La medición de desigualdades e inequidades en salud

Decentralization Can Improve Equity, but Can It Be Sustained?

A major theoretical issue about health system reform involving decentralization has been whether it promotes equity of health system funding. An article by the principal author and others in 2003 showed that, under certain conditions and policies, decentralization improved the equity of allocation of financial resources to different income levels of municipalities in Colombia and Chile. Another recurring issue has been whether reforms can be sustained over time. In a follow-up study in 2015, we found that the equity of national allocations was sustained even though the allocation rules for intergovernmental transfers and insurance funding sources had changed, as long as per capita allocation rules were retained. Nevertheless, the wealthier municipalities in Chile were able to increase their own source funding contributing to a larger gap between wealthy and poor municipalities, suggesting that in order to assure continued equity some compensation for these funds be included in intergovernmental transfer rules or that local source funding be restricted by national policy. These reforms may be more likely to be sustained if they become embedded in existing financial systems and if they receive support of status quo constituencies.

[Composite Index of health Inequity for a Middle Income Country]

OBJECTIVE

To develop and validate a composite index of health inequity based on mortality by grouped causes.

METHODS

An ecological study in a middle-income Latin American country, with aggregate indicators available from municipalities and departments, which were selected from health observatories, research groups and health authorities. They were divided into intolerable and "not completely avoidable" according to current scientific progress, and were added in categories: traffic accident, aggression, kidney disease, HIV infection, intestinal parasitic diseases, syphilis, fecal / oral transmission disease, tuberculosis, disease Vector-borne diseases, respiratory disease, cerebral hemorrhagic / ischemic events, maternal mortality, lower mortality 5 years, meningitis. After analysis of main components, a composite index of health inequity (IIS) is obtained for men and women. Internal consistency was evaluated using Cronbach's Alpha coefficient. Concurrent validation was done with proportion of people in Unsatisfied Basic Needs (UBN), Human Development Index (HDI), Life Expectancy at Birth (LEB), among others.

RESULTS

IIS is built showing higher values for women in most municipalities and departments; And for sites with high HDI, high LEB and low UBN. Cronbach's alpha was 0.6688, IIS-men and 0.725, IIS-women.

CONCLUSIONS

An IIS was obtained, is valid and reproducible. The role of big cities in inequities in health is highlighted, probably due to the effect of intolerable health.