During the COVID-19 Pandemic, researchers, analysts, policy-makers, and international organisations alike for the first time in history started using multidimensional indices of disadvantage, poverty, and vulnerability (Disadvantage indices) to inform equitable health policies, plans, and interventions around the world. In the US, in an unprecedented way, the majority of states added disadvantage indices to prioritize not only across different populations, but also within them, specifically to address the disparate impact Covid-19 had on communities of color. Disadvantage indices typically integrate relevant variables from census data, relating to, for example, educational attainment, income, or housing situation, to characterize the relative levels of advantage and disadvantage of people living in particular geographic areas. Because one of the consequences of structural racism is that it curtails economic opportunity, in countries such as the US, more disadvantaged communities also comprise larger shares of people of color. Depending on available data, geographic areas can be as small as the household level, or more commonly, neighborhoods of around 1,000 people or higher level administrative units. Indices function by scoring each area on each of the variables that constitute an index, and generating an overall score, that can be used to rank areas by disadvantage, either with the national level, or at the subnational level.
This Symposium brings together theorists, empirical researchers, and practitioners at the forefront of exploring the justification, impact, strengths and weaknesses of disadvantage indices in promoting health equity, social and racial justice.
The Ethical Underpinnings of Multidimensional Measures of Disadvantage and Their Use for Equity in Health
Dr Sridhar Venkatapuram | King's College London | United Kingdom
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Dr Sridhar Venkatapuram | King's College London | United Kingdom
It is plausible to think that many people worldwide would agree that a good life consists of more than one thing: To be happy, to avoid pain and suffering, to have meaningful relationships, to be physically and mentally active, and so forth. Despite this shared global understanding that a good or decent life has many dimensions, public policies and even philosophical theories, reduce human lives to one or few dimensions. Perhaps, most famously, utilitarianism sees happiness or utility as being the one and only thing that is valuable in a life. And, public policies, such as poverty alleviation programs focus narrowly on increasing incomes. Such a narrow focus can also be seen in the domain of health and healthcare. For example, a successful outcome of medical treatment is measured by the impact on disease. Or a public health intervention is considered a success based on its impact on disease control. Whether in philosophical theories, or in real-world practice, reducing the scope of concern to just one or a few dimensions of human lives can do great violence to the other dimensions of what people value in their daily life and life plans.
This presentation presents how the capabilities approach was developed in direct response to various conceptual errors and moral harms that come from viewing human lives and their wellbeing narrowly. It can serve as an analytical framework as well as a normative theory of social justice, or a guide for social action. One important use of the capabilities approach is that its argument that a person’s wellbeing, or quality of life, is made up of multiple dimensions or diverse capabilities, can also be used to assess disadvantage. For example, in an approach that is only focused on disease, two individuals who are blind in one eye are equally disadvantaged. However, if we assess the multiple dimensions of their wellbeing, what they are able to be and do, one may be much worse off than the other. Indeed, we may be interested in the differences in the causes of blindness, the health and non-health consequences, the experiences of being blind, and so forth. To treat them as being equally disadvantaged may be appropriate in some situations, but particularly unjust in other instances. For example, the COVID-19 pandemic and its social movements have made it clear that individuals who are suffering COVID or at higher risk because of socially created disadvantage (ie capability constraints) over lifetimes and generations should be given special attention. This is well inline with long standing arguments from capabilities approach advocates that social causes of disadvantage (death, illness, capability constraints) should be recognized as important social injustices that should be addressed in healthcare, health and social policies.
Using Multidimensional Poverty and Vulnerability Indices to Inform Equitable Health Policies, Plans, and Interventions. The Case of the COVID-19 Pandemic
Jakob Dirksen | University of Oxford | United Kingdom
Dr. Niluka Wijekoon Kannangarage | World Health Organization | Switzerland
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Jakob Dirksen | University of Oxford | United Kingdom
Dr. Niluka Wijekoon Kannangarage | World Health Organization | Switzerland
Health emergencies pose serious threats to human lives and livelihoods, including immediate threats to health, survival, the economy and social life. WHO and partners have been collaborating to explore how the global Multidimensional Poverty Index (global MPI) and national Multidimensional Poverty or Vulnerability Indices (MPIs or MVIs) – could be or are already being used in health emergencies and to address health components of humanitarian crises. This paper provides an overview of their use, with the goal of sharing insights and lessons learned, as well as informing further exploration, based on how MPIs and MVIs have been used in Afghanistan, Colombia, Honduras, Iraq and the South Asia region during the COVID-19 pandemic. MPIs and MVIs capture the overlapping deprivations that people experience. They identify who is particularly disadvantaged or vulnerable by integrating information on the many dimensions of human development into a more holistic overall assessment, going beyond income or consumption. In particular, four ways of using multidimensional measures for health emergency preparedness, response and recovery are presented. (1) Constructing MVIs that capture overlapping vulnerabilities and provide information that identifies the most vulnerable and the main indicators increasing their vulnerability; (2) Using existing MPIs to inform the preparation for, response to and recovery from health emergencies; (3) Merging MPIs or MVIs with aggregate-level data to associate multidimensional measures with other indicators relevant in the context of health emergencies; (4) Microsimulating how people’s vulnerabilities or deprivations might be impacted by shocks, such as those associated with a health emergency. The use of multidimensional measures in the context of health emergencies is new. It is a field that invites further study, discussion and exploration.
Rural Health Access Barriers and Multidimensional Poverty. Towards Progressive Universalism in Primary Health Care
Jakob Dirksen | University of Oxford | United Kingdom
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Jakob Dirksen | University of Oxford | United Kingdom
Theadora Swift Koller | World Health Organization | Switzerland
This paper focuses on health inequities and access to health care among the rural poor. Primary Health Care (PHC) access and barriers thereto are unequally distributed within and across countries. A crucial frontier in overcoming such health inequities is to bridge the poor/non-poor and the urban/rural divide in access to health. Both disadvantage in health more generally and multidimensional poverty as measured by the United Nations global Multidimensional Poverty Index are predominantly rural phenonema. This paper, developed in cooperation with governments and World Health Organization Headquarters and Country Offices will draw on a select set of country case studies using data on rural populations experiencing multidimensional poverty. It profiles evidence on rural health inequities, while highlighting select primary health care deficiencies in rural disadvantaged areas. The paper and the country case studies profiled will support equity-oriented health system strengthening directly by national authorities. They also form part of a wider basket of resources for equity-oriented planning to mainstream a rural health equity focus. Country case studies include Kenya and Mongolia amongst others.
The Use of Disadvantage Indices in Targeted Vaccine Allocation in the US: from focussing on maximizing benefits to actively integrating mitigating inequities
Dr Harald Schmidt
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Dr Harald Schmidt
In the US, Covid-19 exposed major inequities across income, racial and ethnic groups—but in an unprecedented turn, policymakers also deployed a major novel tool to address structural racism and social injustice within, and possibly beyond, the pandemic. Vaccine allocation provides a particularly instructive example. Allocation frameworks are determined by each of the Centers for Disease Control and Prevention’s 64 jurisdictions (50 states, the District of Columbia, five cities and eight territories). We analyzed vaccine allocation plans published by 8 November 2020, tracking updates through to 30 March 2021, spanning the entire period of phased allocation through sequential priority groups. We evaluated whether jurisdictions adopted proposals to reduce inequity using disadvantage indices and related place-based measures. By 30 March 2021, 37 jurisdictions (including 34 states) had adopted disadvantage indices, compared to 19 jurisdictions in November 2020. Uptake of indices doubled from 7 to 14 among the jurisdictions with the largest shares of disadvantaged communities. Five applications were distinguished: (1) prioritizing disadvantaged groups through increased shares of vaccines or vaccination appointments; (2) defining priority groups or areas; (3) tailoring outreach and communication; (4) planning the location of dispensing sites; and (5) monitoring receipt. In separate studies, we also ascertained public support for using disadvantage indices in representative surveys in the general population with n=2,003 participants. While support is higher among Democrats than Republicans, 52% overall approve, and 17% oppose. Additional allocations ranged from 42-52% (means) aligning well with expert recommendations and states’ actual use. The presentation will also present findings from ongoing work, centered on how to identify the appropriate share of additional allocation (whether these be vaccines or other resources) to promote equity, with likely relevance for Covid-19 related efforts in the US as well as other countries with similarly pronounced health disparities across income, racial and ethnic groups.
COVID-19 and Poverty and Vulnerability in Bogotá, Colombia
Dr Mónica Pinilla-Roncancio | Universidad de los Andes | Colombia
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Dr Mónica Pinilla-Roncancio | Universidad de los Andes | Colombia
In March 2020, the National Statistics Office of Colombia (DANE) presented the results of an exercise that merged different data sources to analyse the levels of multidimensional poverty and deprivation of households in the country. This exercise was based on the 2018 National Population and Housing Census (NHPC) to estimate a proxy MPI at the municipal level and was complemented with information from administrative records, the Unique Database of Health Affiliation and the Social Security Register. In addition, DANE designed a Multidimensional Vulnerability Index by matching information from the Individual Records of Health Service Provision with the NHPC using the ID number of each individual. The MVI included information about individuals who were diagnosed with hypertension, diabetes, heart disease, chronic lung disease and cancer. Also included in the MVI was information related to the proportion of people affected by overcrowding or considered to be at medium or high risk: household with members older than 60 and also a member aged 20–29 for high risk, given that younger members are more likely to be working, or aged 30–59 for medium risk. DANE also established a geoportal that allows for the triangulation of information from the MPI and the MVI to inform the COVID-19 pandemic emergency response. The portal includes indicators, such as the percentage of individuals older than 60 and older than 70, the number of medical facilities, the number of hotels and information about mobility for each municipality of Colombia.
This exercise was possible because of the granularity of the data and the fact that recent census data were available and could be used for COVID-19 pandemic response measurement and analyses. In the last few years, Colombia has made an effort to merge different household surveys with administrative records, and the results of these exercises have allowed a better analysis of the situation in the country. During the COVID-19 pandemic, this provided an opportunity to improve understanding of how the pandemic affects different population subgroups and spreads and exacerbates deprivation and vulnerability. Policy implications: DANE analysed the distribution of vulnerabilities associated with the levels of multidimensional poverty of each block and triangulated those with indicators, such as the number of health facilities, percentage of people 60+ living in an area, and also an MVI, which was produced to identify vulnerable areas in the country, to inform an appropriate and well-targeted COVID-19 emergency response. The analysis of merged data sources with MPI and MVI provided information on the different levels of deprivation of individuals and households and how those are correlated with other indicators. Merging household surveys with other administrative records helped to reveal if someone identified as multidimensionally poor was already a beneficiary of social protection programmes or at increased risk of contracting disease.