Measuring health inequalities in Albania: a focus on the distribution of general practitioners

Setting

Data on general practitioners by district during 2000–2004 were obtained from the Health Insurance Institute of Albania. All the general practitioners were clinically active, full-time state employees of the Health Insurance Institute of Albania. The study included the average annual population in each of the 36 districts of Albania as reflected by the Albanian National Institute of Statistics for each studied year [10, 11].

Variables

We calculated the general practitioners per 10 000 population ratio (GPPR) and the need-adjusted index (NAI). We used two variables as indicators of population health need: crude mortality rate (CMR) per 10 000 population and consultation rates per population. The NAI was calculated by dividing the GPPR by CMR (NAIM) in the first case, as previously suggested [12, 13], and consultation rates in the second (NAIC). Data concerning mortality figures and consultation rates were obtained from the Albanian National Institute of Statistics [10, 11].

Analyses

In the present study we calculated the level of inequality in the distribution of general practitioners in Albania and the number of general practitioners who must be relocated in order to achieve an equitable distribution. For that purpose we used relative inequality indicators: we plotted the Lorenz curves [14, 15] and calculated the Gini coefficient [14], decile ratio [6], Atkinson index [6] and Robin Hood index [16]. Inequality in all cases was estimated both before and after adjustment for population health need for the studied years. Inequality indices were calculated using the software "DAD" [17]. Graphs were plotted using Microsoft Excel software for Windows.

Inequality indicators

Gini index

The Gini coefficient, one of the most commonly used indicators of inequality [6, 7, 14, 15, 18–21], is derived from the Lorenz curve. The Gini is calculated as the ratio of the area between the Lorenz curve and the 45° line, to the whole area below the 45° line. There are different methods to calculate the Gini index; in the present study we used the formula provided by M. Brown [14]:

G: Gini coefficient

Yi: Cumulative proportion of the health variable (GPs) in the ith district

Xi: Cumulative proportion of the population variable in the ith district

k: total number of districts.

Atkinson index

The Atkinson index is one of the few inequality measures that explicitly incorporate normative judgments about social welfare. The index is derived by calculating the equity-sensitive average studied variable (Y), which is defined as the level of per capita GPs that – if they provides services to everybody – would make total welfare exactly equal to the total welfare generated by the actual distribution of GPs. The index is given by the formula:

where Y _i is the proportion of total number of GPs within the i th group, and ε is the inequality aversion parameter. The parameter ε reflects the strength of society's preference for equality, and can take values ranging from zero to infinity. When ε > 0 there is a social preference for equality, or in other words an aversion to inequality. As ε rises, society attaches more weight to transfers at the lower end of the distribution and less weight to transfers at the top. The more equal the distribution, the closer Y _ε will be to μ, and the lower the value of the Atkinson index. For any given distribution of GPs, the value of I lies between 0 and 1.

Influence of different need adjustments on inequality of GP supply

General practitioners are inequitably distributed in Albania. This becomes apparent when all the relative inequality indices are examined. In order to achieve an equal distribution of general practitioners in all districts of Albania by redistributing the existing human resources, more than one in 10 general practitioners should be relocated from relatively overserved to relatively underserved districts in 2000. After the adjustment for community health needs (mortality), the proportion of general practitioners that should be relocated in order to achieve an equitable distribution of the primary care medical workforce is less. The contrary was true, however, when consultation rates were used as population health needs adjustment. In this case, more – approximately two out of 10 – general practitioners needed to be relocated in order to meet population needs.

International comparisons

Similar studies have been conducted in the past in other countries, such as the USA [19], UK [6, 8], Sweden [7], Japan [20] and Thailand [22]. As previously discussed [21], we should be cautious when comparing inequalities in the distribution of the health workforce between different countries. This is because of the possible differences in health systems and health care provision, differences in geographical divisions and differences in the intracountry cross-boundary flows. Despite all this, we believe that relative inequality could also be used for comparison purposes, either in terms of trends within the same country or for intercountry comparison.

Horev et al. [19], using states as the unit of measure of Gini coefficient, concluded that overall inequality in the distribution of physicians in the USA was rising despite the increase in the ratio of physicians per population over the study period. In their study of the trends in the inequalities in the distribution of GPs in the UK, Hann and Gravelle [8] reported that the inequality in the distribution of GPs, as measured by the Gini coefficient, increased from the mid-1980s to 2003. They concluded that even the increase in the number of GPs did not reduce the maldistribution.

That increasing the supply of human resources does not necessarily lead to decline of the maldistribution has also been reported in a study by Kobayashi and Takaki in Japan [20]. They reported that even though there was a significant increase in the supply of physicians throughout the country, they were still unevenly distributed because they preferred municipalities with higher population density. In a study by Nishiura et al. [22] it was demonstrated that there are inequalities in the distribution of physicians (Gini index = 0.433) by province. As far as Sweden is concerned [7], in 1986 the Gini coefficient for the distribution of GPs was 0.086, while in 2001 it was 0.071.

Methodological implications

It is apparent that the level of inequality in the distribution of GPs in a given year depends on the needs-adjustment method used. In contrast, trends remain unchanged regardless of the relative inequality indicator used. There are, however, some methodological issues that should be taken under consideration. There is a concern as to whether CMR represents an appropriate indicator for measuring a population's need for primary care provision [6]. For that reason we also adjusted for consultation rates, which possibly reflect population need more accurately. Other possible indicators would be measures of self-reported health status or limiting long-term illness, both reflecting more directly than CMR the need for primary care services [6]. Furthermore, analysis and comparison with previous years was not possible, because data on human health resources were destroyed during the 1997 civil war.

Policy implications

Inequality in the distribution of GPs shows a decreasing trend throughout the studied period. This decrease does not seem to have been a result of health policy planning changes, because there is no report of any health policy measure during these years that could have had such an impact. It seems, though, that the underlying reason for this decrease is twofold: first, there is an increase in the overall number of GPs working in Albania (1531 in 2000; 1579 in 2004). This fact alone does not necessarily lead to a more equal distribution in terms of relative inequality measures [6]. It was, however, combined with changes in the number of GPs within each district. Moreover, there has been a change in the population of each district, explained mainly by the migration process towards developed countries, which has been occurring in waves during the last decade.

It seems that without any specific policy change towards the health workforce, a more equal distribution has been achieved through the study period. But this could easily be reversed without an effective policy. When consultation rates are adjusted for, it seems that trends remain stable throughout the study period, and inequalities are high regardless of the indicator used. Effective policies are needed in order to achieve a stable, equitable distribution of the health workforce and increase the opportunity for equal access to primary care services for the Albanian population.

Policy-makers should focus on three main issues that interact with each other, in order to achieve and maintain equality in the distribution of the health workforce [6]. First, increase in the provision of GPs seems to be imperative if improved primary care services provision is to be achieved. Increase in the overall provision of GPs will not necessarily lead to a more equal or equitable distribution of GPs, although all districts will be supplied with more physicians. Second, incentives at the local level could play an important role in health workforce provision. These incentives could be both financial and educational, focused on deprived districts and areas with difficulties in access to health care provision. Finally, policy could also be directed towards entry control in terms of limiting the provision of GPs in areas with oversupply, thus favouring the undersupplied districts.

It is imperative that policy-makers introduce a system that would distribute GPs in a more equal and equitable way, taking into consideration the adjustment for inequality and the interaction of different policies, in a way that would meet the population's health needs.