Analysis of socioeconomic health inequalities using the concentration index

Subjective Well-Being Population Norms and Inequalities in Hungary: A Large Cross-Sectional, Internet-Based Survey

OBJECTIVES

This study aimed to provide subjective well-being (SWB) population norms in Hungary and explore the contribution of explanatory factors of SWB inequality among the Hungarian adult general population.

METHODS

The data originated from a large representative internet-based cross-sectional survey in Hungary, which was conducted in 2020. We applied validated multi-item instruments for measuring SWB, namely Satisfaction With Life Scale (SWLS) and World Health Organization-Five Well-Being Index (WHO-5). Multiple linear regressions were used to examine the relationship between demographic-socioeconomic-health status and both well-being instruments. The concentration index (CI) was used to measure the degree of income-related inequality in well-being.

RESULTS

A total of 2001 respondents were enrolled with the means ± SD WHO-5 scores and SWLS scores of 0.51 ± 0.21 and 0.51 ± 0.23, respectively. Higher household income, higher educational level, better general health status, and absence of chronic morbidity were significant positive predictors for both WHO-5 and SWLS scores. The CI of WHO-5 scores was lower than that of SWLS scores in the total sample (0.0480 vs 0.0861) and in subgroups by gender (male, 0.0584 vs 0.1035; female, 0.0302 vs 0.0726). The positive CI values implied a slight pro-rich SWB inequality in this population. The regression analyses showed a positive association of SWB with having a higher household income and a better general health status.

CONCLUSIONS

This is the first representative study in Hungary to compare population norm of 2 well-being instruments and analyze well-being inequality. Slight pro-rich inequality was found consistently with both SWB measures. Our findings support the need for health and social policies that effectively tackle inequalities in Hungary.

Examining factors contributing to the socioeconomic inequalities in handgrip strength among older adults in India: a decomposition analysis

The purpose of this study was to examine (a) the socioeconomic status (SES)-related inequalities associated with handgrip strength (HGS); and (b) the extent to which several demographic, health, and behavioral factors contributed to such SES disparities in HGS among older adults in India. Data were drawn from the 2017-2018 wave 1 of the Longitudinal Ageing Study of India (LASI). The study sample included 27,707 older adults (13,199 men and 14,508 women) aged 60 years and older. HGS was assessed using a handheld Smedley's Hand Dynamometer with a cut-off of 19.5 kg for men and 12.5 kg for women. Bivariate analysis showed the weighted percentage distribution of weak HGS across respondent characteristics. Multivariate logistic regression assessed factors linked to weak HGS. The concentration curve and index (CCI) was used to determine the inequalities in the prevalence of weak HGS by wealth index scores. Wagstaff's decomposition approach was used to test the contribution of each explanatory variable to weak HGS. Around 9% of older adults in this study reported a weak HGS. It was significantly higher among those aged 80 or older (19.21%) and males (15.55%). Weak HGS was concentrated among older adults from poor SES (CCI: 0.05, p < 0.001). A higher percentage of wealth-based inequality in weak HGS was explained by being underweight (38.83%), belonging to the richest wealth quintile (27.95%), and having a higher subjective social status (32.20%). Moreover, about 23.29% of the inequality in weak HGS was explained by Western region and 22.54% by female gender. Additionally, having a secondary level of education explained a higher percentage (22.09%) of inequality, followed by current working status (- 20.68%). Rural residence (13.08%), limitations in instrumental activities of daily living (IADL) (12.21%), and engagement in yoga-related activities (11.55%) explained a higher percentage of wealth-based inequalities. The findings provide evidence of significant SES-related inequalities in HGS and the contribution of various demographic, health, and behavioral factors to such inequality. As such, public health policies and programs focusing on reducing the burden of disability must consider the contribution of social and economic equity to the preservation of muscle strength among older adults.

Comparing income-related inequality on health service utilisation between older rural-to-urban migrant workers and older rural residents in China: a cross-sectional study

OBJECTIVES

This study quantifies income-related inequalities in health service utilisation of older rural-to-urban migrant workers, by comparison with older rural residents, and identify with factors giving rise to the inequalities.

SETTING

Nationally representative survey conducted in 29 provinces, municipalities and autonomous regions of China.

PARTICIPANTS

952 older rural-to-urban migrant workers and 2676 older rural residents were identified for further analysis.

MAIN OUTCOME MEASURES

The probability of 2 weeks outpatient utilisation and inpatient utilisation.

DESIGN

Coarsened exact matching was used to control the confounding factors between older rural-to-urban migrant workers and their rural counterparts. Concentration index was used to depict the inequality in health service utilisation, and it can be decomposed proportionally into contributions.

RESULTS

The concentration indices of 2 weeks outpatient utilisation of two groups were -0.2061 (95% CI: 0.0193 to 0.1364) and -0.2041 (95% CI: 0.0594 to 0.1469), respectively. The concentration indices of inpatient of two groups were -0.0024 (95% CI: -0.0047 to 0.0639) and -0.1412 (95% CI: 0.0235 to 0.1125), respectively. The contributors of the inequality of 2 weeks outpatient utilisation of two groups were poor self-assessed health (SAH) status and richest group. The contributors of the inequality of inpatient utilisation of the rural elderly were poor SAH, fair SAH and sense of happiness. The horizontal inequality indices for 2 weeks outpatient of two groups were 0.1321 and -0.0.992, respectively. The horizontal inequality indices for the inpatient of two groups were -0.0032 and -0.0396, respectively.

CONCLUSIONS

The results illustrated the existence of a socioeconomic gradient in health service utilisation between older rural-to-urban migrant workers and older rural residents. Our studies provided evidences to take full account of the health service needs, contributing to more reliable understandings of inequalities in the health service utilisation. The results may be referential to identify policy priorities conducive to the health policy reform in the process of active ageing in China.

Socioeconomic Inequalities in the Prevalence of Non-Communicable Diseases among Older Adults in India

Understanding socioeconomic inequalities in non-communicable disease prevalence and preventive care usage can help design effective action plans for health equality programs among India's aging population. Hypertension (HTN) and diabetes mellitus (DM) are frequently used as model non-communicable diseases for research and policy purposes as these two are the most prevalent NCDs in India and are the leading causes of mortality. For this investigation, data on 31,464 older persons (aged 60 years and above) who took part in the Longitudinal Ageing Survey of India (LASI: 2017-2018) were analyzed. The concentration index was used to assess socioeconomic inequality whereas relative inequalities indices were used to compare HTN, DM, and preventive care usage between the different groups of individuals based on socioeconomic status. The study reveals that wealthy older adults in India had a higher frequency of HTN and DM than the poor elderly. Significant differences in the usage of preventive care, such as blood pressure/blood glucose monitoring, were found among people with HTN or DM. Furthermore, economic position, education, type of work, and residential status were identified as important factors for monitoring inequalities in access to preventive care for HTN and DM. Disparities in non-communicable diseases can be both a cause and an effect of inequality across social strata in India.

Wealth disparity and frailty among community-dwelling older adults in India

Background

Due to the vast socioeconomic diversity among its residents, studying health inequality in India is of particular interest. This study aimed to investigate the wealth-based inequalities in physical frailty and to quantify the contributions of potential predictors of frailty to this inequality.

Methods

Data were drawn from the first wave of the Longitudinal Ageing Study in India (LASI) conducted during 2017–18. Logistic regression analysis was used to examine the association between wealth status and frailty. We used the concentration index to measure the magnitude of wealth-related inequality in frailty. A decomposition analysis based on the logit model was used to assess the contribution of each predictor to the total inequality.

Results

The prevalence of physical frailty was significantly higher among the older adults in the poor group than in the non-poor group [Difference (poor vs. non-poor): 6.4%; p < 0.001]. Regression results indicated that older adults in the poorest group were 23% more likely to be physically frail than those in the richest category [Adjusted odds ratio (AOR) = 1.23; 95% confidence interval (CI): 1.11, 1.38]. The overall concentration index of frailty was 0.058 among the older adults, indicating that frailty is more concentrated among older adults with poor wealth status. Body mass index, wealth index, educational status, and region were the major and significant contributors to the socioeconomic status (SES) related inequalities in frailty.

Conclusions

Results suggest the need for formulating effective prevention and intervention strategies to decelerate the development of physical frailty among older adults in India, especially those with poor socioeconomic background.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14434-9.

Socioeconomic inequalities in low birth weight in South Asia: A comparative analysis using Demographic and Health Surveys

Background

Low Birth Weight (LBW) continues to be a prominent universal cause of various short- and long-term health hazards throughout infancy and adulthood. However, no study has revealed the socioeconomic inequalities in LBW among South Asian countries. This study assesses the socioeconomic inequalities among under-five South Asian children with LBW.

Methods

Secondary data were derived from six (Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan) nationally representative South Asian Demographic and Health Surveys conducted between 2015 and 2021, and included 170,547 under-five years of age children. The study employed the concentration curve and concentration index to assess the socioeconomic inequalities of those with LBW. Additionally, mixed-effect logistic regression was applied to determine the factors associated with LBW.

Results

A significant negative concentration index indicates the wealth-related and education-related inequalities of LBW among under-five South Asian children. LBW is highly concentrated in the socio-economically poor section of the society. Our study found statistically significant negative concentration index in all South Asian countries: Afghanistan (Education: -0.108), Bangladesh (wealth: -0.070 & education: -0.083), India (wealth: -0.059 & education: -0.052), Nepal (by wealth: -0.064 & by education: -0.080), and Pakistan (by wealth: -0.080 & by education: -0.095). Findings from the mixed-effects logistic regression model also show that children from the poorest quintiles (AOR: 1.53, 95% CI: 1.41-1.67) and illiterate mothers (AOR: 1.39, 95% CI: 1.29-1.51) had higher odds of being afflicted with LBW compared to the wealthiest quintiles and educated mothers respectively. Women's pregnancy assessments, such as antenatal care utilisation, iron supplementation intake, and normal delivery mode, are significantly correlated with decreased odds of children's LBW.

Conclusion

There exists a strong association between LBW cases and socioeconomic inequalities among South-Asian children below five years of age. This indicates the urgent need for health education and prenatal care services for women from Afghanistan, Bangladesh, India, Nepal, and Pakistan, especially those with lower socioeconomic status.

Socioeconomic inequalities in prostate cancer screening in low- and middle-income countries: An analysis of the demographic and health surveys between 2010 and 2019

INTRODUCTION

Prostate cancer screening is a valuable public health tool in the early detection of prostate cancer. In this study, we aimed to determine the socioeconomic inequalities in the coverage of prostate cancer screening in Low and Middle-Income Countries (LMICs).

METHODS

This was a retrospective analysis of men's recode data files that were collected by the Demographic and Health Surveys (DHS) in LMICs (Armenia, Colombia, Honduras, Kenya, Namibia, Dominican Republic, and the Philippines). We included surveys that were conducted from 2010 to 2020 and measured the coverage of prostate cancer screening and the study population was men aged 40 years or older. Socioeconomic inequality was measured using the Concertation Index (CIX) and the Slope Index of Inequality (SII).

RESULTS

Eight surveys from seven countries were included in the study with a total of 47,863 men. The coverage of prostate cancer screening was below 50% in all the countries with lower rates in the rural areas compared to the urban areas. The pooled estimate for the coverage of screening was 10.4% [95% CI, 7.9-12.9%). Inequalities in the coverage of prostate cancer screening between the wealth quintiles were observed in the Democratic Republic, Honduras, and Namibia. Great variation in inequalities in the coverage of prostate cancer screening between rural and urban residents was observed in Colombia and Namibia.

CONCLUSION

The coverage of prostate cancer screening was low in LMICs with variations in the coverage by the quintile of wealth (pro-rich) and type of place of residence (pro-urban).

POLICY SUMMARY

To achieve the desired impact of prostate cancer screening services in LMICs, it is important that the coverage of screening programs targets men living in rural areas and those in low wealth quintiles.

Socioeconomic and health-related inequalities in major depressive symptoms among older adults: a Wagstaff's decomposition analysis of data from the LASI baseline survey, 2017-2018

OBJECTIVES

To find out the association between socioeconomic and health status and depression among older adults and explore the contributing factors in the socioeconomic and health-related inequalities in late-life depression.

DESIGN

A cross-sectional study was conducted using large representative survey data.

SETTING AND PARTICIPANTS

Data for this study were derived from the baseline wave of the Longitudinal Ageing Study in India conducted during 2017-2018. The effective sample size was 30 888 older adults aged 60 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variable in this study was depression among older adults. Descriptive statistics along with bivariate analysis was conducted to report the preliminary results. Multivariable binary logistic regression analysis and Wagstaff's decomposition were used to fulfil the objectives of the study.

RESULTS

There was a significant difference for the prevalence of depression (4.3%; p<0.05) among older adults from poor (11.2%) and non-poor categories (6.8%). The value of the Concentration Index was -0.179 which also confirms that the major depression was more concentrated among poor older adults. About 38.4% of the socioeconomic and health-related inequality was explained by the wealth quintile for major depression among older adults. Moreover, about 26.6% of the inequality in major depression was explained by psychological distress. Self-rated health (SRH), difficulty in activities of daily living (ADL) and instrumental ADL (IADL) contributed 8.7%, 3.3% and 4.8% to the inequality, respectively. Additionally, region explained about 23.1% of inequality followed by life satisfaction (11.2) and working status (9.8%) for major depression among older adults.

CONCLUSIONS

Findings revealed large socioeconomic and health-related inequalities in depression in older adults which were especially pronounced by poor household economy, widowhood, poor SRH, ADL and IADL difficulty, and psychological distress. In designing prevention programmes, detection and management of older adults with depression should be a high priority, especially for those who are more vulnerable.

Minimizing the Risk of Catastrophic Health Expenditure in China: A Multi-Dimensional Analysis of Vulnerable Groups

Background: In moving toward universal health coverage in China, it is crucial to identify which populations should be prioritized for which interventions rather than blindly increasing welfare packages or capital investments. We identify the characteristics of vulnerable groups from multiple perspectives through estimating catastrophic health expenditure (CHE) and recommend intervention priorities. Methods: Data were from National Health Service Survey conducted in 2003, 2008, and 2013. According to the recommendation of WHO, this study adopted 40% as the CHE threshold. A binary regression was used to identify the determinants of CHE occurrence; a probit model was used to obtain CHE standardized incidence under the characteristics of single and two dimensions in 2013. Results: The total incidence of CHE in 2013 was 13.9%, which shows a general trend of growth from 2003 to 2013. Families in western and central regions and rural areas were more at risk. Factors related to social demography show that households with a female or an unmarried head of household or with a low socioeconomic status were more likely to experience CHE. Households with older adults aged 60 and above had 1,524 times higher likelihood of experiencing CHE. Among the health insurance schemes, the participants covered by the New Rural Cooperative Medical Scheme had the highest risk compared with the participants of all basic health insurance schemes. Households with several members seeking outpatient, inpatient care or with non-communicable diseases were more likely to experience CHE. Households with members not seeing a doctor or hospitalized despite the need for it were more likely to experience CHE. Characteristics such as a household head with characteristics related to low socioeconomic status, having more than two hospitalized family members, ranked high. Meanwhile, the combination of having illiterate household heads and with being covered by other health insurance plans or by none ranked the first place. Cancer notably caused a relatively high medical expenditure among households with CHE. Conclusion: In China, considering the vulnerability of the population across different dimensions is conducive to the alleviation of high CHE. Furthermore, people with multiple vulnerabilities should be prioritized for intervention. Identifying and targeting them to offer help and support will be an effective approach.

Investigation of Economic Inequality in Eye Care Services Utilization and Its Determinants in Rural Regions Using the Oaxaca- Blinder Decomposition Approach

PURPOSE

This study was conducted to determine economic inequality in Eye Care Services Utilization (ECSU) and its determinants in the underserved rural population of Iran.

METHODS

In this population-based study, two underserved regions in the north and southwest of Iran were randomly selected and 3850 individuals living in these regions were invited to participate in the study. ESCU was defined as a history of at least one optometric or ophthalmologic visit during the lifetime. Concentration index (C) was used to evaluate economic inequality and the Oaxaca- Blinder decomposition was applied to decompose the gap between the rich and poor.

RESULTS

Of 3851 individuals, 3314 participated in the study (response rate: 86%). The data of 3094 participants were analyzed. The concentration index was 0.139 (95% CI: 0.218 - 0.590), indicating a pro-rich inequality in the ECSU. The ECSU was 12.38% (10.46 to 14.31) in the poor and 21.15% (18.38 to 23.92) in the rich, and the gap between them was about 90% in favor of the rich (p < 00.001). A marked percentage of the gap was due to the explained portion (b: -11.49; p < .001). The unexplained portion coefficient was b: 2.72 (p: 0.020). In the explained portion, economic status (b: -12.37; p < .001) and age (b: 0.90; p: 0.021) caused inequality in favor of the rich and poor respectively while only economic status (b:-21.1; p < .001) had a significant effect on inequality in favor of the rich in the unexplained portion.

CONCLUSION

There is a significant pro-rich inequality in ECSU in the rural areas of Iran. A major portion of this inequality is related to differences in age and economic status between the two groups. Economic status has direct and indirect effects on inequality in ECSU; therefore, health policymakers should focus on economic improvement to remove the gap.

Income-related inequality in distribution of health human resource among districts of Pakistan

BACKGROUND

Solving inequality of health human resource (HHR) is one of the motives of Pakistan health policies, however, there is still exists a massive quantity of HHR inequality in almost every district of Pakistan. The main goal of this research is to scrutinize the disparity in allocation of human health resources among 114 regions of Pakistan from the year 2012 to 2016 and to expose the foundations and aspects of HHR inequality.

METHODS

The data regarding this research has been obtained from Pakistan Statistical Bureau from the year 2012 to 2016. The statistics had also been collected from United Nation Development Program (UNDP) Pakistan 2017, Pakistan economic surveys, Ministry of finance Islamabad, Pakistan, Pakistan Social and Living standards Measurement (PSLM) Surveys from 2012 to 2016. The information incorporates district wise; the number of specialists and medical caretakers those are doctors and nurses, number of hospitals, number of beds, number of dispensaries, number of beds in dispensaries, urbanization, total estimated GNI per capita, infant mortality rate, geographical area, and population size. The concentration index is used to compute the extent of disparity in allocation of human health resources and decomposition analysis is also carried out to enumerate the contribution of each variable towards total inequality. Furthermore, the horizontal concentration was used to measure the participation of the need variable.

RESULTS

7. The consequent Concentration Indexes (CI) of the doctors and nurses for the year 2016 are 0.60 (95% CI= 0.42, 0.78) and 0.67 (95% CI= 0.42, 0.92) respectively. Decomposition of the concentration indexes exposed that the monetary status accounts are the leading percentage contributor in doctors disparity (77.5, 44.9, 30.6, - 11.6% and 13%) and population size (- 20.7,-10.5%, 4.6, 49.8, 19.7%). Furthermore, the monetary status formulates the superior contribution HHR disparity from nurses inequality (104.5, 75.1, 59.2, - 54.3%, - 40.1%), and population size (- 53.7, - 53.6%, - 36.3, 83.8, 65.3%). Moreover, after the identification of the need variable the Horizontal Concentration Index (HCI) values of doctors from the year 2012 to 2016 are 0.62, 0.64, 0.63, 0.62 and 0.61 and HCI of the nurses are 0.69, 0.70, 0.69, 0.68 and 0.67.

CONCLUSION

The pro-rich disparity in allocation of HHR has been scrutinized from the year 2012 to 2016 among 114 districts of Pakistan. The hard concern of HHR disparity should be concentrated by the complete procedures from a multidisciplinary approach.

Spatiotemporal distribution and socioeconomic disparities of dengue, chikungunya and Zika in two Latin American cities from 2007 to 2017

OBJECTIVE

To assess the presence, pattern and magnitude of socioeconomic inequalities on dengue, chikungunya and Zika in Latin America, accounting for their spatiotemporal distribution.

METHODS

Using longitudinal surveillance data (reported arboviruses) from Fortaleza, Brazil and Medellin, Colombia (2007-2017), we fit Bayesian hierarchical models with structured random effects to estimate: (i) spatiotemporally adjusted incidence rates; (ii) Relative Concentration Index and Absolute Concentration Index of inequality; (iii) temporal trends in RCIs; and (iv) socioeconomic-specific estimates of disease distribution. The spatial analysis was conducted at the neighbourhood level (urban settings). The socioeconomic measures were the median monthly household income (MMHI) for Brazil and the Socio-Economic Strata index (SES) in Colombia.

RESULTS

There were 281 426 notified arboviral cases in Fortaleza and 40 887 in Medellin. We observed greater concentration of dengue among residents of low socioeconomic neighbourhoods in both cities: Relative Concentration Index = -0.12 (95% CI = -0.13, -0.10) in Fortaleza and Relative Concentration Index = -0.04 (95% CI = -0.05, -0.03) in Medellin. The magnitude of inequalities varied over time across sites and was larger during outbreaks. We identified a non-monotonic association between disease rates and socioeconomic measures, especially for chikungunya, that changed over time. The Relative Concentration Index and Absolute Concentration Index showed few if any inequalities for Zika. The socioeconomic-specific model showed increased disease rates at MMHI below US$400 in Brazil and at SES-index below level four, in Colombia.

CONCLUSIONS

We provide robust quantitative estimates of socioeconomic inequalities in arboviruses for two Latin American cities. Our findings could inform policymaking by identifying spatial hotspots for arboviruses and targeting strategies to decrease disparities at the local level.

Socioeconomic inequality in short birth interval in Ethiopia: a decomposition analysis

BACKGROUND

Short birth interval, defined as a birth-to-birth interval less than 33 months, is associated with adverse maternal and child outcomes. Evidence regarding the association of maternal socioeconomic status and short birth interval is inconclusive. Factors contributing to the socioeconomic inequality of short birth interval have also not been investigated. The current study assessed socioeconomic inequality in short birth interval and its contributing factors in Ethiopia.

METHODS

Data from 8448 women collected in the 2016 Ethiopia Demographic and Health survey were included in the study. Socioeconomic inequality in short birth interval was the outcome variable. Erreygers normalized concentration index (ECI) and concentration curves were used to measure and illustrate socioeconomic-related inequality in short birth interval, respectively. Decomposition analysis was performed to identify factors explaining the socioeconomic-related inequality in short birth interval.

RESULTS

The Erreygers normalized concentration index for short birth interval was - 0.0478 (SE = 0.0062) and differed significantly from zero (P < 0.0001); indicating that short birth interval was more concentrated among the poor. Decomposition analysis indicated that wealth quintiles (74.2%), administrative regions (26.4%), and not listening to the radio (5.6%) were the major contributors to the pro-poor socioeconomic inequalities in short birth interval.

CONCLUSION

There was a pro-poor inequality of short birth interval in Ethiopia. Strengthening the implementation of poverty alleviation programs may improve the population's socioeconomic status and reduce the associated inequality in short birth interval.

The Effects of China's Targeted Poverty Alleviation Policy on the Health and Health Equity of Rural Poor Residents: Evidence from Shaanxi Province

Objective: China’s targeted poverty alleviation policy has a profound impact on the country’s rural economic and social development now. This study aimed to learn about the health status and health equity of rural poor residents under the implementation of the policy. It further explores the factors affecting the health status and health equity of rural poor residents in order to contribute to the improvement of the policy. Methods: The data of 1233 rural poor residents were collected from a questionnaire survey from 12 prefecture-level cities and areas of Shaanxi province in 2017, and the self-reported health was used to reflect the health status. A concentration index was applied to measure the inequity of the health status of rural poor residents. The decomposition method was employed to explore the source of health inequity. Results: The results showed that 44.56% of rural poor residents in Shaanxi province had a poor or very poor health status, which was affected by their economic level, gender, age, degree of education, and marital status. Additionally, participation in agricultural industry development, relocation, health poverty alleviation, and basic living standards were significantly correlated with health status. The concentration index of the health status of rural poor residents was 0.0327. The primary contributors to the health inequity in different regions varied, but the economic level and the degree of education were the most significant factors, and the targeted poverty alleviation policy had a significant impact on health equity. Conclusions: The results indicated that the health status of rural poor residents in Shaanxi province was generally poor, there was a pro-rich inequity in the health status, and the degree of education and economic level were the primary factors affecting the health status and health equity. The targeted poverty alleviation policy greatly impacted the health status and health equity of rural poor residents, and the difference in health status would lead to the inequity of benefits of the targeted poverty alleviation policy. In the future, the policy should focus on ensuring the sustainable development ability of rural residents with poor health status.

Inequalities in health-related quality of life and the contribution from socioeconomic status: evidence from Tibet, China

Background

This study aimed to understand the association between socioeconomic status (SES) and Health Related Quality of Life (HRQoL) and the contribution of SES to health inequality among Tibetans of agricultural and pastoral areas (APA) in Tibet, China.

Methods

The data were from Health Survey of Tibetans in APA conducted in 2014. A total of 816 respondents were enrolled for the analysis Multiple linear regression was employed to examine the relationship between SES and HRQoL. Concentration index (CI) was used to measure the degree of health inequality and a Wagstaff-type CI decomposition method was applied to measure the contribution of SES to inequality.

Results

SES had significant association with HRQoL among the Tibetans in APA. The high SES group was more likely to have a higher Eq-5d index (0.77 vs. 0.67, P < 0.001) and VAS (72.94 vs. 62.41, P < 0.001) than the low SES group. The Concentration index of the Eq-5d index and VAS for total sample was 0.022 and 0.026 respectively, indicating a slight pro-rich inequality among this population. The decomposition analyses showed the SES is the main contributor to health inequality and contributed 45.50 and 41.39% to inequality for the Eq-5d index and VAS, respectively.

Conclusion

The results showed SES is positively associated with HRQoL among Tibetans in APA. There was a slight pro-rich inequality in the health of the participants and most health inequality was attributable to SES. This study is helpful in gaining an insight into the HRQoL, health inequality and the relationship between SES and health inequality among Tibetans of APA in China.

Socioeconomic inequalities in the prevalence of chronic diseases and preventive care among adults aged 45 and older in Shaanxi Province, China

Background

Monitoring inequalities in chronic disease prevalence and their preventive care can help build effective strategies to improve health equality. Using hypertension and diabetes as a model, this study measures and decomposes socioeconomic inequalities in their prevalence and preventive care among Chinese adults aged 45 years and older in Shaanxi Province, an underdeveloped western region of China.

Methods

Data of 27,728 respondents aged 45 years and older who participated in the fifth National Health Services Survey conducted in 2013 in Shaanxi Province were analyzed. The relative indexes of inequalities based on Poisson regressions were used to assess disparities in the prevalence of hypertension and diabetes and their preventive care between those with the lowest and the highest socioeconomic status, and the concentration index was used to measure the magnitude of the socioeconomic-related inequality across the entire socioeconomic spectrum. The contribution of each factor to the inequality was further estimated via the concentration index decomposition.

Results

Our results indicate a higher prevalence of hypertension and diabetes among the rich than the poor individuals aged 45 years and older in Shaanxi Province, China. Among individuals with hypertension or diabetes, significant inequalities favoring the rich were observed in the use of preventive care, i.e. in adequate use of medication and of blood pressure/blood glucose monitoring. Furthermore, economic status, educational level, employment status, and urban-rural areas were identified as the key socioeconomic indicators for monitoring the inequalities in the patient preventive care.

Conclusions

Our study suggests that the existence of clear inequities in the prevalence of chronic diseases and preventive care among adults aged 45 and older in Shaanxi Province, China. These inequalities in chronic diseases could be as much a cause as a consequence of socioeconomic inequalities.

Inequalities in basic activities of daily living among older adults: ELSI-Brazil, 2015

OBJECTIVE

To evaluate the magnitude of wealth-related inequalities in basic activities of daily living among community-dwelling Brazilian older adults and to determine the contribution of demographic, socioeconomic, and health conditions to the inequality.

METHODS

We used data from the 2015 Brazilian Longitudinal Study of Aging (ELSI-Brazil) with a nationally representative sample of adults aged 50 years or older. We assessed wealth-related inequalities in basic activities of daily living by the concentration index. Concentration index was decomposed to determine the contribution of demographic, health, and socioeconomic factors to wealth-related inequalities in basic activities of daily living.

RESULTS

The prevalence of disability in the sample was 15.7% (95%CI 14.9–17.6). The concentration index was -0.145 (95%CI -0.194– -0.097), which indicates that disability is concentrated in the poorest individuals in Brazil. Inequalities in basic activities of daily living disability are primarily explained by socioeconomic status (wealth and own education) not by demographic or health factors.

CONCLUSIONS

There are avoidable wealth-related inequities for those with a disability in Brazil. The strong contribution of the socioeconomic status highlights the need for new public health policies that promote equity, universality, and integrality, in addition to the expansion of home nursing public services.

The Relationship Between Human Development Index and Its Components with Thyroid Cancer Incidence and Mortality: Using the Decomposition Approach

BACKGROUND

The link between age specific-rates of thyroid cancer (TC) and human development index (HDI) and also its components can be a new direction for planning by policy makers.

OBJECTIVES

This study aimed at identifying the relationship between TC rates by gender, and HDI and its components in different regions of the world.

METHODS

An ecological study was conducted; the data was obtained from the GLOBOCAN project in 2012. Inequality in TC estimates (age-specific incidence and mortality rates), according to the HDI and its components was calculated. Concentration index (CI) was used to estimate inequality and CI was decomposed to determine contribution of HDI and its components in inequality.

RESULTS

The inequality index (CI) was 0.29 (95% CI: 0.21 - 0.38) and -0.15 (95% CI: -0.23 - 0.06) for incidence and mortality of TC by HDI, respectively. The important contributors in inequality for incidence rates of TC were life expectancy at birth (0.30), mean years of schooling (0.26), and expected years of schooling (0.18). The important contributors in inequality of mortality rates were mean years of schooling (0.19), expected years of schooling (0.17), and urbanization (0.17).

CONCLUSIONS

According to the findings of this study, global inequalities exist in the TC incidence and mortality rates; incidence rates of TC are more concentrated in countries with high HDI, yet inequality index showed that deaths occurred more in disadvantaged countries.

Unequal distribution of health human resource in mainland China: what are the determinants from a comprehensive perspective?

Background

The inequality of health human resource is a worldwide problem, and solving it also is one of the major goals of China’s recent health system reform. Yet there is a huge disparity among cities in mainland China. The aim of this study is to analyze the distribution inequality of the health human resource in 322 prefecture-level cities of mainland China in 2014, and to reveal the facets and causes of the inequalities.

Methods

The data for this study were acquired from the provincial and municipal Health Statistics Yearbook (2014) and Statistical Yearbook (2014), the municipal National Economic Bulletin (2014), and the official websites of municipal governments, involving 322 prefecture-level cities. Meanwhile, Concentration Index was used to measure the magnitude of the unequal distribution of health human resource. A decomposition analysis was employed to quantify the contribution of each determinant to the total inequality.

Results

The overall concentration index of doctors and nurses in mainland China in 2014 was 0.1038 (95% CI = 0.0208, 0.1865) and 0.0785 (95% CI =0.0018, 0.1561). Decomposition of the concentration index revealed that economic status was the primary contributor (58.5% and 57%) to the inequality of doctors and nurses, followed by the Southwest China (19.1% and 18.6%), urbanization level (− 13.1% and − 12.8%), and revenue (8.0% and 7.8%). Party secretaries with Master degree (7.0%, 6.8%), mayors who were 60 years old or above (6.3%, 6.1%) also were proved to be a major contributor to the inequality of health human resource.

Conclusions

There was inequality of health human resource distribution which was pro-rich in mainland China in 2014. Economic status of the cities accounted for most of the existing inequality, followed by the Southwest China, urbanization level, revenue, party secretaries with Master degree, and mayors who were 60 years old or above in respective importance. Besides, the party secretaries and mayors also had certain influence on the allocation of health human resource. The tough issue of HHR inequality should be addressed by comprehensive measures from a multidisciplinary perspective.

Factors contributing to regional inequalities in acute respiratory infections symptoms among under-five children in Nigeria: a decomposition analysis

BACKGROUND

Acute respiratory infections (ARI) are major causes of morbidity and mortality in many low-income countries. Although factors associated with ARI symptoms in children under 5 years of age have been identified; however, variation in their prevalence resulting from regional-specific proximate determinants has received little attention. Therefore, we aim to investigate the specific regional determinants of overall and wealth-related inequality in children having ARI in Nigeria over a decade.

METHODS

We analyzed trends in development of ARI symptoms among children under 5 years of age in Nigeria using nationally representative cross sectional surveys carried out in 2003, 2008 and 2013. Overall- and household wealth index based- inequality in the distribution of prevalence of ARI symptoms were estimated by region using Gini index and Concentration Index, respectively. Multivariate logistic regressions for complex survey and decomposition analysis for both indexes were used to calculate percentual contribution.

RESULTS

We found a decreasing trend in development of ARI symptoms over the decade between regions. Children in South Western region had reduced likelihood of developing the symptoms. Concentration index (CI) for the prevalence of ARI symptoms over the years and across regions had negative values (all p < 0.05). Gini index (GI) varies from 0.21 in North East to 0.62 in South Western region. Furthermore, the mapping showed that the extent at which both inequalities contribute to ARI symptoms prevalence in each region is different. The four major sources of wealth-related inequalities were poor households, no maternal education, biomass cooking, and rural area. The major contributors to overall inequalities were having a child aged 6 to 23 months, having no maternal education, having no vaccination card, and having a high birth order/short birth interval.

CONCLUSIONS

Although ARI prevalence decreased over the decade, it has remained unequally distributed between regions and over the time. The sources of those inequalities are context sensitive. Thus, in future health promotion initiatives, it is imperative to account for regional variations in the distribution of ARI.

Wealth-related inequality in early uptake of HIV testing among pregnant women: an analysis of data from a national cross-sectional survey, South Africa

OBJECTIVES

Wealth-related inequality across the South African antenatal HIV care cascade has not been considered in detail as a potential hindrance to eliminating mother-to-child HIV transmission (EMTCT). We aimed to measure wealth-related inequality in early (before enrolling into antenatal care) uptake of HIV testing and identify the contributing determinants.

DESIGN

Cross-sectional survey.

SETTINGS

South African primary public health facilities in 2012.

PARTICIPANTS

A national-level sample of 8618 pregnant women.

OUTCOME MEASURES

Wealth-related inequality in early uptake of HIV testing was measured using the Erreygers concentration index (CI) further adjusted for inequality introduced by predicted healthcare need (ie, need-standardised). Determinants contributing to the observed inequality were identified using the Erreygers and Wagstaff decomposition methods.

RESULTS

Participants were aged 13 to 49 years. Antenatal HIV prevalence was 33.2%, of which 43.7% came from the lowest 40% wealth group. A pro-poor wealth-related inequality in early HIV testing was observed. The need-standardised concentration index was -0.030 (95% confidence interval -0.038 to -0.022). The proportion of early HIV testing was significantly better in the lower 40% wealth group compared with the higher 40% wealth group (p value=0.040). The largest contributions to the observed inequality were from underlying inequalities in province (contribution, 65.27%), age (-44.38%), wealth group (24.73%) and transport means (21.61%).

CONCLUSIONS

Our results on better early uptake of HIV testing among the poorer subpopulation compared with the richer highlights inequity in uptake of HIV testing in South Africa. This socioeconomic difference could contribute to fast-tracking EMTCT given the high HIV prevalence among the lower wealth group. The high contribution of provinces and age to inequality highlights the need to shift from reliance on national-level estimates alone but identify subregional-specific and age-specific bottlenecks. Future interventions need to be context specific and tailored for specific subpopulations and subregional settings.

Health, Social, and Economic Variables Associated with Depression Among Older People in Low and Middle Income Countries: World Health Organization Study on Global AGEing and Adult Health

OBJECTIVE

Although depression among older people is an important public health problem worldwide, systematic studies evaluating its prevalence and determinants in low and middle income countries (LMICs) are sparse. The biopsychosocial model of depression and prevailing socioeconomic hardships for older people in LMICs have provided the impetus to determine the prevalence of geriatric depression; to study its associations with health, social, and economic variables; and to investigate socioeconomic inequalities in depression prevalence in LMICs.

METHODS

The authors accessed the World Health Organization Study on Global AGEing and Adult Health Wave 1 data that studied nationally representative samples from six large LMICs (N = 14,877). A computerized algorithm derived depression diagnoses. The authors assessed hypothesized associations using survey multivariate logistic regression models for each LMIC and pooled their risk estimates by meta-analyses and investigated related socioeconomic inequalities using concentration indices.

RESULTS

Cross-national prevalence of geriatric depression was 4.7% (95% CI: 1.9%-11.9%). Female gender, illiteracy, poverty, indebtedness, past informal-sector occupation, bereavement, angina, and stroke had significant positive associations, whereas pension support and health insurance showed significant negative associations with geriatric depression. Pro-poor inequality of geriatric depression were documented in five LMICs.

CONCLUSIONS

Socioeconomic factors and related inequalities may predispose, precipitate, or perpetuate depression amongolder people in LMICs. Relative absence of health safety net places socioeconomically disadvantaged older people in LMICs at risk. The need for population-based public health interventions and policies to prevent and to manage geriatric depression effectively in LMICs cannot be overemphasized.

Impact of a peer-counseling intervention on breastfeeding practices in different socioeconomic strata: results from the equity analysis of the PROMISE-EBF trial in Uganda

Background

Undernutrition is highly prevalent among infants in Uganda. Optimal infant feeding practices may improve nutritional status, health, and survival among children.

Objective

Our study evaluates the socioeconomic distribution of exclusive breastfeeding (EBF) and growth outcomes among infants included in a trial, which promoted EBF by peer counselors in Uganda.

Design

Twenty-four clusters comprising one to two communities in Uganda were randomized into intervention and control arms, including 765 mother-infant pairs (PROMISE-EBF trial, 200608, ClinicalTrials.gov no. NCT00397150). Intervention clusters received the promotion of EBF by peer counselors in addition to standard care. Breastfeeding and growth outcomes were compared according to wealth quintiles and intervention/control arms. Socioeconomic inequality in breastfeeding and growth outcomes were measured using the concentration index 12 and 24 weeks postpartum. We used the decomposition of the concentration index to identify factors contributing to growth inequality at 24 weeks.

Results

EBF was significantly concentrated among the poorest in the intervention group at 24 weeks postpartum, concentration index −0.060. The control group showed a concentration of breastfeeding among the richest part of the population, although not statistically significant. Stunting, wasting, and underweight were similarly significantly concentrated among the poorest in the intervention group and the total population at 24 weeks, but showing non-significant concentrations for the control group.

Conclusion

This study shows that EBF can be successfully promoted among the poor. In addition, socioeconomic inequality in growth outcomes starts early in infancy, but the breastfeeding intervention was not strong enough to counteract this influence.

The association between education and induced abortion for three cohorts of adults in Finland

This paper explores whether the likelihood of abortion by education changed over time in Finland, where comprehensive family planning services and sexuality education have been available since the early 1970s. This subject has not previously been studied longitudinally with comprehensive and reliable data. A unique longitudinal set of register data of more than 250,000 women aged 20–49 born in 1955–59, 1965–69, and 1975–79 was analysed, using descriptive statistics, concentration curves, and discrete-time event-history models. Women with basic education had a higher likelihood of abortion than others and the association grew stronger for later cohorts. Selection into education may explain this phenomenon: although it was fairly common to have only basic education in the 1955–59 cohort, it became increasingly unusual over time. Thus, even though family planning services were easily available, socio-economic differences in the likelihood of abortion remained.

Measurement and explanation of socioeconomic inequality in catastrophic health care expenditure: evidence from the rural areas of Shaanxi Province

Background

Policy interventions have been taken to protect households from facing unpredictable economic changes that may cause catastrophe in China. This study aims to estimate the change of overall proportion of households incurring catastrophic health care expenditure (CHE) and its income-related inequality in the rural areas of Shaanxi Province from 2008 to 2013.

Methods

The data were drawn from the National Household Health Service Surveys of Shaanxi Province conducted in the years 2008 and 2013. In total, 3,217 households in 2008 and 13,085 households in 2013 were selected for analysis. A “Capacity to pay” approach was used to measure the incidence of CHE. The concentration index was employed to measure the extent of income-related inequality in CHE. A decomposition method, based on a logit model, was used to decompose the concentration index into its determining components.

Results

From 2008 to 2013, the overall proportion of households incurring CHE dropped from 17.19 % to 15.83 %, while conversely, the inequality in facing CHE strongly increased. The majority of observed inequalities in CHE were explained by household economic status and household size in 2013. In addition, the absence of commercial health insurance and having elderly members were also important contributors to inequality in CHE.

Conclusions

Even though we used a conservative method to measure CHE, the overall proportion of households incurring CHE in Shaanxi Province is still considerably high in both years. Furthermore, there exists a strong pro-rich inequality of CHE in rural areas of Shaanxi Province. Our study suggests that narrowing the gap of household economic status, improving the anti-risk capability of small scale households, establishing prepayment mechanisms in health insurance, strengthening the depth of reimbursement and subsidising vulnerable households in Shaanxi Province are helpful for both reducing the probability of incurring CHE and the pro-rich inequality in CHE.

A Monte Carlo method to estimate the confidence intervals for the concentration index using aggregated population register data

In this paper, we introduce several statistical methods to evaluate the uncertainty in the concentration index (C) for measuring socioeconomic equality in health and health care using aggregated total population register data. The C is a widely used index when measuring socioeconomic inequality, but previous studies have mainly focused on developing statistical inference for sampled data from population surveys. While data from large population-based or national registers provide complete coverage, registration comprises several sources of error. We simulate confidence intervals for the C with different Monte Carlo approaches, which take into account the nature of the population data. As an empirical example, we have an extensive dataset from the Finnish cause-of-death register on mortality amenable to health care interventions between 1996 and 2008. Amenable mortality has been often used as a tool to capture the effectiveness of health care. Thus, inequality in amenable mortality provides evidence on weaknesses in health care performance between socioeconomic groups. Our study shows using several approaches with different parametric assumptions that previously introduced methods to estimate the uncertainty of the C for sampled data are too conservative for aggregated population register data. Consequently, we recommend that inequality indices based on the register data should be presented together with an approximation of the uncertainty and suggest using a simulation approach we propose. The approach can also be adapted to other measures of equality in health.

Decomposing social capital inequalities in health

BACKGROUND

Research has shown network social capital associated with a range of health behaviours and conditions. Little is known about what social capital inequalities in health represent, and which social factors contribute to such inequalities.

METHODS

Data come from the Montreal Neighbourhood Networks and Healthy Aging Study (n=2707). A position generator was used to collect network data on social capital. Health outcomes included self-reported health (SRH), physical inactivity, and hypertension. Social capital inequalities in low SRH, physical inactivity, and hypertension were decomposed into demographic, socioeconomic, network and psychosocial determinants. The percentage contributions of each in explaining health disparities were calculated.

RESULTS

Across the three outcomes, higher educational attainment contributed most consistently to explaining social capital inequalities in low SRH (% C=30.8%), physical inactivity (15.9%), and hypertension (51.2%). Social isolation, contributed to physical inactivity (11.7%) and hypertension (18.2%). Sense of control (24.9%) and perceived cohesion (11.5%) contributed to low SRH. Age reduced or increased social capital inequalities in hypertension depending on the age category.

CONCLUSIONS

Interventions that include strategies to reduce socioeconomic inequalities and increase actual and perceived social connectivity may be most successful in reducing social capital inequalities in health.

Simulation models for socioeconomic inequalities in health: a systematic review

Background: The emergence and evolution of socioeconomic inequalities in health involves multiple factors interacting with each other at different levels. Simulation models are suitable for studying such complex and dynamic systems and have the ability to test the impact of policy interventions in silico. Objective: To explore how simulation models were used in the field of socioeconomic inequalities in health. Methods: An electronic search of studies assessing socioeconomic inequalities in health using a simulation model was conducted. Characteristics of the simulation models were extracted and distinct simulation approaches were identified. As an illustration, a simple agent-based model of the emergence of socioeconomic differences in alcohol abuse was developed. Results: We found 61 studies published between 1989 and 2013. Ten different simulation approaches were identified. The agent-based model illustration showed that multilevel, reciprocal and indirect effects of social determinants on health can be modeled flexibly. Discussion and Conclusions: Based on the review, we discuss the utility of using simulation models for studying health inequalities, and refer to good modeling practices for developing such models. The review and the simulation model example suggest that the use of simulation models may enhance the understanding and debate about existing and new socioeconomic inequalities of health frameworks.

Socioeconomic disparities and the familial coexistence of child stunting and maternal overweight in Guatemala

The double burden of malnutrition, defined here as households with a stunted child and an overweight mother (SCOM), is a growing problem in Guatemala. We explored the magnitude of SCOM and the identification of socio-economic factors associated with this malnutrition duality. From the 2000 Living Standards Measurement Study from Guatemala, we obtained a sample of 2492 households with pairs of children 6-60 months and their mothers (18-49 years) and estimated the prevalence of SCOM. Economic characteristics of this sample were assessed with the Concentration Index (CI). Results revealed higher prevalence of child stunting, but a lower prevalence of maternal overweight among the poor compared to the rich households. Economic inequality in child stunting was greater than economic inequality in maternal overweight (CI=-0.22 vs. +0.14). SCOM pairs were more prevalent among the poor and middle SES groups as compared to the rich households. A multivariate logistic regression model showed that SCOM was more likely to occur in households from the middle consumption quintile than in those from the first quintile (odds ratio=1.7). The findings reported here add new insights into the complex phenomenon observed in households with both extremes of the malnutrition continuum, and support the need for the identification of economic, social and biological interventions aimed at, on the one hand, the prevention of this duality of the malnutrition in those households where it is still non-existent, and on the other hand, to deter or correct the economic, social and biological environments where those mother-child dyads are already affected by such phenomena.

On age-specific variations in income-related inequalities in diabetes, hypertension and obesity

OBJECTIVE

This article examines whether the social health gradients in diabetes, hypertension and obesity for men and women vary significantly across different age groups.

METHODS

We use a pooled sample of German survey data from the years 2002 and 2006 with a total of 87,601 observations. We employ a varying Wagstaff index derived from the class of Gini-type concentration indices to estimate age-specific income-related health inequalities.

RESULTS

We find significant health disadvantages among poor women in mid-age, but no significant age-specific income-related health inequalities among men. Some leveling of inequalities in diabetes is observed.

CONCLUSIONS

The results suggest that variations in age-specific inequalities are unlikely to be a purely artificial result of health-related selection into retirement or mortality.

Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach

BACKGROUND

Mental health is of special importance regarding socioeconomic inequalities in health. On the one hand, mental health status mediates the relationship between economic inequality and health; on the other hand, mental health as an "end state" is affected by social factors and socioeconomic inequality. In spite of this, in examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and then to untangle and quantify the contributions of potential determinants of mental health to the measured socioeconomic inequality.

METHODS

In a cross-sectional observational study, mental health data were taken from an Urban Health Equity Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and covering people aged 15 and above. Principal component analysis was used to measure the economic status of households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and decomposed into its determinants.

RESULTS

The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057). Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence (12.5%) and employment status (6.5%) also proved further important contributors to the inequality.

CONCLUSIONS

Socioeconomic inequalities exist in mental health status in Iran's capital, Tehran. Since the root of this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of mental health.

[Evolution of socioeconomic inequalities in infant and child mortality in Brazil, 1993-20]

In Brazil, infant and child mortality reveal a downward trend. Few studies have investigated the temporal trends in the inequalities of these deaths, at individual level, according to socio-economic status. The scope of this article was to investigate the temporal trends of the magnitude of inequalities in infant and child mortality, between groups defined by maternal education and household income per capita in the 1993-2008 period in Brazil. Microdata from the National Household Sample Survey were used. The inequality measure was the concentration index (CI). It was calculated for infant and child deaths, according to maternal education and household income per capita. During the 2003-2008 period, there was a reduction in inequalities in infant and child mortality, at individual level, and according to maternal education and household income per capita. In 2008, the concentration of child deaths among children whose mothers had less education was higher than the concentration of infant deaths. The CI according to income had greater variability, but also demonstrated a lower concentration of deaths at the end of the period. The measurement of inequalities in health is important for monitoring the population health situation.

The inequity in out-of-pocket expenditures for healthcare in Tajikistan: evidence and implications from a nationally representative survey

OBJECTIVE

Out-of-pocket expenditures (OPE) for healthcare are a widespread and enduring phenomenon in post-communist countries. However, evidence regarding their effect on health equity is limited, especially in the low-income countries of Central Asia. With this in mind, the current paper presents the results of an analysis of the impact of OPE on equity in Tajikistan, one of the poorest transitional countries.

METHODS

Utilizing a sample from a nationally representative household survey, this paper presents a systematic examination of the effect of OPE on equity using concentration curve, quintile analysis and concentration indices. The impact was disaggregated by inpatient and outpatient services, and medication purchase. Further disaggregation was performed according to spatial dimensions, by types of providers, condition or disease, by place of medication purchase, and by type of facility and treatment received.

RESULTS

Overall, OPE in Tajikistan are equally distributed across the population, with the poorest and the wealthiest, in most cases, bearing a similar level of burden. However, the poor bear the heaviest burden in terms of expenditures for medication and other supplies in inpatient services. There is considerable spatial variation in the expenditures burden, with regional variation being more substantial than rural-urban variation. More importantly, the poor experience a larger proportion of burden with regard to expenditures in vital areas such as those of infectious diseases and maternal health.

CONCLUSIONS

While current economic constraints and the ongoing health sector reform in Tajikistan promote OPE for healthcare utilization, the lack of financial protection against the risk of these conditions should be of major concern to policy-makers. In particular, the problems of OPE, which have been found to place a higher burden on the poor, should be taken into consideration during healthcare reform in Tajikistan.