Health care services utilization and access inequalities in the Sao Paulo Metropolitan Region

This paper presents case study findings in five municipalities in the S?o Paulo Metropolitan Region. Inequalities in access to health care services and their utilization were described through advanced tabulation data from the 1998 SEADE Life Conditions Survey. The variables analyzed were: owning or not owning private health care insurance, income and age brackets. The health care service attributes studied were: health care services coverage by a health insurance plan, health services demands and average waiting time to receive health care. Compared with other studies, using the 1998 IBGE PNAD, the results allowed us to confirm interregional imbalances which can only be detected in shorter special scale studies: the municipalities. Despite showing the high private health insurances coverage the S?o Paulo Metropolitan Region has a great inner heterogeneity. The inequalities in private health care insurance, access, waiting time, and type of insurance coverage were observed through income quintiles and age classes analyses. Findings suggest that an expansion of the State's regulation capacity is necessary in order to empower the Brazilian Health Care System principles of universality and equity to be qualified to offer Brazilians the right to access health care services.     

Health status indices and access to medical care

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure.     

Socioeconomic inequalities in the access to and quality of health care services

OBJECTIVE

To assess the inequalities in access, utilization, and quality of health care services according to the socioeconomic status.

METHODS

This population-based cross-sectional study evaluated 2,927 individuals aged ≥ 20 years living in Pelotas, RS, Southern Brazil, in 2012. The associations between socioeconomic indicators and the following outcomes were evaluated: lack of access to health services, utilization of services, waiting period (in days) for assistance, and waiting time (in hours) in lines. We used Poisson regression for the crude and adjusted analyses.

RESULTS

The lack of access to health services was reported by 6.5% of the individuals who sought health care. The prevalence of use of health care services in the 30 days prior to the interview was 29.3%. Of these, 26.4% waited five days or more to receive care and 32.1% waited at least an hour in lines. Approximately 50.0% of the health care services were funded through the Unified Health System. The use of health care services was similar across socioeconomic groups. The lack of access to health care services and waiting time in lines were higher among individuals of lower economic status, even after adjusting for health care needs. The waiting period to receive care was higher among those with higher socioeconomic status.

CONCLUSIONS

Although no differences were observed in the use of health care services across socioeconomic groups, inequalities were evident in the access to and quality of these services.     

Racial inequalities in access to women's health care in southern Brazil

The aim of this population-based cross-sectional study was to investigate access by 20 to 60 year-old women--both black and white--to early detection (pap-smear) exams for breast and cervical cancer in two towns--S?o Leopoldo and Pelotas--in Rio Grande do Sul State, southern Brazil. Estimates of the association between race/color and access to Pap-smear and breast exams were adjusted for income, education, economic class and age. Of the 2,030 women interviewed, 16.1% were black and 83.9%, white. Black women were significantly less likely to have had a Pap-smear and/or breast exam than white women. Racial inequalities in access to cancer early detection exams persisted after controlling for age and other socioeconomic factors. Racial differentials in access to early detection (Pap-smear) exams for breast and cervical cancers might result from racial and socioeconomic inequalities experienced by black women in access to reproductive health care services and programs.     

Health status and access to care among rural minorities

This paper provides a review of the scholarly and applied literature published between 1970 and 1993 on health and health care access problems among racial and ethnic minority group members living in rural U.S. areas. Results on the distribution of specific illnesses and diseases, and utilization of medical services are summarized for two major minority groups--African Americans and Hispanic Americans. Findings generally document the expected pattern of rural and minority disadvantage. A review of the conceptual and methodological limitations of existing research suggests that research does not yet permit any clear understanding of the underlying structures and processes that give rise to racial health disparities. Very little is known about the health of rural minorities living in some areas of the country, for example, the west north central United States (Kansas, Missouri, Nebraska, Iowa, North Dakota, South Dakota and Minnesota).     

Socioeconomic inequalities in access to health care: examining the case of Burkina Faso

The past decade has recorded remarkable interest in socioeconomic inequalities in health care. A multivariate analysis of the World Health Survey data for Burkina Faso was conducted using STATA. This included questions on household economic factors, perceived need, and access to health care. Poverty was defined using Principal Components Analysis. There was no significant difference in perceived need on the basis of poverty or gender. The less poor accessed health care more than the poor, but this difference was significant only among males. Respondents who lived in urban areas accessed health care more than those in rural areas, but this difference was significant only among females. We argue that health care financing arrangements affect self-reported need and access to health care. Even when they perceive need, the poor do not access care, probably because of cost, exacerbated by non-availability of readily accessible health care facilities.     

Clinic expands adolescents' access to care: Health promotion.

A Minneapolis health center opened a mini-clinic in a local high school to provide adolescents with better access to care, appropriate referrals, and health education.     

Health care inequalities: hospitalization and socioeconomic position in Rome

Although the interest for equity is growing, scanty attention has been reserved so far in Italy to health care inequalities. The relation between hospitalization and socioeconomic position in Rome has been studied by evaluating overall heterogeneity and differences in access to effective non-discretionary treatments or at high degree of generic or specific inappropriateness. An area-based socioeconomic index was assigned to 86.4% out of 554.168 discharges of Rome residents identified during 1997 through the hospital information system. The analysis was performed by comparing standardized hospitalization rates across socioeconomic groups through linear trends and risk ratios. A significant inverse relation of overall hospitalization with socioeconomic position was observed for both acute admissions (+44% for most deprived males) and day hospital (+25%). No difference was found in use of effective treatments such as admissions in coronary care units for acute myocardical infarction or surgery for hip fractures. The inverse relation between socioeconomic position and acute hospitalization blunted in day hospital for inguinal hernia repair and actually reversed for cataract removal among females. The hospitalization risk for minor skin diseases, an ambulatory care sensitive condition, resulted inversely associated to socioeconomic position. An excess of hospitalization was also observed for poorest females undergoing appendectomy. Results indicate that observed heterogeneity between socioeconomic groups does not depend only on different health needs but also on an unequal utilization of services: although disadvantaged groups have equal access to treatments of non-discretionary effectiveness, they hardly use innovative services and are more vulnerable in receiving unnecessary treatments.     

Patient cost sharing and social inequalities in access to health care in three western European countries

This study evaluates the association between social class and health services use in France, Germany and Spain, three countries with universal health coverage but with different cost-sharing systems. In France, patients share the cost of both physician visits and hospitalization, in Germany they share the cost of hospitalization, and in Spain there is no system of patient cost sharing. The data were obtained from national health surveys carried out in each of these countries during the last decade of the 20th century. We found that persons belonging to a low social class had fewer physician visits than those belonging to a high social class in France, whereas the opposite occurred in Germany and Spain. After adjusting for a measure of the need for health care, the results in France changed little, whereas no significant differences by social class were seen in Germany and Spain. Persons of low social class had more hospital admissions than those of high social class in France and Spain, while no statistically different differences were seen in Germany. After adjusting for need, no significant differences were seen in any of the three countries. Although other factors related with the structure of the health system can not be ruled out, our findings suggest that patient cost sharing reduces the frequency of physician visits and that this decrease is greater in the low social classes, whereas the effect of co-payment for hospitalization on the frequency of hospital admission is not clear.     

Children of homeless families: Health status and access to health care

The parents and children of homeless families are highly vulnerable to illness and the failure to receive timely and continuous health care. Data on health status and health care utilization were collected from 70 homeless families selected for an intensive case management program and compared to data for low-income families. The data suggest that homeless children do not utilize primary care or preventive care on a regular basis in comparison to low income children generally. These results have implications for the delivery of health care services to homeless families in shelters.Lisa Roth, M.S.S. is a Research Associate; Elaine R. Fox, M.A. is Director, Homeless Programs, Philadelphia Health Management Corporation, 260 South Broad Street, Philadelphia, PA. 19102An earlier version of this article was presented at the 116th Annual Meeting of the American Public Health Association in Boston, Massachusetts on November 14, 1988. This research was made possible by a grant from the United Way of Southeastern Pennsylvania.     

Health status and access to health care of migrant workers in China

OBJECTIVES: We explored living and working conditions, health status, and health-care access in Chinese rural-to-urban migrants and compared them with permanent rural and urban residents. METHODS: A questionnaire was administered to 1,958 urban workers, 1,909 rural workers, and 4,452 migrant workers in Zhejiang Province, Eastern China, in 2004. Blood samples for human immunodeficiency virus (HIV) and syphilis were taken from the migrant and urban workers. RESULTS: Migrants were young, worked very long hours, and their living conditions were very basic. Nineteen percent had some form of health insurance and 26% were entitled to limited sick pay compared with 68% and 66%, respectively, for urban workers. Migrants had the best self-rated health and reported the least acute illness, chronic disease, and disability, after controlling for age and education. There were no HIV infections detected in either the migrant or urban workers. However, 15 urban workers (0.68%, 95% confidence interval [CI] 0.35, 1.02) and 20 migrants (0.48%, 95% CI 0.26, 0.66, p=0.06) tested positive for syphilis. The high cost of health care in the city was a barrier to health-care access in the last year for 15% of the migrants and 8% of the urban workers. Forty-seven percent of the migrants were unwilling to make contributions to health insurance. CONCLUSIONS: These migrants demonstrated the "healthy migrant effect." However, poor living conditions and inattention to health may make migrants vulnerable to poor long-term health. Because health insurance schemes will remain limited for the forseeable future, attention should focus on providing affordable health care to both uninsured migrants and the urban poor.     

Health inequalities

The evidence bearing on the nature and extent of health inequalities documented globally and in the UK is addressed, twin foci within the UK being (a) associations between socioeconomic classification and health and longevity, and (b) the notion of a 'social gradient'. A consideration of the various 'models' that have been developed by sociologists and their allies - most conspicuously social epidemiologists - to account for (a) and (b) is offered, drawing on government-sponsored commissions and reviews as well as the peer-reviewed literature. This is followed by a portrayal of specifically sociological theories of health inequalities, featuring those that hold social structures as well as cultural shifts in convention and behaviour to be causally efficacious for health inequalities. The summary and conclusions of the review incorporate an outline of pertinent questions the sociological community has so far been reluctant to address and an agenda for future research.     

Health professional shortage and health status and health care access

Although areas designated as Health Professional Shortage Areas (HPSAs) have fewer primary care physicians than non-HPSAs, few studies have tested whether HPSA designation is related to health status and medical service access. This study examined whether residents living in HPSAs were more likely to report worse health status and to be more likely to have difficulty in getting access medical services than residents living in non-HPSAs, with survey data of 10,940 adult West Virginians. Multiple regression results indicate that HPSA is associated with worse general health status and poor physical health, and less access to medical services (measured by had usual place for medical care, experienced not getting needed health care and had outpatient care) but not to inpatient care. These findings indicate that the current HPSA designation system does capture the significant differences between residents of HPSAs and residents of non-HPSAs in health status and medical services access.