건강 형평성이란 무엇인가?

건강 불평등이란 무엇인가?

용어

격차 Disparities

변이 Variations

불평등 Inequalities

비형평 Inequities

불평등(inequalities)은 관찰 결과에 근거한다.

• 가난한 사람은 부자보다 일찍 죽는다.

• 낮은 사회계층의 신생아는 출생시 체중이 덜 나간다.

• 흡연자는 비흡연자보다 더 잘 폐암에 걸린다.

• 여성은 남성보다 오래 산다.

비형평(inequities)은 윤리적 판단에 근거한다.

• 가난한 사람은 부자보다 일찍 죽어야 하나?

• 낮은 사회계층의 신생아는 출생시 체중이 덜 나가야 하나?

• 흡연자는 비흡연자보다 더 잘 폐암에 걸려야 하나?

• 여성은 남성보다 오래 살아야 하나?

건강 불평등 측정에서 가치의 문제

Value Judgments in Health Inequality

Measurement

상대 vs 절대 불평등

Relative Risk = Rate in Exposed / Rate in the Unexposed

Rate Ratio

Excess Risk = Rate in Exposed – Rate in the Unexposed

Risk Difference

예를 들어,

3/100 vs. 6/100 : RR = 2, RD = 3/100

5/100 vs. 9/100 : RR = 1.8, RD = 4/100

우리나라 30-59세 남성에서의 교육수준별 연령표준화 사망률의 변화(인구 10만명당)

1990-1991년 2000-2001년

초등학교 이하 1383 1284

대졸 이상 293 211

사망률 비(초졸 이하/대졸 이상) 4.7 6.1

사망률 차이(초졸 이하 - 대졸 이상) 1090 1073

자료원: Khang et al. J Epidemiol Community Health 2004 논문에서 일부 자료를 발췌함.

유럽 국가에서의 45-64세 남성에서의 직업계층간(육체직 대 비육체직) 사망률 비와 차이

국가 사망률 비 사망률 차이(100명당)

스웨덴 1.41 5.6

스페인 1.37 5.8

이탈리아 1.35 6.0

자료원: Mackenbach et al. Lancet 1997 논문에서 일부 자료를발췌함.

“… our data do not support the hypothesis that inequalities in

health are smaller in countries whose social, economic, and health

care policies are more influenced by egalitarian principles, such as

Sweden and Norway.

… our results challenge widely held views on the relations

between societal characteristics and the size of inequalities in

health.”

Mackenbach, et al. Lancet (1997)

Mortality for non-manual and manualworkers in nine European countries.

Ranked by absolute level of mortality of manual workers; age groups 45–59.

Vagero & Erickson, Lancet 1997

How to understand the large relative, but small absolute inequalities in health in Nordic

countries?“I wanted to raise the question of whether or not relative health inequalities should be the yardstick against which social policies are evaluated. Ever since the Black report there has been an assumption that the Nordic countries have, or should have, smaller relative inequalities in health and mortality. While this assumption seemed reasonable and in line with the Nordic countries having lower income inequalities and poverty rates than other countries (as well as being supported by some earlier studies), later and more comprehensive studies did not find clearly lower relative inequalities in the Nordic countries. This, in turn, sparked a discussion about relative versus absolute measures of inequalities. However, any measure of inequalities, absolute or relative, will by definition include the state of health among the privileged, and a positive development for all social groups will often result in stable or even increasing inequalities.”

Olle Lundberg. Int J Epidemiol 2010

“Universal social policies, unlike means-tested ones, are designed for the

population at large and not only for the poorest. By including the broad middle

classes, universal programmes tend to be more sustainable, to have a higher

degree of generosity and a higher quality of services. While this will be

beneficial for the poorer segments of society, especially in comparison with

lean means-tested programmes, the middle classes are likely to benefit also. If

that is actually the case, the types of policies often associated with the social-

democratic type of welfare state will promote better health among lower and

middle classes alike, and hence better public health in general, but not

necessarily lower (relative) inequalities.”

Olle Lundberg. Int J Epidemiol 2010

사망률(인구 10만 명 당) 변화의 가상적 사례: 정책

시행 전후 사회계층별 사망률의 변화에 따른 사망률

차이와 사망률 비의 양상

정책 시행 전 사망률 사망률 감소량 정책 시행 후 사망률

높은 사회계층 100 50 50

낮은 사회계층 200 75 125

사망률 차이 100 75

사망률 비 2 2.5

Inverse Equity Hypothesis

“[F]ollowing the introduction of new

public-health interventions, inequities in

infant and child health status between

richer and poorer groups in society

usually widen before they get smaller and

improve. We have called this the “inverse

equity hypothesis”.

Victora et al. Lancet (2000)

Justification of relative measures

“In these analyses, we have used ratio measures of inequity, rather than

absolute or difference measures. Difference measures will almost

inevitably lead to an apparent reduction in equity gaps, because baseline

rates tend to be already low in absolute terms among the wealthiest.

Ratio scales, however, take baseline levels into account and are thus

more appropriate for deciding whether or not inequity is decreasing.

This is consistent with the use of ratio measures in epidemiological

research.”

Victora et al. Lancet (2000)

Do we need to implement public health programs without concerns about increasing inequalities?

“The pessimistic conclusion is that public-health programmes specifically targeted towards the poorest may not succeed in closing the overall gap in child health within a reasonable time period. However, such programmes may perhaps prevent the inequities from deteriorating even further.”

“We would argue that investment in public-health interventions is a priority in order to prevent inequities becoming worse among poor people in the developing world. … In most less-developed societies, the wealthiest are likely to continue to benefit from the introduction of new health technologies. Unless investment is also made to make existing and new interventions more widely accessible to the poorest, inequity gaps may widen rather than be reduced.”

Victora CG. Lancet 2000

불평등 평가에서 상대비가 더 중요한가?

사망자수Time 1 Time 2

높은 계층 (10,000명), A 100 90

낮은 계층 (10,000명), B 200 185

상대 비(배), B/A 2 2.06

절대 차(명), B-A 100 95

생존자Time 1 Time 2

높은 계층 (10,000명), B 1000 1100

낮은 계층 (10,000명), A 500 575

상대 비(배), B/A 2 1.91절대 차(명), B-A 500 525

상대 vs 절대 지표의 차이는 다른 보건문제들에서도 나타난다

• “The RR of myocardial infarction in the hour after coffee intake was 1.49 (95% CI = 1.17-1.89).”– Baylinet al. Epidemiol.(2006)

• “Average 10-year risk of MI is 10%, so the 1-hour risk is approximately 1/1,000,000. The RR of 1.5 above implies 1 extra hourly MI for each 2,000,000 cups of coffee.”

• “researchers should routinely provide this kind of information to readers: the absolute differences that are implied by the ratios of risks, rates, and prevalences we typically estimate.”– Poole, Epidemiol.(2007)

“Yet the evaluative judgments made about the distributional changes associated with globalization may depend crucially on whether one thinks about inequality in absolute or relative terms. There is no economic theory that tells us that inequality is relative, not absolute. It is not that one concept is right and the other wrong. Nor are they two ways of measuring the same thing. Rather, they are two different concepts. The revealed preferences for one concept over another reflect implicit value judgment about what constitutes a fair division of the gains from growth. Those judgments need to be brought into the open and given critical scrutiny before one can take a well-considered position in this debate.”

Martin Ravallion, Competing Concepts of Inequalityin the Globalization Debate 2004

사회계층(집단)의 수와 크기

2005년도 새국민건강증진종합계획 상의건강 형평성 목표

목표 2001년 현황 2010년 목표

사망률 목표

소득수준별 상위 20%와 하위 20% 간 사망률 차이를 25% 감소시킨다. 2.07배 1.80배

건강행태 목표

소득수준별 상위 20%와 하위 20% 간 건강행태의차이를 25% 감소시킨다.

- 20세 이상 매일 흡연율 8.8% 6.6%

- 20세 이상 적절 운동실천율 10.4% 7.8%

자료원. 2005년도 보건복지부와 한국보건사회연구원이 발간한<새국민건강증진종합계획 수립> 보고서에서 발췌함.

1.001.19

1.491.75

2.07

0.0

0.5

1.0

1.5

2.0

2.5

1분위 2분위 3분위 4분위 5분위

1.001.14

1.371.56

1.80

0.0

0.5

1.0

1.5

2.0

2.5

1분위 2분위 3분위 4분위 5분위

1.001.19

1.491.75 1.80

0.0

0.5

1.0

1.5

2.0

2.5

1분위 2분위 3분위 4분위 5분위

(가)

(나)

소득 상위 20%와 하위 20% 간 사망률 상대비 감소(2.07배 --> 1.80배)의 두 가지 가상적 사례

서로 다른 인구 구성비를 지닌 두 국가에서의직업계층에 따른 사망률 불평등: 가상적 사례

사망률 상대비(가) 국가

인구구성비(%)(나) 국가

인구구성비(%)

비육체직 1 30% 30%

육체직 2 65% 60%

실업자 3 5% 10%

직업계층에 따른 사망률 불평등의 시계열적변화: 가상적 사례

인구 구성비(%) 시점 1에서의사망률 상대비

시점 2에서의사망률 상대비

비육체직 30% 1 1

육체직 65% 2 1.8

실업자 5% 3 3.5

기준 집단

Definition of health inequalities and the reference group

• “Health disparities occur when one group of people has a higher incidence or mortality rate than another, or when survival rates are less for one group than another.”—NCI Center to Reduce Cancer Health Disparities, 2003 (46)

• “A population is a health disparity population if...there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population.”—Minority Health and Health Disparities Research and Education Act of 2000 (47, page 2498)

Definition of health inequalities and the reference group

• “For all the medical breakthroughs we have seen in the past century, there remain significant disparities in the medical conditions of racial groups in this country.... [W]hat we have done through this initiative is to make a commitment—really, for the first time in the history of our government—to eliminate, not just reduce, some of the health disparities between majority and minority populations.”—Dr. David Satcher, Former U.S. Surgeon General, 1999 (48, page 18–19)

• “Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” —NIH Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, Vol. 1, Fiscal Years 2002–2006

기준 집단의 종류

• 가장 높은 사회계층

• 전체 평균

• “Better than best” method– US Healthy People 2010

준거 기준(Norm)을 설정하는 경우

• 형평하다고 여겨지는 수준에서 최소 기준, 표준, 또는 목표치을 설정하는 방법

• 어린이 예방접종률 : 95%를 목표로 설정

• 영아 사망률 기준 : 10/1000 미만

• 출생시 기대 여명 : 80세

• 미달치 또는 부족분(shortfall)이 건강 불평등의 크기

SMR (Standardized Mortality Ratio)의 준거 기준은?

인구 규모가 동일한 4개 지역의 사망률(인구10만 명 당) 변화에 따른 격차 지표의 변화 양

상: 가상적 사례

시점 1에서의 사망률 시점 2에서의 사망률

(가) 지역 300 300(나) 지역 120 120(다) 지역 150 200(라) 지역 250 250평균 205 217.5최상 값 120 120평균값 기준 격차지표 34.1 26.4최상값 기준 격차 지표 94.4 108.3

비고: 격차지표(index of disparity)는 기준 집단의 건강 수준에서 개별 집단의 건강 수준 값의평균적인 차이를 의미하는데, 기준이 되는 집단(평균값 또는 최상값)의 건강 수준과 개별 집단의 건강 수준의 차이 값을 기준 집단의 건강 수준으로 나눈 후, 집단의 수(최상값을 기준으로 할 경우 집단의 수에서 1을 뺀 수)로 나눈 값의 100분율에 해당

지역별 사망률(인구 10만 명 당) 변화의두 가지 가상적 사례

지역별 사망률 A 사례 B 사례

(가) 지역 300 300 250

(나) 지역 120 120 120

(다) 지역 150 150 150

(라) 지역 250 200 250

Prioritarianism vs Utilitarianism

Adapted from John Broome 2008

무엇을 측정할 것인가?

Total health inequality vs socioeconomic

health inequality

Inequality in life expectancy

• International comparison에서의 어려움 극복

• 소득에 대하여 GINI를 계산하는데, 왜 건강

에 대해 불평등을 계산하지 못하느냐?

• 건강에서의 차이는 꼭 사회경제적 변수에

대해서만 기술을 하여야 하는가?

• 경제학 분야에서 연구가 이루어져 옴.

Total Health Inequality

Mortality GINI

Rank of France by World Health Report 2000

육체, 비육체노동자간 국가별 총사망률의 차이

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

245 - 59 year old males

Rat

e R

atio

Mackenbach, et al. Lancet (1997)

Total inequality in mortality vs Socioeconomic mortality

inequality

Houweling TAJ, Kunst AE, Mackenbach JP. Lancet 2001

Total inequality in mortality vs Socioeconomic mortality

inequality

Braveman P, Starfield B, Geiger HJ. BMJ 2001

Asada Y, Hedemann T. Int J Equity Health 2002

연구결과의 차이를 무엇으로

설명하여야 하나?

Khang et al, J Prev Med Public Health, 2005

Changes in relative index of inequality (RII) for all-cause mortality in relation to the economic crisis: use of area-based socioeconomic

position

85

90

95

100

105

110

115RII=1.29 RII=1.26 RII=1.31 RII=1.10 RII=1.10 RII=1.11

Males Females

1995-1997 1998-1999 2000-20011995-1997 1998-1999 2000-2001

Khang et al, J Prev Med Public Health 2005

SMR

P for trends = 0.67P for trends = 0.64

Murray CJL, BMJ 2001

Definition of “Equity in Health”

• International Society for Equity in Health (ISEqH)

• “Absence of potentially remediable, systematic differences in one or more aspects of health across socially, economically, demographically, or geographically defined population groups or subgroups”

“Even if we take inequality as an objective notion, our interest in its measurement must relate to our normative concern with it, and in judging the relative merits of different objective measures of inequality, it would indeed be relevant to introduce normative considerations. At the same time, even if we take a normative view of the measures of income inequality, this is not necessarily meant to catch the totality of our ethical evaluation.”

Amartya Sen, On Economic Inequality, 1973

Key Reference

Harper S, King NB, Meersman SC, Reichman ME, Breen N, Lynch J. Implicit

Value Judgments in the Measurement of Health Inequalities. The Milbank

Quarterly 2010;88(1):4-29.