Socioeconomic inequalities in health care utilisation in Norway: the population-based HUNT3 survey

ABSTRACT: BACKGROUND: In this study we investigated the distribution of self-reported health care utilisation by education and household income in a county population in Norway, in a universal public health care system based on ideals of equal access for all according to need, and not according to wealth. METHODS: The study included 24,147 women and 20,608 men aged 20 years and above in the third Nord-Trondelag Health Survey (HUNT 3) of 2006--2008. Income-related horizontal inequity was estimated through concentration indexes, and inequity by both education and income was estimated as risk ratios through conventional regression. RESULTS: We found no overall pro-rich or pro-educated socioeconomic gradient in needs-adjusted utilisation of general practitioner or inpatient care. However, we found overall pro-rich and pro-educated inequity in utilisation of both private medical specialists and hospital outpatient care. For these services there were large differences in levels of inequity between younger and older men and women. CONCLUSION: In contrast with recent studies from Norway, we found pro-rich and pro-educated social inequalities in utilisation of hospital outpatient services and not only private medical specialists. Utilisation of general practitioner and inpatient services, which have low access threshold or are free of charge, we found to be equitable.     

Explaining income-related inequalities in doctor utilisation in Europe

This paper presents new international comparative evidence on the factors driving inequalities in the use of GP and specialist services in 12 EU member states. The data are taken from the 1996 wave of the European Community Household Panel (ECHP). We examine two types of utilisation (the probability of a visit and the conditional number of positive visits) for two types of medical care: general practitioner and medical specialist visits using probit, truncated Negbin and generalised Negbin models. We find little or no evidence of income-related inequity in the probability of a GP visit in these countries. Conditional upon at least one visit, there is even evidence of a somewhat pro-poor distribution. By contrast, substantial pro-rich inequity emerges in virtually every country with respect to the probability of contacting a medical specialist. Despite their lower needs for such care, wealthier and higher educated individuals appear to be much more likely to see a specialist than the less well-off. This phenomenon is universal in Europe, but stronger in countries where either private insurance cover or private practice options are offered to purchase quicker and/or preferential access. Pro-rich inequity in subsequent visits adds to this access inequity but appears more related to regional disparities in utilisation than to other factors. Despite decades of universal and fairly comprehensive coverage in European countries, utilisation patterns suggest that rich and poor are not treated equally.     

Inequity and inequality in the use of health care in England: an empirical investigation

Achieving equity in healthcare, in the form of equal use for equal need, is an objective of many healthcare systems. The evaluation of equity requires value judgements as well as analysis of data. Previous studies are limited in the range of health and supply variables considered but show a pro-poor distribution of general practitioner consultations and inpatient services and a pro-rich distribution of outpatient visits. We investigate inequality and inequity in the use of general practitioner consultations, outpatient visits, day cases and inpatient stays in England with a unique linked data set that combines rich information on the health of individuals and their socio-economic circumstances with information on local supply factors. The data are for the period 1998-2000, just prior to the introduction of a set of National Health Service (NHS) reforms with potential equity implications. We find inequalities in utilisation with respect to income, ethnicity, employment status and education. Low-income individuals and ethnic minorities have lower use of secondary care despite having higher use of primary care. Ward level supply factors affect utilisation and are important for investigating health care inequality. Our results show some evidence of inequity prior to the reforms and provide a baseline against which the effects of the new NHS can be assessed.     

Incentives for voluntary health insurance in a national health system: Evidence from Italy

ObjectivesThe paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).MethodsAd hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers’ characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.ResultsTax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.ConclusionOur analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.     

INCOME‐RELATED INEQUITY IN HEALTHCARE UTILISATION AMONG INDIVIDUALS WITH CARDIOVASCULAR DISEASE IN ENGLAND—ACCOUNTING FOR VERTICAL INEQUITY

Economic analyses of equity which focus solely on horizontal inequity offer a partial assessment of socioeconomic inequity in healthcare use. We analyse income‐related inequity in cardiovascular disease‐related healthcare utilisation by individuals reporting cardiovascular disease in England, including both horizontal and vertical aspects. For the analysis of vertical inequity, we use target groups to estimate the appropriate relationship between healthcare needs and use. We find that including vertical inequity considerations may lead us to draw different conclusions about the nature and extent of income‐related inequity. After accounting for vertical inequity in addition to horizontal inequity, there is no longer evidence of inequity favouring the poor for nurse visits, whereas there is some evidence that doctor visits and inpatient stays are concentrated among richer individuals. The estimates of income‐related inequity for outpatient visits, electrocardiography tests and heart surgery become even more pro‐rich when accounting for vertical inequity. Copyright © 2012 John Wiley & Sons, Ltd.     

Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey

This paper assesses the extent to which Canada's universal health care system has eliminated socio-economic barriers in the use of physician services by examining the role of socio-economic status in the differential use of specific, publicly-insured, primary and specialist care services. Data from the 1994 National Population Health Survey, a nationally representative survey, were analysed using multiple logistic regression. In order to control for the association between primary and specialist utilisation, a two-staged least squares method was used for models explaining specialist utilisation. Health need, as measured by perceived health status and number of health problems, was found to be consistently associated with increased physician utilisation, for both primary and specialist visits. Whereas the likelihood of an individual making at least one visit to a primary care physician was found to be independent of income, those with lower incomes were more likely to be frequent users of primary care, that is, make at least six visits to a primary care physician. Even after adjusting for the greater utilisation of primary care services by those in lower socio-economic groups, and, therefore, their higher exposure to the risk of referral, the utilisation of specialist visits was greater for those in higher socio-economic groups. Canadians lacking a regular medical doctor were less likely to receive primary and specialist care, even after adjustments for socio-economic variables such as income and education. Although financial barriers may not directly impede access to health care services in Canada, differential use of physician services with respect to socio-economic status persists. After adjusting for differences in health need, Canadians with lower incomes and fewer years of schooling visit specialists at a lower rate than those with moderate or high incomes and higher levels of education attained despite the existence of universal health care.     

Constraints to universal coverage: inequities in health service use and expenditures for different health conditions and providers

Background  

There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage.     

Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study

Utilisation of health services is a complex behavioural phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilisation of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilisation of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilisation, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilisation of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.     

Health care expenditure and life expectancy in Australia: how well do we perform?

Abstract: The Australian health care system consists of mixed public and private financing underpinned by Medicare, a universal government-run insurance scheme paid through taxation (and levy) on income. Australia has improved its ranking for life expectancy (at birth) since 1960, and in 1990 ranked ninth and seventh of 24 countries for females and males respectively; this is ahead of the United States and United Kingdom, and approximately equal to Canada. Australian hospital bed supply and utilisation are average, after deletion of day-only cases. The proportion of gross domestic product (GDP) spent on health, in relation to GDP per capita (adjusted for purchasing power), in Australia in 1990 was average, and the prices for health care from 1975 to 1990 did not increase when adjusted for inflation. Although 68 per cent of health expenditure emanates from public sources in Australia, this is lower than in the majority of European countries and Canada. Some countries are doing poorly (such as the United States, with lower than average life expectancy and higher than predicted health expenditure) and some countries are doing well (with higher than average life expectancy and lower than predicted health expenditure; for example, Japan). Australia has higher than average life expectancy and only slightly higher than predicted health expenditure per capita. Although the Australian system could be improved, there are no indications that radical changes are required. The relatively high life expectancy in Australia can be attributed to favourable social and economic conditions, successful public health programs, and the availability of universal quality health care.     

Equity in prevention and health care

STUDY OBJECTIVE: There is an increasing body of evidence about socioeconomic inequality in preventive use, mostly for cancer screening. But as far as needs of prevention are unequally distributed, even equal use may not be fair. Moreover, prevention might be unequally used in the same way as health care in general. The objective of the paper is to assess inequity in prevention and to compare socioeconomic inequity in preventive medicine with that in health care. DESIGN: A cross sectional Health Interview Survey was carried out in 1997 by face to face interview and self administered questionnaire. Two types of health care utilisation were considered (contacts with GPs and with specialists) and four preventive care mostly delivered in a GP setting (flu vaccination, cholesterol screening) or in a specialty setting (mammography and pap smear). SETTING: Belgium. PARTICIPANTS: A representative sample of 7378 residents aged 25 years and over (participation rate: 61%). Outcome measure: Socioeconomic inequity was measured by the HI(wvp) index, which is the difference between use inequality and needs inequality. Needs was computed as the expected use by the risk factors or target groups. MAIN RESULTS: There was significant inequity for all medical contacts and preventive medicine. Medical contacts showed inequity favouring the rich for specialist visits and inequity favouring the poor for contacts with GPs. Regarding preventive medicine, inequity was high and favoured the rich for mammography and cervical screening; inequity was lower for flu immunisation and cholesterol screening but still favoured the higher socioeconomic groups. In the general practice setting, inequity in prevention was higher than inequity in health care; in the specialty setting, inequity in prevention was not statistically different from inequity in health care, although it was higher than in the general practice setting. CONCLUSIONS: If inequity in preventive medicine is to be lowered, the role of the GP must be fostered and access to specialty medicine increased, especially for cancer screening.     

Ethnic and Indigenous access to early childhood healthcare services in Australia: parents' perceived unmet needs and related barriers

Objective: To evaluate the parents’ perceived unmet needs in early childhood healthcare services among Indigenous, non‐English‐speaking background (NESB) and English‐speaking background (ESB) children and the related barriers. Method: Data was from the Longitudinal Study of Australian Children (LSAC). Rao‐Scott chi‐square was used to examine the level of parents’ perceived unmet needs in three ethnic groups in early childhood healthcare services over a 12 month period. Survey logistic regression was used to assess the association between the groups of infants and the barriers to utilisation. Results: Ten per cent of Australian infants have at least one parents’ perceived unmet need in early childhood healthcare services. NESB (15.3%) and Indigenous (15.1%) infants were more likely than ESB infants (9.9%, p<0.001) to have parents’ perceived unmet needs in health care services. The barriers to service access include cost, transport problems, child care difficulties, service availability and family reasons. Parents of ESB infants were more likely to cite operating hours as the major barrier to accessing services. Conclusion: There were parents’ perceived unmet needs in a number of health services for all Australian infants, but at different levels by Indigenous, NESB and ESB groups. The most common barrier to services utilisation related to cost or private health insurance, availability and accessibility of service provision and other socioeconomic issues. Implications: Policy attention and operational changes are required to improve equity in accessing early childhood services, as well as to improve the overall access to healthcare services for all Australian infants.     

Measuring horizontal inequity in Belgian health care using a Gaussian random effects two part count data model

We estimate the determinants of utilisation of physician and hospital services in Belgium using a one- and two-part panel count data model, and a one- and two-part pooled count data model. We conclude that the two-part panel count data model is most appropriate as it controls for unobserved heterogeneity and allows for a two-part decision-making process. The estimates of the determinants of utilisation of health care are then used to calculate indices of horizontal inequity. We find that inequity for general practitioner and hospital services is stable across time and in favour of low-income individuals, in the sense that, overall, they consume more than one would expect on the basis of their need, albeit the indices for hospital care are not significant. Horizontal equity applies to specialist care in all years, but from 1999 onwards, some evidence (although not statistically significant) of pro-rich inequity is found.     

Horizontal equity in utilisation of care and fairness of health financing: a comparison of micro-health insurance and user fees in Rwanda

This paper uses two methods to compare the impact of health care payments under insurance and user fees. Concentration indices for insured and uninsured groups are computed following the indirect standardisation method to evaluate horizontal inequity in utilisation of basic health care services. The minimum standard approach analyses the extent to which out-of-pocket health spending contributed to increased poverty. The analysis uses cross-sectional household survey data collected in Rwanda in 2000 in the context of the introduction of community-based health insurance. Results indicate that health spending had a small impact on the socio-economic situation of uninsured and insured households; however, this is at the expense of horizontal inequity in utilisation of care for user-fee paying individuals who reported significantly lower visit rates than the insured.     

Horizontal equity in health care utilization evidence from three high-income Asian economies

This paper compares the extent to which the principle of "equal treatment for equal need"(ETEN) is maintained in the health care delivery systems of Hong Kong, South Korea and Taiwan. Deviations in the degree to which health care is distributed according to need are measured by an index of horizontal inequity. Income-related inequality in utilization is split into four major sources: (i) direct effect of income; (ii) need indicators (self-assessed health status, activity limitation, and age and gender interaction terms); (iii) non-need variables (education, work status, private health insurance coverage, employer-provided medical benefits, Medicaid status (low-income medical assistance), geographic region and urban/rural residency and (iv) a residual term. Service types studied include western doctor, licensed traditional medicine practitioner (LTMP), dental and emergency room (ER) visits, as well as inpatient admissions. Violations of the ETEN principle are observed for physician and dental services in Hong Kong . There is pro-rich inequity in western doctor visits. Unusually, this inequity exists for general practitioner but not specialist care. In contrast, South Korea appears to have almost comprehensively maintained ETEN although the better-off have preferential access to higher levels of outpatient care. Taiwan shows intermediate results in that the rich are marginally more likely to use outpatient services, but quantities of western doctor and dental visits are evenly distributed while there is modest pro-rich bias in the number of LTMP episodes. ER visits and inpatient admissions in Taiwan are either proportional or slightly pro-poor. Future work should focus on the evaluation of policy interventions aimed at reducing the observed unequal distributions.     

Income-based disparities in health care utilisation under universal health coverage in Brazil, 2002–2003

Since Brazil's adoption of universal health care in 1988, the country's health care system has consisted of a mix of private providers and free public providers. We test whether income-based disparities in medical visits and medications remain in Brazil despite universal coverage using a nationally representative sample of over 48,000 households. Additional income is associated with less public sector utilisation and more private sector utilisation, both using simple correlations and regressions controlling for household characteristics and local area fixed effects. Importantly, the increase in private care use is greater than the drop in public care use. Also, income and unmet medical needs are negatively associated. These results suggest that access limitations remain for low-income households despite the availability of free public care.     

Is inequity undermining Australia's ‘universal’ health care system? Socio‐economic inequalities in the use of specialist medical and non‐medical ambulatory health care

Objectives: To quantify need-adjusted socio-economic inequalities in medical and non-medical ambulatory health care in Australia and to examine the effects of specific interventions, namely concession cards and private health insurance (PHI), on equity.
Methods: We used data from a 2004 survey of 10,905 Australian women aged 53 to 58 years. We modelled the association between socio-economic status and health service use — GPs, specialists, hospital doctors, allied and alternative health practitioners, and dentists — adjusting for health status and other confounding variables. We quantified inequalities using the relative index of inequality (RII) using Poisson regression. The contribution of concession cards and PHI in promoting equity/inequity was examined using mediating models.
Results: There was equality in the use of GP services, but socio-economically advantaged women were more likely than disadvantaged women to use specialist (RII=1.41, 95% CI:1.26–1.58), allied health (RII=1.21,1.12–1.30), alternative health (RII=1.29,1.13–1.47) and dental services (RII=1.61,1.48–1.75) after adjusting for need, and they were less likely to visit hospital doctors (RII=0.74,0.57–0.96). Concession cards reduced socio-economic inequality in GP but not specialist care. Inequality in dental and allied health services was partly explained by inequalities in PHI.
Conclusions and implications: Substantial socio-economic inequity exists in use of specialist and non-medical ambulatory care in Australia. This is likely to exacerbate existing health inequalities, but is potentially amenable to change.     

Patients’ perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

Background

A universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.

Methods

A qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.

Results

Twenty-nine participants (mean age, 56.76?±?16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.

Conclusions

The factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.

     

Income-related inequality in the use of dental services in Finland

The aim of this article is to measure and explain income-related inequalities in dentist utilisation. We apply concentration and horizontal inequity indices and the decomposition method to decompose observed inequalities into sources. The data are from the Finnish Health Care Survey of 1996. We examine three measures of utilisation: (a) the total number of visits; (b) the probability of visiting a dentist; and (c) the conditional number of positive visits for (i) visits to all dentists, (ii) those to public dentists and (iii) those to private dentists. The results for the whole sample show pro-poor inequities in all three measures of utilisation in public care, whereas in the first two measures there are pro-rich inequities nationwide and in private care. Among those entitled to age-based subsidised dental care, we find equality and equity in all three measures of utilisation nationwide. The two main factors related to pro-rich distributions of use are income and dentist's recall. To enhance equity in dental care across income groups, attention should be focused on supply factors and other incentives to encourage the poor to contact dentists more often.     

Redistribution or horizontal equity in Hong Kong's mixed public-private health system: a policy conundrum

We examine the distributional characteristics of Hong Kong's mixed public-private health system to identify the net redistribution achieved through public spending on health care, compare the income-related inequality and inequity of public and private care and measure horizontal inequity in health-care delivery overall. Payments for public care are highly concentrated on the better-off whereas benefits are pro-poor. As a consequence, public health care effects significant net redistribution from the rich to the poor. Public care is skewed towards the poor in part not only because of allocation according to need but also because the rich opt out of the public sector and consume most of the private care. Overall, there is horizontal inequity favouring the rich in general outpatient care and (very marginally) inpatient care. Pro-rich bias in the distribution of private care outweighs the pro-poor bias of public care. A lesser role for private finance may improve horizontal equity of utilisation but would also reduce the degree of net redistribution through the public sector.