Geospatial Health Equity in the US and India
Brady, Eoghan Séamus
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Background Health equity is a public health priority in the US and globally, as people and their governments view large, objectively measurable health disparities through a lens of social justice. Inequities in child and adult mortality rates can result from sustained systems of public health and healthcare provision that favor members of a certain population, often defined by income or race. Characteristics of a community can be associated with health inequities, including environmental factors and the public health amenities provided by local governments. Geospatial inequities can result from the resources available to local governments and the characteristics of their populations. This analysis investigates the extent and trend in such inequities and the role of local governments in their mitigation. Methods This thesis adapts the concentration index and concentration curve, established economic measures, to a geospatial context. The Inter-County Concentration Index (ICCI) was used to measure inequities in age-adjusted mortality rates from 1972 to 2012 across the US and within each state. In India, the Inter-District Concentration Index (IDCI) was used to measure inequities in under-five mortality rates in 2001 and 2012. Spatial associations between key variables were measured in both the US and India using Moran’s I. To measure the effects of state and county-level expenditures upon state-level inequities in the US, a panel model for 47 states was fitted to data from 1972 to 2012. The effects of state to county intergovernmental transfers were measured, as were the effects of total county spending on social programs. Results ICCI was statistically significant for every year in the national-level analysis and there was a significant trend upwards, with all but one concentration curve statistically dominating that of the previous time period. In 2012, 4.2% of mortality would have to be redistributed from low income to high income counties to achieve equality. State and regional level analyses broadly followed similar trends. ICCIs remained significant after adjusting for county level demographic and economic controls. In India, IDCIs were statistically significant of a larger order. In 2012, 10.7% of under-five mortality would have had to be redistributed from poor to wealthier districts to achieve equality. The national level concentration curve for 2012 dominated that of 2001, as did state-level concentration curves in approximately half of the individual states. In the US, state to local transfers were found to reduce state ICCIs over the period of analysis by a small but statistically significant amount and total social spending by county governments increased ICCIs by a larger amount. Results are robust to a wide range of specifications. Conclusions Geospatial health inequity, as measured by ICCI and IDCI, has been shown to be statistically significant and increasing in both countries of this analysis. Results must be interpreted in the context of absolute levels of mortality and under-five mortality respectively, as policymakers face a potential trade-off between the efficiency and equity of public health investments. The significant effect of intergovernmental transfers in reducing ICCI demonstrates that governments have the tools to improve equity in their populations. These measures provide a mechanism to include geospatial perspective in health equity discourse and to hold governments accountable for their policies as rich places become healthier and poor places become sicker.
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