A resource-sensitive framework for defining and measuring equality of opportunity in health. Theoretical analysis and empirical applications to Italian data.

We offer a new methodology for defining and measuring disparities in the distribution of health opportunities. We apply such a methodology to Italian data. In particular, we will measure whether and to what extent the adoption of regional plans for budget deficit reduction in the health sector (so called Piani di rientro), have affected the distribution of health opportunities, thus fostering patients’ outflow from southern regions. Our methodological approach is novel. The existing health literature adopts an ex-post approach that is not able to disentangle the opportunities individuals enjoy, from the effective utilization of health services. This is a relevant shortcoming. As utilization also depends on individuals’ preferences and attitudes, conceptualizing (hence measuring) opportunities as utilization is misleading. The existing health literature is therefore not able to provide an acceptable notion of health opportunities that can be used as a basis for measurements and comparisons (across areas and over time). We propose a new approach based on an ex-ante perspective, hence not affected by the above mentioned shortcoming. In such an approach what is salient is how the monetization of access barriers (either nominal or real costs of access) to a fixed-quality bundle of health services is distributed across cells, where each cell is defined by a set of characteristics which are relevant in determining barriers (age, geographic location, presence of a disability, being part of an ethnic minority, etc.). As access is what gives concrete meaning to the more abstract notion of opportunity, the cornerstone of our methodological approach is the intuition that equality of opportunity is not a meaningless expression only if access is ex-ante granted from any cell. Therefore, in our perspective, equality can only increase either when an additional cell gains access, or when the costs of access are somewhat equalized across cells provided that universal access is granted. Our approach remarkably integrates an assessment of the objective chances of access, typical of the literature focusing on poverty gaps, with a measure of the disparities in the barriers individuals have to overcome, typical of the literature on income inequality. The index we aim to develop for measuring disparities in health opportunities, will be grounded in these principles. The approach we propose is compatible with the consideration of both monetary and real barriers of access (formal and effective equality of opportunity). As for the empirical analysis, according to the Program for the Assessment of the National Health Service developed by the Italian Ministry of Health, we propose to consider the monetization of access barriers to specific treatments: Heart Valve Replacement, Specific services related to cancer prevention, diagnosis and treatment; Thighbone (Femur) Fractures. For some of these treatments (e.g. Thighbone (Femur) Fractures) data from the Italian Ministry of Health already provide the chance of ranking providers (hence treatments) on the basis of the quality of the health service provided. Once set the fixed quality health treatment under consideration, by means of simulation analysis based on real data - concerning the distribution of: population, income and wealth, age, transport facilities, and all the other variables affecting the direct cost of access – we will construct a sample of cells representative of the loci occupied by Italian citizens. We will apply this methodology to measure disparities in the geographic distributions of health opportunities. By means of more standard statistical tools we will also assess how public finance budget cuts have affected the distribution of health opportunities and patients’ mobility among Italian regions.