osteoarthritis, using two analytical techniques. We obtained data from 44,732 THA and 30,756 TKA patients with preoperative and 12-month follow-up PROMs between 2014 and 2020 from the Dutch Arthroplasty Registry. A deprivation indicator based on neighborhood income, unemployment rate, and education level was linked and categorized into quintiles. The primary outcome measures were the EQ-5D-3L index and Oxford Hip/Knee Score (OHS/OKS) preoperative, at 12-month follow-up, and the calculated change score between these measurements. We contrasted the most and least deprived quintiles using multivariable linear regression, adjusting for patient characteristics. Concurrently, we calculated concentration indices as a non-arbitrary tool to quantify inequalities. Compared to the least deprived, the most deprived THA patients had poorer preoperative (EQ-5D -0.03 (95%CI -0.02, -0.04), OHS -1.26 (-0.99, -1.52)) and 12-month follow-up health (EQ-5D -0.02 (-0.01, -0.02), OHS -0.42 (-0.19, -0.65)), yet higher mean change (EQ-5D 0.02 (0.01, 0.03), OHS 0.84 (0.52, 1.16)). The most deprived TKA patients had similar results. The higher mean change among the deprived resulted from lower preoperative health in this group (confounding). After accounting for this, the most deprived patients had a lower mean change. The concentration indices showed similar inequality effects and provided information on the magnitude of inequalities over the entire socio-economic range. The most deprived THA and TKA patients have worse preoperative health, which persisted after surgery. The concentration indices allow comparison of inequalities across different outcomes (e.g., revision risk).

Inequalities in unmet need for health care services and medications in Brazil: a decomposition analysis

Unmet need is a metric used to assess the performance of health care systems throughout the world. One of the primary objectives of the Brazilian health care system is to identify ways to improve the health outcomes of all citizens. To accomplish this challenging goal, the health care system in Brazil will need to identify and eliminate barriers and provide timely and adequate access to health care services to all. This study assessed the performance of the Brazilian health care system by focusing on the unmet need for health care services and medications. We evaluated the Brazilian National Health Survey data collected in 2013 and 2019 to determine the magnitude of socioeconomic-related inequalities associated with unmet health care needs. Primary contributing factors were identified via decomposition analysis of the calculated concentration indices (CInds). Despite the availability of universal health care, 3.8% and 7.5% of the population in Brazil reported unmet needs for health care services and medications, respectively in the 2019 survey. Although the overall unmet need for medications remained unchanged between 2013 and 2019, CInd analysis revealed significant pro-poor inequalities with respect to unmet needs for both health care services and medications. The overall magnitude of these inequalities was higher in the poorer regions of the country. The use of private health insurance as well as individual health and socioeconomic status contributed significantly to the inequalities associated with unmet needs for health care services and medication throughout Brazil. Policy interventions should focus on improving access to health care services, extending coverage to include pharmaceuticals, and targeting both financial and non-financial barriers to obtaining care, particularly those experienced by the poor and vulnerable populations in Brazil. None.

Catastrophic health care expenditure and impoverishment in Bhutan.

Monitoring financial hardship due to out-of-pocket spending on health care is a critical determinant of progress towards universal health coverage. This study investigates the occurrence, intensity and determinants of catastrophic health expenditure and impoverishment in Bhutan using three rounds of the cross-sectional Bhutan Living Standard Surveys carried out in 2007, 2012 and 2017. We use a composite financial hardship measure defined as households experiencing either catastrophic health expenditure or impoverished/further impoverished due to health spending, or both. We calculated concentration indices to examine socioeconomic inequalities. We used logistic regression to examine the factors associated with financial hardship. We find that, in the context of a significant increase in living standards, there is a sharp increase in the incidence of catastrophic health expenditure (using 40% of capacity to pay) and impoverishment (based on equivalized average food-share-based poverty line) between 2007 and 2017. In 2017, catastrophic health expenditure was estimated at 0.51%, impoverishment at 0.32% and further impoverishment at 1.93% of the population, cumulating to financial hardship affecting 2.55% of the population. Financial hardship particularly burdened rural dwellers and poorer households. Transportation costs almost doubled the risk of facing financial hardship. Households that were poor, had an unemployed head, were larger and had more elderly members had higher odds of financial hardship. This evidence should prompt policy and programmatic interventions to support Bhutan's progress towards universal health coverage.

2022 Multiple-country Monkeypox Outbreak and Its Importation Risk into China: An Assessment Based on the Risk Matrix Method

ObjectiveTo analyze the 2022 multiple-country monkeypox outbreak and assess its importation risk into China. MethodsData was from United States Centers for Disease Control and Prevention. We described the global epidemic and calculated concentration index to measure economic-related inequality. Importation risk into China was evaluated and ranked by using risk matrix method and Borda count method, respectively. ResultsAs of July 29, 2022, of 79 countries or territories, 39 (49.37%, 39/79), 17 (21.52%, 17/79), 6 (7.59%, 6/79), 12 (15.19%, 12/79), and 5 (6.33%, 5/79) country or territories identified cases < 10, 10–, 51–, 101–, and > 1,000. There were economic-related health disparities exist in the distribution of cases (the concentration index = 0.42, P = 0.027), and the inequality disadvantageous to the rich (pro-poor). There were 12 (15.38%, 12/78), 15 (19.23%, 15/78), 6 (7.69%, 6/78), and 45 (57.69%, 45/78) countries or territories with extremely high, high, moderate, and low importation risk. United States and France ranked first with the highest Borda points of 156, and counts of zero. ConclusionOf 78 countries or territories, the key attention need be paid to the United States and France, relatively. As the epidemic progresses, preparing prevention and control measures to further reduce importation risk was crucial.

Economic-related inequalities in hepatitis B virus infection among 115.8 million pregnant women in China from 2013 to 2020.

SummaryBackgroundHepatitis B virus (HBV) infection is a serious global health problem and China has the largest disease burden. Literatures focusing on economic-related inequalities in HBV infection among pregnant women are scarce. We aimed to quantify the economic-related inequalities and the change over time in HBV infection among pregnant women in mainland China from 2013 to 2020 to inform strategies considering economic-related inequalities.MethodsWe used national cross-sectional secondary data of pregnant women in 30 provinces from the National Integrated Prevention of Mother-to-Child Transmission of HIV, Syphilis and Hepatitis B Programme (iPMTCT Programme) from 2013 to 2020. We calculated concentration index and adjusted difference between the rich and the poor in the multivariable generalized estimating equation (GEE) model to measure economic-related inequality, after adjusted other risk factors.FindingsIn this study, a total of 115,789,148 pregnant women of mainland China from 2013 to 2020 were included, the overall hepatitis B surface antigen (HBsAg) prevalence was 6.27% (95%CI: 6.26%-6.28%). The curve lay above the equality line, with the negative value of the concentration index of -0.027, which indicated that economic-related health disparities exist in the distribution of HBV infection and the inequality disadvantageous to the poor (pro-poor). The concentration index showed a trend of fluctuating decline, indicating that economic-related inequalities in HBsAg prevalence were narrowing. The adjust difference between counties with lowest economic level and counties with highest economic level (reference group) were 46.3% in HBsAg prevalence (all p<0.05) in the multivariable GEE model, after controlling other confounders. A significant dose-response relationship was observed between low economic level and high HBsAg prevalence that the adjust difference increased from 15.6% (aOR=1.156, 95% CI: 1.064–1.257) in the high-economic group to 46.3% (aOR=1.463, 95% CI: 1.294–1.824) in the lowest-economic group, compared with the highest-economic group. The association between low economic level and high HBsAg prevalence was stable in the sensitivity analysis.InterpretationHBV infection was more concentrated among population with lower economic status. Economic-related inequalities in HBV infection decreased in the past decade. Our findings highlight the importance of developing equity-oriented policies and targeted interventions to reduce HBV infection among the poor and hard-to-reach populations to achieve the 2030 HBV elimination goals on time.Funding10.13039/501100001809National Natural Science Foundation of China.

Prevalence and inequality in persistent undiagnosed, untreated, and uncontrolled hypertension: Evidence from a cohort of older Mexicans.

Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and substantial gaps in diagnosis, treatment and control signal failure to avert premature deaths. Our aim was to estimate the prevalence and assess the socioeconomic distribution of hypertension that remained undiagnosed, untreated, and uncontrolled for at least five years among older Mexicans and to estimate rates of transition from those states to diagnosis, treatment and control. We used data from a cohort of Mexicans aged 50+ in two waves of the WHO Study on Global AGEing and adult health (SAGE) collected in 2009 and 2014. Blood pressure was measured, hypertension diagnosis and treatment self-reported. We estimated prevalence and transition rates over five years and calculated concentration indices to identify socioeconomic inequalities using a wealth index. Using probit models, we identify characteristics of those facing the greatest barriers in receiving hypertension care. More than 60 percent of individuals with full item response (N = 945) were classified as hypertensive. Over one third of those undiagnosed continued to be in that state five years later. More than two fifths of those initially untreated remained so, and over three fifths of those initially uncontrolled failed to achieve continued blood pressure control. While being classified as hypertensive was more concentrated among the rich, missing diagnosis, treatment and control were more prevalent among the poor. Men, singles, rural dwellers, uninsured, and those with overweight were more likely to have persistent undiagnosed, untreated, and uncontrolled hypertension. There is room for improvement in both hypertension diagnosis and treatment in Mexico. Clinical and public health attention is required, even for those who initially had their hypertension controlled. To ensure more equitable hypertension care and effectively prevent premature deaths, increased diagnosis and long-term treatment efforts should especially be directed towards men, singles, uninsured, and those with overweight.

COVID-19 and Unmet Healthcare Needs of Older People: Did Inequity Arise in Europe?

Background: The disruption in healthcare provision due to the COVID-19 pandemic forced many non-urgent medical treatments and appointments to be postponed or denied, which is expected to have huge impact on non-acute health conditions, especially in vulnerable populations such as older people. Attention should be paid to equity issues related to unmet needs during the pandemic. Methods: We calculated concentration indices to identify income-related inequalities and horizontal inequity in unmet needs due to postponed and denied healthcare in people over 50 during COVID-19, using data from the Survey on Health, Ageing and Retirement in Europe (SHARE). Results: Very few countries show significant income-related inequalities in postponed, rescheduled or denied treatments and medical appointments, usually favouring the rich. Only Estonia, Italy and Romania show a significant horizontal inequity (HI) in postponed healthcare, which apparently favours the poor. Significant pro-rich inequity in denied healthcare is found in Italy, Poland and Greece. Conclusions: Although important income-related horizontal inequity in unmet needs of European older adults during the early waves of the COVID-19 pandemic is not evident for most countries, some of them have to carefully monitor barriers to healthcare access. Delays in diagnosis and treatments may ultimately translate into adverse health outcomes, reduced quality of life and, even, widen socio-economic health inequalities among older people.

Change in full immunization inequalities in Indian children 12\u201323\u2009months: an analysis of household survey data

BackgroundIndia has made substantial progress in improving child health in recent years. However, the country continues to account for a large number of vaccine preventable child deaths. We estimated wealth-related full immunization inequalities in India. We also calculated the degree to which predisposing, reinforcing, and enabling factors contribute to these inequalities.MethodsWe used data from the two rounds of a large nationally representative survey done in all states in India in 2005–06 (n = 9582) and 2015–16 (n = 49,284). Full immunization status was defined as three doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of Bacillus Calmette–Guérin vaccine, and one dose of measles vaccine in children 12–23 months. We compared full immunization coverage by wealth quintiles using descriptive statistics. We calculated concentration indices for full immunization coverage at the national and state levels. Using predisposing, reinforcing, and enabling factors associated with full immunization status identified from the literature, we applied a generalized linear model (GLM) framework with a binomial distribution and an identity link to decompose the concentration index.ResultsNational full immunization coverage increased from 43.65% in 2005–06 to 62.46% in 2015–16. Overall, full immunization coverage in both 2005–06 and 2015–16 in all states was lowest in children from poorer households and improved with increasing socioeconomic status. The national concentration index decreased from 0.36 to 0.13 between the two study periods, indicating a reduction in poor-rich inequality. Similar reductions were observed for most states, except in states where inequalities were already minimal (i.e., Tamil Nadu) and in some northeastern states (i.e., Meghalaya and Manipur). In 2005–06, the contributors to wealth-related full immunization inequality were antenatal care, maternal education, and socioeconomic status. The same factors contributed to full immunization inequality in 2015–16 in addition to difficulty reaching a health facility.ConclusionsImmunization coverage and wealth-related equality have improved nationally and in most states over the last decade in India. Targeted, context-specific interventions could help address overall wealth-related full immunization inequalities. Intensified government efforts could help in this regard, particularly in high-focus states where child mortality remains high.

МЕТОДИКА ОЦІНЮВАННЯ ЕКСПОРТНОГО ПОТЕНЦІАЛУ ВІТЧИЗНЯНИХ ВИРОБНИКІВ СІЛЬСЬКОГОСПОДАРСЬКОЇ ПРОДУКЦІЇ

The article is devoted to the prognostic assessment of increasing the export potential of state agricultural producers. For its complex study, the calculation of indicators of using of this potential at the state level, namely: geographical and commodity structure of exports; level of export orientation; export per person; export quota; intra-industry trade index; Hirschman index, etc. A multi-indicator analysis of the export potential of agri-food markets allowed us to draw the following conclusions. Observing the export of food products in value form, we can say about their growth in 2018 for the following food groups: sugar and confectionery; finished grain products; various food products; residues and waste from the food industry, etc. The analysis of the geographical structure of agricultural exports shows that the largest volumes of such products in 2018, Ukraine exported to India (1856 million USD or 19,68 %), to China (1171 million USD, or 12,41 %), to the Netherlands (1158 million USD, or 12,28 %), to Spain (1040 million USD, or 11,03 %), etc. Thus, India today is the largest export market for Ukraine and the largest trading partner of Eastern Europe. Indicators of the level of export orientation showed that its level of almost all food groups of goods is still quite low. Only some food groups are characterized by a significant level of export orientation, in particular: grain and grain products, the level of export orientation of which increased by 25,0 % compared to 2010, as well as oil, which is characterized by an export orientation of 95,9% in 2018 However, a negative trend is the decrease of the above indicator for milk and dairy products by 0,5 % and fruits, berries and grapes – by 5,5 %. It was found that an important indicator for forecasting the export potential of the state food industry is the index of food export concentration, or Hirschman’s index. The results of the calculations show that the calculated concentration indices for 2010–2018 have, in our opinion, average values, which indicates the average structure of exports of state food products. It is proved that the Hirschman index is used in the analysis of export potential, taking into account the commodity structure of exports of food products.

Magnitude, temporal trends and inequality in global burden of tracheal, bronchus and lung cancer: findings from the Global Burden of Disease Study 2017

IntroductionWe aimed to assess the magnitude, temporal trends and socioeconomic disparity in the global burden of tracheal, bronchus and lung (TBL) from 1990 to 2017, using data extracted from the...

An evolution of socioeconomic related inequality in teenage pregnancy and childbearing in Malawi.

BackgroundTeenage pregnancies and childbearing are important health concerns in low-and middle-income countries (LMICs) including Malawi. Addressing these challenges requires, among other things, an understanding of the socioeconomic determinants of and contributors to the inequalities relating to these outcomes. This study investigated the trends of the inequalities and decomposed the underlying key socioeconomic factors which accounted for the inequalities in teenage pregnancy and childbearing in Malawi.MethodsThe study used the 2004, 2010 and 2015–16 series of nationally representative Malawi Demographic Health Survey covering 12,719 women. We used concentration curves to examine the existence of inequalities, and then quantified the extent of inequalities in teenage pregnancies and childbearing using the Erreygers concentration index. Finally, we decomposed concentration index to find out the contribution of the determinants to socioeconomic inequality in teenage pregnancy and childbearing.ResultsThe teenage pregnancy and childbearing rate averaged 29% (p<0.01) between 2004 and 2015–16. Trends showed a “u-shape” in teenage pregnancy and childbearing rates, albeit a small one (34.1%; p<0.01) in 2004: (25.6%; p<0.01) in 2010, and (29%; p<0.01) in 2016. The calculated concentration indices -0.207 (p<0.01) in 2004, -0.133 (p<0.01) in 2010, and -0.217 (p<0.01) in 2015–16 indicated that inequality in teenage pregnancy and childbearing worsened to the disadvantage of the poor in the country. Additionally, the decomposition exercise suggested that the primary drivers to inequality in teenage pregnancy and child bearing were, early sexual debut (15.5%), being married (50%), and wealth status (13.8%).ConclusionThe findings suggest that there is a need for sustained investment in the education of young women concerning the disadvantages of early sexual debut and early marriages, and in addressing the wealth inequalities in order to reduce the incidences of teenage pregnancies and childbearing.

Health inequality among middle-aged and older people aged 45 years and older in China: a systematic analysis of the China Health and Retirement Longitudinal Study 2011–16

BackgroundChina has a history of promoting measures to achieve equity in health, including efforts to encourage the prevention and control of infectious diseases. However, there are no comprehensive assessments of health inequality for chronic diseases in China. This study aimed to estimate health inequalities for chronic diseases in China and to investigate health system factors that might be correlated with these inequalities. MethodsData for this study were obtained from the China Health and Retirement Longitudinal Study from 2011 to 2016. A total of 50 244 middle-aged and older Chinese adults, aged 45 years and older, were included (16 128 in 2011, 16 646 in 2013, and 17 470 in 2015). Principal component analysis was used to obtain a comprehensive index of socioeconomic status. We calculated concentration indices and corresponding CIs for 14 chronic diseases and comorbidities. We then estimated the Kendall rank correlation coefficient for inequalities and GDP per capita among provinces. FindingsFor ten of the 14 chronic diseases (hypertension, chronic lung disease, heart disease, stroke, kidney disease, stomach and other digestive diseases, emotional or psychiatric problems, memory-related disorders, arthritis or rheumatism, and asthma), prevalences were higher for the poorest tertiles than the richest tertiles. The concentration indices of dyslipidaemia (0·1256 [95% CI 0·1052–0·151]), diabetes or high blood sugar (0·098 [0·0704–0·1244]), and cancer or malignant tumour (0·1305 [0·0528–0·215]) in 2015–2016 were indicative of higher prevalence in people with higher income. Health inequality for chronic lung diseases and eight other diseases grew markedly from 2011 to 2016. Overall, health inequality was lower for urban residents (−0·035 in 2011–2012, −0·036 in 2013–2014, and −0·05 in 2015–2016) than rural residents (−0·053, −0·064, −0·08), and healthy inequality was twice as high among women (−0·051, −0·05, −0·072) than among men (−0·023, −0·02, −0·032). There was a significant inverse association between per capita GDP among provinces and the concentration indices of dyslipidaemia (Kendall's τ=−0·2328, p=0·015), kidney disease (τ=−0·3545, p=0·0077), and asthma (τ=−0·2646, p=0·0079). InterpretationFor many chronic diseases in China, prevalences are higher for people with lower income, and this health inequality is considerable and growing. Policies associated with health equity need to be facilitated to achieve the UN Sustainable Development Goals. FundingThis study was funded by the National Natural Science Foundation of China (81402761), the Foundation Research Project of Jiangsu Province (BK20140361), and the Suzhou Xiangcheng district people's livelihood science and technology project (XJ201655, XJ201706).

Socioeconomic Inequality in Mortality from Road Traffic Accident in Iran.

Although the epidemiology of road traffic accidents (RTAs) and their determining factors have been extensively investigated and debated in Iran, yet there is no data regarding socioeconomic inequalities in mortality from RTA in Iranian context. Since effective interventions to control, management and diminish the negative influence of RTAs would require understanding of numerous contributing factors, including the inequalities We aimed to quantify for the first time the socioeconomic differential in mortality or injuries from RTAs. A cross-sectional study. Overall, 50755 died and injured people from RTA from Mar 2015 to Feb 2016 were evaluated. The data were taken from traffic police department in Iran. We calculated concentration index (CI) to measure socioeconomic inequality in traffic-related mortality & injury. Data were analyzed using Stata software. The mortality and injury rate from accidents was 1130.80 per 10000 accidents. The concentration index was negative for mortality rate (-0.11) of RTA, indicating the higher concentration of the rates among deprived groups. People with low socioeconomic level were more at risk for fatal accidents and injuries. Therefore, specific interventions on road safety should be delivered in the deprived drivers which uses from low safety level vehicles.

Effect of an Intensive Multi-Modal Intervention for Attention-Deficit Hyperactivity Disorder (ADHD) on Equity in Children’s Health and Educational Outcomes

ABSTRACTObjectivesTo determine whether an intensive multi-modal ADHD intervention for children and teens resulted in improved long-term health and educational outcomes and in reduced inequity in these outcomes across the socioeconomic gradient.&#x0D; ApproachWe used administrative data from the healthcare and education sectors in the Population Health Data Repository at the Manitoba Centre for Health Policy. We identified children and teens aged 5-17 who had 3+ visits to the ADHD intervention program between 2007 and 2012. A matched control group was constructed, and confounders were controlled using inverse probability of treatment weights. We examined rates of hospital episodes, emergency department visits, psychostimulant use and adherence, contact with child and family services, and whether the children were in the school grade appropriate to their age. We calculated concentration indices to measure changes in inequity.&#x0D; ResultsThere were 485 children in the ADHD intervention group and 1,884 controls. Children who received the intervention were more likely to be prescribed medication (patients with 1+ prescription(s), rate ratio [RR] 1.21, 95% CI 1.08-1.36) and be adherent to their medication (RR 1.42, 95% CI 1.03-1.96). They were also more likely to be in their age-appropriate grade (RR 1.33, 95% CI 1.09-1.63) compared to controls. Moreover, the intervention was associated with reduced inequity in these outcomes across income deciles. No difference in the rates of hospital episodes or emergency department visits was found, nor in rates of contact with child and family services.&#x0D; ConclusionsA multi-modal ADHD intervention program was associated with increased use and adherence to medication, and may boost academic achievement for vulnerable children and teens. It contributed to closing the equity gap between children from low- and high-income families. ADHD interventions that combine approaches may be more effective than medication alone.

A long way to go - Estimates of combined water, sanitation and hygiene coverage for 25 sub-Saharan African countries.

BackgroundWater, sanitation and hygiene (WASH) are essential for a healthy and dignified life. International targets to reduce inadequate WASH coverage were set under the Millennium Development Goals (MDGs, 1990–2015) and now the Sustainable Development Goals (SDGs, 2016–2030). The MDGs called for halving the proportion of the population without access to adequate water and sanitation, whereas the SDGs call for universal access, require the progressive reduction of inequalities, and include hygiene in addition to water and sanitation. Estimating access to complete WASH coverage provides a baseline for monitoring during the SDG period. Sub-Saharan Africa (SSA) has among the lowest rates of WASH coverage globally.MethodsThe most recent available Demographic Household Survey (DHS) or Multiple Indicator Cluster Survey (MICS) data for 25 countries in SSA were analysed to estimate national and regional coverage for combined water and sanitation (a combined MDG indicator for ‘improved’ access) and combined water with collection time within 30 minutes plus sanitation and hygiene (a combined SDG indicator for ‘basic’ access). Coverage rates were estimated separately for urban and rural populations and for wealth quintiles. Frequency ratios and percentage point differences for urban and rural coverage were calculated to give both relative and absolute measures of urban-rural inequality. Wealth inequalities were assessed by visual examination of coverage across wealth quintiles in urban and rural populations and by calculating concentration indices as standard measures of relative wealth related inequality that give an indication of how unevenly a health indicator is distributed across the wealth distribution.ResultsCombined MDG coverage in SSA was 20%, and combined basic SDG coverage was 4%; an estimated 921 million people lacked basic SDG coverage. Relative measures of inequality were higher for combined basic SDG coverage than combined MDG coverage, but absolute inequality was lower. Rural combined basic SDG coverage was close to zero in many countries.ConclusionsOur estimates help to quantify the scale of progress required to achieve universal WASH access in low-income countries, as envisaged under the water and sanitation SDG. Monitoring and reporting changes in the proportion of the national population with access to water, sanitation and hygiene may be useful in focusing WASH policy and investments towards the areas of greatest need.

Urbanization and Inequality in Hypertension Diagnosis and Medication in Indonesia

Urbanization has been progressing quickly in Indonesia and the consequences on health and health inequities are still not well understood. In this paper, we present new empirical evidence on the differences in the utilization of health care services between rural and urban areas as well as for the respective health inequities. Exploiting the rich data set of the Indonesian Family Life Survey, this paper measures the socioeconomic inequality of health care utilization for the case of the diagnosis of hypertension and its medication. In the Indonesian Family Life Survey, about 45% of all respondents over the age of 39 were found to suffer from hypertension (average systolic blood pressure higher than 140). However, more than half of the people with hypertension have never been diagnosed by a health care professional, and only a small fraction of the people suffering from hypertension are taking medicine for it. Our analysis further shows that diagnosis and medication rates are significantly higher in urban areas than in rural areas, implying that urban areas offer better access to health care services and medicines. Calculating concentration indices, we find that under-diagnosis of hypertension is more prevalent among the poor and this health inequality is more pronounced in rural areas. For the case of medication, we are unable to detect strong evidence of inequality either in rural or urban areas, as most Indonesians with hypertension do not take medicine irrespective of their socioeconomic status. Finally, decomposition analysis shows that the inequality in education, living standards, sanitary conditions, and the possession of vehicle and home appliances can explain a large fraction of the inequality of diagnosis and medication.

Does a pay-for-performance program for primary care physicians alleviate health inequity in childhood vaccination rates?

IntroductionChildhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates.MethodsThe study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1–Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort.ResultsThe PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008, 0.021).ConclusionsThe P4P program had a limited impact on vaccination rates and did not address health inequity.

Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008

BackgroundTurkish health system showed major improvements in health outcomes since initiation of the Health Transition Programme (HTP) in 2003, however little is known regarding income-related inequalities in health care use. The aim of this study was to assess horizontal inequities in health care use in Turkey. MethodsWe used the data from Turkish Health Survey 2008 with 14,655 respondents. We calculated concentration index (C) and horizontal inequity index (HI) to measure the socioeconomic inequalities in utilization of general practitioner (GP) care, specialist care, inpatient care, dental care and emergency care. Contributions of each factor to the observed inequality in health care utilization were assessed through decomposition method. ResultsThere was a significant pro-rich inequality in specialist care and oral health care utilization among individuals as indicated by positive values of HI (=0.1149) and HI (=0.1137), respectively. However, the poor were more likely to utilize emergency care (HI=−0.0461) and inpatient care (HI=−0.0731). GP care was also slightly pro-poor distributed (HI=−0.0042). ConclusionPro-poor income-related inequalities in health care use were largely explained by greater health care need among low income groups, while non-need factors were the main determinants for pro-rich utilization (education, residence area). Inequalities in dental and specialist care linked to low income, low education level and rural areas should be given priority by decision makers to reduce the negative impact of utilization on health. Our results provide some evidence of inequity in 2008, after the introduction of HTP and provide a baseline against which the effects of the new reforms can be assessed.

Use of concentration indices of Hospital Episode Statistics data to monitor inequality in English children and young people (1999–2000 to 2009–10)

BackgroundNew methods are needed to monitor inequality in child health. The National Health Service (NHS) reforms introduced a statutory duty to reduce inequality at a time when UNICEF predicts a substantial increase in child poverty. The government believes that the previous focus on infant mortality was too narrow and that inequality should be measured across a range of indicators that matter most for children and young people. We propose that the concentration index of hospital activity could be a valuable aid to monitor one aspect of inequality with routinely collected data. As illustration, inequality trends in inpatient activity among children and young people for 10 years are analysed. MethodsHospital Episode Statistics data from 1999–2000 and 2009–10 were accessed via the NHS Information Centre. Activity was measured by finished consultant episodes and socioeconomic status by index of multiple deprivation decile, derived from the patient's postcode. The proportion of inpatient activity accounted for by each deprivation decile was calculated, stratifying by sex and age (<1, 1–4, 5–9, 10–14, and 15–19 years). Age-specific population estimates and deprivation scores were then accessed from the Office of National Statistics for all 6781 medium super output areas (MSOAs) in England. Linking and ranking of these data allowed estimation of the proportion of age-specific populations within each deprivation decile. We then calculated concentration indices and standard errors in Microsoft Excel using formulae published by the World Bank (appendix). FindingsComparing the concentration indices, inequality in inpatient care increased for infants (boys in 1999: −0·046, 95% CI −0·042 to −0·050; boys in 2009: −0·071, −0·067 to −0·075; girls in 1999: −0·040, −0·036 to −0·044; girls in 2009: −0·067, −0·063 to −0·071). For children aged 1–4 years, inequality was unchanged for boys (1999: −0·067, −0·065 to −0·069; 2009: −0·066, −0·064 to −0·068) but increased for girls (1999: −0·064, −0·063 to −0·066; 2009: −0·070, −0·068 to −0·072). Inequality decreased in all other groups, most substantially in girls aged 15–19 years (1999: −0·245, −0·243 to −0·247; 2009: −0·183, −0·181 to −0·185). InterpretationThe negative concentration indices suggest that children and young people from more deprived areas account for a greater proportion of inpatient care than do those living in more affluent areas. These data show converging inequality trends in different ages of childhood and adolescence during the 10 year period. Inequality in the need for hospital treatment was lowest in the early years, but increased during the 10 years. Inequality in late adolescence was much greater than at younger ages, especially for girls, but significantly reduced. Despite the policy focus on outcomes that matter most for children and young people, financial constraints have reduced the available data. Concentration indices use routinely collected, robust data and can be calculated at national, regional, or local level. They can conveniently be adapted to assess inequality in specific activity—eg, asthma, injuries, or alcohol-related admissions. Although they are affected by access factors as well as objective patient need, they might be a valuable aid for public health professionals and commissioners who wish to reduce inequality, contain costs of acute care, or interpret regional variation in hospital activity, particularly when used in conjunction with the recently published NHS Atlas of Variation in Healthcare for Children and Young People. FundingNone.