Equity in Healthcare

Awatef Amer Nordin & Jabrullah Ab Hamid

Centre for Health Equity Research (CHER)
Institute for Health Systems Research (IHSR)
National Institutes of Health (NIH)

Bengkel Pembiayaan Kesihatan anjuran Seksyen National Health Financing, Bahagian Perancangan
19 Oktober 2023
 Social Determinants of Health
Outline Equality vs Equity
Aim of presentation:
Health vs Healthcare
To share a general overview of
equity in healthcare, and some
related projects conducted by the
Centre for Health Equity Research, Approaching Equity in
IHSR
Healthcare

Spotlight: Examples of related

projects
Social Determinants of Health
WHO Definition:

The social determinants of health (SDH) are the non-medical factors that influence health
outcomes. They are the conditions in which people are born, grow, work, live, and age, and the
wider set of forces and systems shaping the conditions of daily life. These forces and systems
include economic policies and systems, development agendas, social norms, social policies and
political systems.

Marmot reports “Knowing the nature and size of the problem and understanding
what works to make a difference must be at the heart of taking
action to achieve a fairer distribution of health.”

sources:
1. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
2. https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review
 Are these
inequalities
acceptable?

source: www.krinstitute.org/assets/contentMS/img/template/editor/KRI%20-%20Full%20Report%20-%20Social%20Inequalities%20and%20Health%20in%20Malaysia_latest.pdf
Equality
vs
Equity
 Not all health differences are health
disparities.

Health disparities – being closely linked with

economic, social or environmental
disadvantage
– leads to health inequities.

Health equity is the strife for the highest

possible standard of health for all people
regardless of backgrounds, and giving
special attention to the needs of those at
greatest risk of poor health.
 Health is….

Health Healthcare is…

Vs
Healthcare
WHITE PAPER: Determinants of Health

The 20% WE can

directly contribute
towards

source: Health White Paper for Malaysia, MOH (2023)

What about Equity y & n e s s
li it ity y o ity
en
ab bi
l li it ati il t
h a b d b ia
da
in HealthCARE? r oa
c
cc
e p t li a o
va m
m
ff
o r
p r o p r

p p A A co A p
A c A
A
Supply side

Access to Ways Healthcare

Perception
of needs Healthcare Healthcare Healthcare Health
access is needs and desire
for care
seeking reaching utilization outcomes

healthcare realised

Demand side

Ability to Ability to Ability to Ability to Ability to

perceive seek reach pay engage

Adapted from Levesque et al 2013

 Inequality dimensions
How can health In pursuit of data for equity analysis

Initiatives towards assessment of equity

equity analysis be in healthcare:
● NHMS Healthcare Demand
● Malaysia Healthcare Demand
approached? Analysis

Spotlight: Financial protection

Spotlight: Geography, Accessibility &

Equity
Inequality Dimensions

Socio-demography
Gender
variables a common
starting point
(but not limited to only these)
Age

Education

Importantly:
Income
Disaggregated data

Health status Research data

Vs
Administrative data
In pursuit of data for health equity analysis…
Evaluation of Data Sources for the SDG and UHC Indicators in MOH Malaysia using WHO's Data Source
Mapping for Inequality Monitoring (NMRR-21-556-58917)

Question:
To what extent are inequality
dimensions available in data
sources used to report
indicators for SDG and UHC
in Malaysia?
Initiatives towards assessment of equity in healthcare:
NHMS HEALTHCARE DEMAND (HCD) MODULE
●Inequality dimensions incorporated in the tool, with data at Figure A:
household and individual levels. Households of B40,
M40, T20 and
●Analysis of sub-groups or areas of priority conducted to having
provide insight into the Malaysian context. supplementary
financial coverage

Figure B: Individuals with co-existing NCDs and hospital care by sector, 2011-2019

Both figures show inequality, however, is it directly translatable to

inequity?
 MALAYSIA HEALTHCARE DEMAND ANALYSIS
Conducted in 2013, among objectives of this analysis
was to evaluate equity in the patterns of healthcare use. Composition of healthcare utilisation by public and private sectors,
by SES quintile, NHMS 2011-2019

NHMS 2011 NHMS 2019

Results at the time (NHMS 2011)

showed that the poorer population Has this changed
accessed public sector to a greater since then?
extent.
Spotlight: Financial protection
People who use health services and pay through out-of-pocket
(OOP) can get into financial difficulties.

● Catastrophic health expenditure:

Financial protection means Spending is compared to a
Spending is high compared to a household's ability-to- threshold, e.g 40% of total
financial obstacles are addressed in obtaining health pay for health care. household spending
care services and
OOP spending is not a source of financial hardship
● Impoverishing health expenditure:
for persons receiving treatment. Spending is compared to a
Spending for healthcare results in household poverty line, e.g lower-middle
falling under poverty line income countries
https://www.who.int/data/gho/data/themes/topics/financial-protection
2
 Households with OOP spending more than 40% of households’ capacity to pay
(%)
Malaysia overall (2019), 2.3%

Overall, Malaysia demonstrates “good” financial protection, however, a closer look by income groups
can reveal existing inequalities.

Analysis of HIES 2019; collaborative work between Planning Division, IHSR, DOSM, WPRO related to updating SDG indicator 3.8.2 (2019).
 HIES
HIES 2014 2016 2019

2016
48,489 54,498
Sample : 49,844
EST Total Household : 7,155,850 7,565,309 8,000,963
EST Total population : 30,360,353 30,608,992 30,713,471

INCIDENCE OF CATASTROPHIC HEALTH EXPENDITURE (%)

AT OOP >40% HOUSEHOLD CAPACITY TO PAY, HIES 2014-2019

2.14 2.27 2.33

Overall

B40
4.71 5.03 5.48

M40
0.54 0.57 0.31

0.19 0.15 0.09

T20
 HIES
HIES 2014 2016 2019

2016
48,489 54,498
Sample : 49,844
EST Total Household : 7,155,850 7,565,309 8,000,963
EST Total population : 30,360,353 30,608,992 30,713,471

INCIDENCE OF IMPOVERISHING HEALTH EXPENDITURE (%)

AT $3.20 A DAY, HIES 2014-2019

Overall
0.27 0.20 0.19

B40
0.60 0.42 0.44

M40
0.13 0.11 0.77

TBD TBD TBD

T20
Healthcare expenditure: Distress financing

● A distress or hardship
health financing occurs
when someone turns to
either borrowing or
selling assets to finance
their healthcare
expenses ne
li
l i ty
ua
eq

Concentration curve
for distress financing in
Malaysia, NHMS 2019.

Mohd Hassan, N.Z.A., Mohd Nor Sham Kunusagaran, M.S.J., Zaimi, N.A. et al. The inequalities and determinants of Households’ Distress Financing on Out-off-Pocket Health expenditure in Malaysia. BMC
Public Health 22, 449 (2022). https://doi.org/10.1186/s12889-022-12834-5
Concentration curve
for selling assets as
source of health
financing, NHMS
2019.

Mohd Hassan, N.Z.A., Mohd Nor Sham Kunusagaran, M.S.J., Zaimi, N.A. et al. The inequalities and determinants of Households’ Distress Financing on Out-off-Pocket Health expenditure in Malaysia. BMC
Public Health 22, 449 (2022). https://doi.org/10.1186/s12889-022-12834-5
 Concentration curves for borrowing with and without interest as a source for health
financing, NHMS 2019.

y l in
e
y line
ual i t ual i t
eq eq

Mohd Hassan, N.Z.A., Mohd Nor Sham Kunusagaran, M.S.J., Zaimi, N.A. et al. The inequalities and determinants of Households’ Distress Financing on Out-off-Pocket Health expenditure in Malaysia. BMC
Public Health 22, 449 (2022). https://doi.org/10.1186/s12889-022-12834-5
 Spotlight: Geography, Accessibility & Equity
Project: Situational analysis of MOH hospital Emergency Departments (ED) in Malaysia and geospatial
accessibility to surrounding healthcare facilities (NMRR ID-23-02129-WVC)

“An equity map combines information about how data related to specific issues are spatially distributed and
how they overlap with other demographic, economic and social vulnerability data.”
How We Can Do More with GIS
https://www.directionsmag.com/article/11217

Our starting point:

● Spatial distribution of healthcare facilities, with
hospitals as the focal point to visualise the
availability of surrounding public and private
providers

• Overlapping with selected population characteristics

to observe existing inequalities, which can lead
inequitable access to healthcare
To illustrate,

Selangor:
Hospital Tuanku Ampuan
Rahimah (HTAR), Klang

Map I: Public and Private

facilities

Network of healthcare
facilities within proximity
Selangor:
Hospital Tuanku Ampuan
Rahimah (HTAR), Klang
Map II: Population
characteristics - density

Legend:
Population density, per 2-km grid
None
<=500
>500 - 1,000
>1,000 - 5,000
>5,000 - 10,000
>10,000 - 15,000
>15,000 - 20,000
>20,000

GP (PeKA B40)
GP (Skim Perubatan Madani)
Private hospital
Klinik Kesihatan
Klinik Komuniti
Radius buffer (5km)
Radius network (5km)
Selangor:
Hospital Tuanku Ampuan
Rahimah (HTAR), Klang
Map III: Population
characteristics - older adults
(65+)

Legend:
Proportion of older adults (%)
<=3
>3 - 5
>5 - 7
>7 - 10
>10 - 13
>13

GP (PeKA B40)
GP (Skim Perubatan Madani)
Private hospital
Klinik Kesihatan
Klinik Komuniti
Radius buffer (5km)
Radius network (5km)
Sabah:
Hospital Queen Elizabeth 1

Map I: Public and Private

facilities
Sabah:
Hospital Queen Elizabeth 1

Map II: Population

characteristics - density

Legend:
Population density, per 2-km grid
None
<=500
>500 - 1,000
>1,000 - 5,000
>5,000 - 10,000
>10,000 - 15,000
>15,000 - 20,000
>20,000

GP (PeKA B40)
GP (Skim Perubatan Madani)
Private hospital
Klinik Kesihatan
Klinik Komuniti
Radius buffer (5km)
Radius network (5km)
Sabah:
Hospital Queen Elizabeth 1

Map III: Population

characteristics - older adults
(65+)

Legend:
Proportion of older adults (%)
<=3
>3 - 5
>5 - 7
>7 - 10
>10 - 13
>13

GP (PeKA B40)
GP (Skim Perubatan Madani)
Private hospital
Klinik Kesihatan
Klinik Komuniti
Radius buffer (5km)
Radius network (5km)
In Contrast,
Map I HTAR Klang Map I HQE Sabah

Quantity and density of healthcare facilities differ, what are the possible implications of equity?
In Contrast,
Map II HTAR Klang Map II HQE Sabah

Relative to population density, are facilities “adequate”?

In Contrast,
Map III HTAR Klang Map III HQE Sabah

Relative to density of aging population, are services “adequate”?

Spatial analysis and possible implications on equity in
healthcare
● Spatial analysis provided a starting point of
observing possible inequalities. However, Maps
I,II,III focused on small areas of 5km radius.

● In line with IHSR involvement in discussions

related to PeKa B40, preliminary exploration of
data was done, using Peka B40 clinics as a case
example.

Objective of the presentation:

To assess spatial distribution and confluence of Peka B40
clinics with population characteristics; northern region
was visualised.
Clinics’ spatial distribution vs. population density

Distribution of the PeKa B40

clinics aligned with the population
distribution
- populated areas; availability

33
Pockets of underserved areas
observed in several districts
- populated areas; availability

IHSR, 2023. Spatial distribution and confluence of PeKa B40 clinics with population density in the
northern region of Malaysia. Presented (oral) at 23rd National Public Health Colloquium 2023.
Swiss-Garden Hotel Bukit Bintang, Kuala Lumpur, Malaysia. 22-23 August 2023.
https://www.researchgate.net/publication/373433686
Overlay analysis vs. poverty

DUN with >10% incidence of poverty

Potential areas that need

attention can be identified (sites
for PeKA B40 enrollment?)
- Areas with high potential users (poor
34 population) but no PekA B40 clinics
nearby

● Poverty Line Income (PLI) defined as household income <RM2,208, based

on HIES 2019 conducted by Department of Statistics Malaysia (DOSM).
● Spatial data on poverty – Based on open data DOSM (
https://kawasanku.dosm.gov.my/)
 Any further questions or
feedback?

The 20% WE can

directly contribute
towards
Summary: Equity in Healthcare
Principle concept: There are variations between groups (health disparities)
that can compromise health outcomes (health inequity)

Aim of equity-related analysis

Identify and assess health disparities
to pursue improvement of the health system

Perspective
• Inequality dimensions
• For healthcare, many aspects with access being
one of them

Data considerations
• Disaggregated data
• Research and Administrative data

Policy relevant
• Prioritised based on
stakeholder priorities
Team members:
Fathullah Iqbal Ab Rahim,
Suhana Jawahir,
Adilius Manual
Sarah Nurain Mohd Noh
Nur Elina Abdul Mutalib
Thank you
Appreciation also goes to
Sondi Sararaks for content review.