Measurement and

Measuring Inequalities
Diana Bowser
Associate Professor of Global Health, Brandeis University
Director of Global Executive Programs, Harvard TH Chan School of Public Health

1
Agenda
• Measurement is important

• Equity and Inequality

• Inequality Measures (3 measures)

• Disability Adjusted Life Year (if we have time)

 The level of equity and
Measurement inequality is really unknown
is important unless we measure them

National averages usually

mask important within country
distributions

3
Inequality Measures
90/10 ratio
% of income held by the lowest X percent
% of income held by the top X percent
Relative poverty (% of people with income <0.6 median income)
Relative mean deviation
Coefficient of variation
Standard deviation of logs
Gini coefficient
Mehran measure
Piesch measure
Kakwani measure
Theil index (GE(a), a = 1)
Mean Log Deviation (GE(a), a = 0)
Entropy index (GE(a), a = -1)
Half (Coeff.Var. squared) (GE(a), a = 2) 4
Equity and Equality are not “equal”

• Equity
• A measure of social justice or fairness
• Equity is measured in terms of gaps from an ideal point
• Policy maker is worried about addressing injustices within by the system
(poverty alleviation programs)
• Inequality or disparities
• Absolute or relative difference between groups (percentages, ratios)
• The distribution of resources across groups
• Policy maker is concerned with reducing differentials between groups
(rich/poor, urban/rural, men/women)
Equity versus Equality
Equity is a social concept based on judgements of fairness
Has this society achieved equity?
Has this society achieved equality?

MINIMUM SOCIALLY
ACCEPTABLE
= EQUITY GAP

= HEALTH CARE/POVERTY ALLEVIATON

Health Inequalities/Disparities Between
Selected Countries

Life Expectancy Maternal Mortality

Equity versus Equality
Can you have equity, but not have equality?

MINIMUM SOCIALLY
ACCEPTABLE

= HEALTH CARE/POVERTY ALLEVIATION

Inequality Measures

• 90/10 ratio
• Decile Ratios (20:80, 30:70, 40:60)
• Coefficient of variation
• Gini coefficient
Dimensions of inequality in health

• Before you choose the measures, you need to decide what inequality
strata and outcome you are interested in comparing
• Inequality metrics
• Gender, race, ethnicity, region, education, occupation, place,
income
• Health Outcomes
• Risk, disease + disability (DALY), wealth, housing
Data: WHO Health Equity Monitor

http://apps.who.int/gho/data/view.wrapper.HE-
VIZ07a?menu=hide
Data: IDB Equity Dashboard
Inequality Measures: 90/10 Ratio

• Simply comparing the strata or outcome of the 90th percentile to that

of the 10th percentiles
• If you know everyone’s income in your population
• What is the income held by the top 10% of your population (90th percentile)?
• What is the income held by the bottom 10% of your population (10th
percentile)?
• Ratio of these two numbers can be compared across countries
Inequality Measures: 90/10 Ratio
Inequality Measures: Decile Ratios

• Comparing the strata or outcome of varying percentiles

• 20:80, 30:70, 40:60
• Allows broader examination of income variation and outcomes across
various categories of income
• Would help you target programs
Inequality Measures: Decile Ratios
BRA COL GTM HND SLV URY
90/10 44.3 36.9 30.3 45.3 13.9 17.5
80/20 18.4 16.9 15.0 19.9 7.9 9.5
70/30 10.8 10.4 9.6 11.7 5.5 6.4
60/40 7.2 7.2 6.7 7.7 4.2 4.7
50/50 5.2 5.2 4.9 5.4 3.3 3.6

Gini 0.526 0.526 0.498 0.522 0.394 0.418

Income* $ 543 $ 405 $ 210 $ 250 $ 295 $ 701

*Avg Monthly Income Per Capita PPP

Inequality Measures: Coefficient of Variation

• Coefficient of Variation = Standard Deviation/mean

• Standard Deviation = measure of how spread out your variables are
• The higher the CV the more spread/more unequal
• The lower the CV the more equal the population
Inequality Measures: Coefficient of Variation
• In health care we do not always want spread; little variation (lower
CV) in hip and knee replacements
Gini Coefficient
• Measures the variation of an indicator within an area or across
different areas
• Most commonly used to express inequality of income or wealth
• We have extended it to health
• 0=perfect equality; everyone has the same income/health
• 1=perfect inequality; one person has all the income/health
Gini Coefficient
• Allows for an examination of income inequality within the entire
population
• Traces out (in the form of a curve—Lorenz Curve) how the percent of
income/outcome rises as we aggregate from the most vulnerable
groups to the highest social group
• X axis=cumulative distribution of income/SES of a population
• Y axis=cumulative proportion of health
% of Under 5 year Lorenz
old mortality
Curve
100%

75%

50%

25%

25% 50% 75% 100%

Household standard of living
% of U5 deaths Lorenz Curve

100%
90%
80%

60%

35%

10% 20% 40% 60% 80% 100%

Household standard of living

% Cumulative
share of U5 deaths Gini Coefficient
Gini
Index Range:
100 G= 0 (equality)
G=1 (inequality)
65 Prefect distribution
A line
35
B Lorenz
20 curve
10

10 20 40 60 80 100
Household standard of living
Gini Coefficient Calculation

Gini coefficient
= | 1- Σ (Li+Li-1)*(Pi-Pi-1) |
where

pi is the difference in the cumulative percent of the

sample ranked by GDP

Li is the corresponding cumulative health risk for the ith

level of U5MR
 How to calculate Gini coefficient for
income and MMR
country GDPP MMR
Haiti 729 488 Gini coefficient
Nicaragua 1836 101
Mexico 10,037 36 =|1-Σ (Li+Li-1)*(Pi-Pi-1)|
Panama 10,766 58
Brazil 11,431 63 where
Uruguay 13,939 18
Chile 14,722 14 pi is the cumulative percent of
Barbados 15,836 31 the sample ranked by GDP
Honduras 2067 67
Argentina 10,568 41 Li is the corresponding
cumulative health risk for the ith
level of GDP
 How to calculate Gini coefficient
country GDPP MMR
Haiti 729 488
Step 1. Order your data
Nicaragua 1836 101
Mexico 10,037 36
and countries on the
Panama 10,766 58 indicator you will use
Brazil 11,431 63 on your x-axis
Uruguay 13,939 18
Chile 14,722 14
Barbados 15,836 31
Honduras 2067 67
Argentina 10,568 41
MMR
Gini Coefficient
Gini
Index
G= 0 = equality
100
G= 1 = inequality

65 Prefect distribution
A line
38
B Lorenz curve
20

4
10 20 40 60 80 100
GDP per Capita
 How to calculate Gini coefficient
country GDPP MMR
Haiti 729 488 Step 1. Order your data
Nicaragua 1836 101 and countries on the
Honduras 2067 67 indicator you will use
Mexico 10,037 36 on your x-axis
Argentina 10,568 41
Panama 10,766 58 Step 2. Calculate the
Brazil 11,431 63
Uruguay 13,939 18 percent contribution to
Chile 14,722 14 the total GDP of each
Barbados 15,836 31 country
 Per capita %GDP_P
GDP (US$)
729/91932=
0.0079
Haiti 729 0.0079
Nicaragua 1836 0.0200
Honduras 2067 0.0225
Mexico 10037 0.1092
Argentina 10568 0.1150
Panama 10766 0.1171
Brazil 11431 0.1243
Uruguay 13939 0.1516
Chile 14722 0.1601
Barbados 15836 0.1723
91932
 Calculate your Pi = is the cumulative percent of the
sample ranked by GDP (becomes x axis of graph)
Per capita %GDP_P CGDPP
GDP (US$)
0.0079 +
0.0200 =
0.0079 0.0079
0.0279
Haiti 729
Nicaragua 1836 0.0200 0.0279
Honduras 2067 0.0225 0.0504 0.0279 +
Mexico 10037 0.1092 0.1596 0.0225 =
Argentina 10568 0.1150 0.2745 0.0504
Panama 10766 0.1171 0.3916
Brazil 11431 0.1243 0.5160
Uruguay 13939 0.1516 0.6676
Chile 14722 0.1601 0.8277
Barbados 15836 0.1723 1.0000
91932
 How to calculate Gini coefficient
GDPP MMR
Haiti 729 488 Step 3. Using the
Nicaragua 1836 101
countries as they were
Honduras 2067 67
Mexico 10,037 36 ordered by GDP,
Argentina 10,568 41 calculate percent
Panama 10,766 58
contribution to the total
Brazil 11,431 63
Uruguay 13,939 18 MMR of each country
Chile 14,722 14
Barbados 15,836 31
 MMR CMMR CMMRP

Haiti 488 0.5322 0.5322

Nicaragua 101 0.1101 0.6423
Honduras 67 0.0731 0.7154
Mexico 36 0.0393 0.7546
Argentina 41 0.0447 0.7993
Panama 58 0.0632 0.8626
Brazil 63 0.0687 0.9313
Uruguay 18 0.0196 0.9509
Chile 14 0.0153 0.9662
Barbados 31 0.0338 1.0000
917
 Per capita MMR (per CGDPP CMMRP
GDP (US$) 100,000 live
births)

Haiti 729 488 0.0079 0.5322

Nicaragua 1836 101 0.0279 0.6423
Honduras 2067 67 0.0504 0.7154
Mexico 10037 36 0.1596 0.7546
Argentina 10568 41 0.2745 0.7993
Panama 10766 58 0.3916 0.8626
Brazil 11431 63 0.5160 0.9313
Uruguay 13939 18 0.6676 0.9509
Chile 14722 14 0.8277 0.9662
Barbados 15836 31 1.0000 1.0000
91932 917
Go back to your definition of Gini

Gini coefficient
=Σ (Li+Li-1)*(Pi-Pi-1)
where

pi is the difference in the cumulative percent of the

sample ranked by GDP

Li is the corresponding cumulative health risk for the ith

level of GDP
Final Coefficient=|1-Σ (Li+Li-1)*(Pi-Pi-1)|
 CGDPP CMMRP A= CMMR+(CMMR- B= CGDPP-(CGDPP-1) (A*B)
1)

Haiti 0.0079 0.5322 0.5322 0.0079 0.0042

Nicaragua 0.0279 0.6423 1.1745 0.0200 0.0235

Honduras 0.0504 0.7154 1.3577 0.0225 0.0305

Mexico 0.1596 0.7546 1.4700 0.1092 0.1605

Argentina 0.2745 0.7993 1.5540 0.1150 0.1786

Panama 0.3916 0.8626 1.6619 0.1171 0.1946

Brazil 0.5160 0.9313 1.7939 0.1243 0.2231

Uruguay 0.6676 0.9509 1.8822 0.1516 0.2854

Chile 0.8277 0.9662 1.9171 0.1601 0.3070

Barbados 1.0000 1.0000 1.9662 0.1723 0.3387

1.7461
-0.7461
0.7461
MMR
Gini Coefficient
Gini
Index
G= 0 = equality
100
G= 1 = inequality

65 Perfect distribution
A line
38
B Lorenz curve
20

4
10 20 40 60 80 100
GDP per Capita
Gini coefficient= |1-1.7461|=0.7461

• Gini coefficient in this case is 0.7461 indicating

high inequality between the selected group of
countries (1=unequal; 0=equal)
Inequality in Maternal/Infant Mortality
• If you had a data on the level of IMR/MMR by income level in a
country before and after an intervention
• Could you tell whether the intervention impacted inequality in
IMR/MMR?
Did the program work?

…it can be concluded that there was more equality across income
groups in this country after (B) the program was implemented than
before (A)
Results: Outpatient Utilization
All Public Outpatient Public Primary Outpatient Public Hospital Outpatient

Public Utilization for All Outpatient Visits Public Utilization for Public Primary Outpatient Visits Public Utilization for Public Hospital Outpatient Visits
1

1
Cumulative Sum of Public Visits

Cumulative Sum of Public Visits

Cumulative Sum of Public Visits

.8

.8

.8
• Public hospital
.6

.6

.6
National

outpatient and
.4

.4

.4
C = 0.112 C = 0.014 C = 0.161
.2

.2

.2
public outpatient
0

0
0 .2 .4 .6 .8 1 0 .2 .4 .6 .8 1 0 .2 .4 .6 .8 1

favor the rich

Cumulative Population by Income Status Cumulative Population by Income Status Cumulative Population by Income Status

45 degree line Outpatient Visits 45 degree line Outpatient Visits 45 degree line Outpatient Visits

Public Utilization for Rural Outpatient Visits Public Utilization for Rural Public Primary Outpatient Visits Public Utilization for Rural Public Hospital Outpatient Visits

1
1

1
• Urban public

Cumulative Sum of Public Visits

.8
Cumulative Sum of Public Visits

Cumulative Sum of Public Visits

.8

.8
Rural
outpatient visits are

.6
.6

.6

.4
more equal (less
.4

.4

C = 0.129 C = 0.082 C = 0.163

.2
.2

.2

pro-rich) than rural

0
0

0 .2 .4 .6 .8 1
0 .2 .4 .6 .8 1 0 .2 .4 .6 .8 1
Cumulative Population by Income Status

public outpatient
Cumulative Population by Income Status Cumulative Population by Income Status
45 degree line Outpatient Visits
45 degree line Outpatient Visits 45 degree line Outpatient Visits

Public Utilization for Urban Outpatient Visits Public Utilization for Urban Public Primary Outpatient Visits Public Utilization for Urban Public Hospital Outpatient Visits
visits for both
1

1
primary and
Cumulative Sum of Public Visits

Cumulative Sum of Public Visits

Cumulative Sum of Public Visits

.8

.8

.8
Urban
hospital care.
.6

.6

.6
.4

.4

.4
C = 0.036 C = 0.042 C = 0.034
.2

.2

.2
0

0
0 .2 .4 .6 .8 1 0 .2 .4 .6 .8 1 0 .2 .4 .6 .8 1
Cumulative Population by Income Status Cumulative Population by Income Status Cumulative Population by Income Status

45 degree line Outpatient Visits 45 degree line Outpatient Visits 45 degree line Outpatient Visits
Disability Adjusted Life Years (DALY)
• Common measurement unit that combines measures of morbidity
and mortality in one unit
• Facilitates the comparison of different health states

42
Uses of DALY
• Used to estimate the burden of disease (GBOD) which has been done
looking across countries using the number of DALYs per country
• Cost-effectiveness analysis to compare different interventions (costs
per DALY avoided)

43
Calculating DALYs
• Gap between current health status and an ideal health situation
where the entire population lives to an advanced age, free of disease
and disability
• Two main components of an analysis of DALYs
• Quality of life reduced due to a disability, time lived with disability (YLD)
• Life time lost due to premature mortality-PYLL, potential years of life lost (YLL)

• DALY = YLL + YLD

• Higher number the worse it is

44
Some Examples
• Premature death-no disability
• A man who dies instantly from a heart attack at age 50
• His normal life expectancy would have been 80
• He loses 30 years but since he dies instantly there is no disability weight
(omitting age weighting and discounting-other weights assigned that we can
discuss)
• DALY = YLL + YLD
• DALY = 30 YLL + 0
• 30 DALY

45
Some Examples
• Just living with disability (no premature death)
• 5 year old who was a victim of a mine explosion
• Say her normal life expectancy would have been 80 and she lives a full life
• Since this happens at age 5 she has 75 years left to live
• But now she is living in a disabled state with a disability weight of 0.3
• DALY = YLL + YLD
• DALY = 0 + 75*0.3
• 22.5 DALY

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Last Example
• Disability and premature death
• A woman who has been deaf since she was 5 and dies prematurely at 50
• Her normal life expectancy would have been 80
• She lives 45 years with disability (disability of deafness is 0.33)
• Loses 30 years prematurely
• DALY = YLL + YLD
• DALY = 30 YLL + 45*0.33
• 44.85 DALY

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Comparison
• Which of these individuals suffers the most/has the worst health
state?

48
DALY Comparison
• 5 year old mine explosion = 22.5 DALYs
• 50 year old man that dies of heart attack = 30 DALYs
• Deaf woman who dies at 50 years old = 44.85 DALYs

• Are these calculations fair?

49
Disability Weights
• Weights assigned to different health states
• Each weight represents a level of health loss
• Ranges from 0 to 1
• 0 is perfect health and no-disability
• 1 is imperfect health equivalent to death

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Methodologies for disabilities weights
• Early GBD studies used Person Trade-Off methodologies to determine
disability weights for a small set of conditions; to panel of experts
• Example question: Say you had to choose between preventing X
number of people from becoming blind to saving 1000 perfectly
healthy girls from premature death (how close is blindness to death?)
• Would you prevent blindness 8000 people or death of 1000?
• Would you prevent blindness 6000 people or death of 1000?
• Would you prevent blindness 3000 people or death of 1000?
• You cannot choose?
• Weight = 1000/X

51
Current Disability Weight Methodologies
• 220 unique health states
• Household surveys in five countries (Bangladesh, Indonesia, Peru,
Tanzania and US)
• Open-access web based survey that uses PTO type questions

52
Disability Weights

53
Table 1. Deaths by age from Disease A
Age Midpoint Deaths from YLL(100) YLL(100) YLD
group Age disease A Disease A Disease A Disease A
Discounted; not Disability
age weighted Weight 0.3
5–9y 7.5 500 37250 14883 1117.5
10 –14 y 12.5 250 17375 7297 521.25
60 – 64 y 62.5 200 3900 2953 117
65 – 69 y 67.5 300 4350 3527 130.5
70 – 74 y 72.5 500 4750 4133 142.5
75 + y 77.5 700 3150 2947 94.5
2450 70775 35741 2123

Used 82 years as the life expectancy of this population

Assumed each person that died, lived their entire life until death in the
disabled state valued at .3 of a life
54
Allocative Decisions with DALY
• DALYs and QALYs are used in cost effectiveness analysis to help us make allocative
decisions?
• Which programs are the most cost effective?
• Where should we invest our scare dollars

• Incremental Cost Effectiveness Ratio (ICER):

!!"#$%&'%() "!*+(,-(%-
# "#
= 𝐼𝐶𝐸𝑅$%&'()*(+,
!"#$%&'%() *+(,-(%-

• General rule: A program is cost effective if it is below the average citizen’s

willingness to pay for these services, often using a country’s GDP/capita as a
benchmark
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Data Visualization:
Available at
http://www.healthdata.org/results/data-
visualizations

We will look at GBD cause pattern examining: death,

YLL,YLD, DALY.
http://vizhub.healthdata.org/gbd-cause-patterns/

We can also compare GBD by country

http://vizhub.healthdata.org/gbd-compare/