Disparities in perceptions of healthcare access in a community sample

Disparities in health status persist for many sociodemographic groups in the United States. An understanding of barriers to healthcare access and utilization can assist community-based initiatives in developing strategies to improve the health of minority and low-income populations. Using self-reported information from 3014 community residents, a factor analysis was conducted that defined barriers to healthcare by 4 dimensions: (1) time and competing priorities, (2) convenience and availability, (3) healthcare utilization, and (4) healthcare affordability. Differential effects of demographics were observed on all factors. Racial disparities were found where African Americans experienced more problems based on the convenience and availability of services (P < .02) than did whites, after controlling for income, education, age, and marital status. In addition, gender differences showed that women experienced greater difficulty with time and competing priorities than men (P < .001); however, women experienced fewer problems related to utilization (P < .001). Of the covariates, income was significant (P < .01) on 3 of the 4 indicators. This study points to the need to develop interventions that address the unique challenges faced by different population groups to ensure timely healthcare. In addition, the reduction of economic disparities should be considered as an important strategy to improve public health.     

湖南省公立医院经济运行分析

[目的]了解湖南省公立医院2014-2018年经济运行状况,为湖南省公立医院改革提供政策建议和参考.[方法]通过卫生统计年报、卫生财务年报等资料收集相关数据,采用描述性统计和对比分析方法进行分析.[结果] 2014-2018年,湖南省公立医院医疗服务量稳步增长,医师人均每日负担小幅下降,病床使用率也呈下降趋势,但病床使...     

The interdependence of mental health service systems: the effects of VA mental health funding on veterans' use of state mental health inpatient facilities

BACKGROUND: There are relatively few published data on how the financial structures of different health systems affect each other. With increasing financial restrictions in both public and private healthcare systems, it is important to understand how changes in one system (e.g. VA mental healthcare) affect utilization of other systems (e.g. state hospitals). AIMS OF THE STUDY: This study utilizes data from state hospitals in eight states to examine the relationship of VA per capita mental health funding and state per capita mental health expenditures to veterans' use of state hospitals, adjusting for other determinants of utilization. METHODS: This study utilized a large database that included records from all male inpatient admissions to state hospitals between 1984 and 1989 in eight states (n = 152541). Funding levels for state hospitals and VA mental health systems were examined as alternative enabling factors for veterans' use of state hospital care. Logistic regression models were adjusted for other determinants of utilization such as socio-economic status, diagnosis, travel distances to VA and non-VA facilities and the proportion of veterans in the population. RESULTS: The single strongest predictor of whether a state hospital patient would be a veteran was the level of VA mental healthcare funding (OR = 0.81 per $10 of funding per veteran in the population, p = 0.0001), with higher VA funding associated with less use of state hospitals by veterans. Higher per capita state funding, reciprocally, increased veterans' use of state hospitals. We also calculated elasticities for state hospital use with respect to VA mental healthcare funding and with respect to state hospital per capita funding. A 50% increase in VA per capita mental health spending was associated with a 30% decrease in veterans' use of state hospitals (elasticity of -0.6). Conversely, a 50% increase in state hospital per capita funding was associated with only an 11% increase in veterans' use of state hospitals (elasticity of 0.06). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These data indicate that per capita funding for state hospitals and VA mental health systems exerts a significant influence on service use, apparently mediated by the effect on supply of mental health services. Veterans are likely to substitute state hospital care for VA care when funding restrictions limit the availability of VA mental health services. However, due to the relative sizes of the two systems, VA funding has a larger effect than state hospital funding upon state hospital use by veterans. IMPLICATIONS FOR HEALTH POLICIES: These data indicate that changes in the organizational and/or financial structure of any given healthcare system have the potential to affect surrounding systems, possibly quite substantially. Policy makers should take this into account when making decisions, instead of approaching systems as independent, as has been traditional. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed in two areas. First, these results should be replicated in other systems of care using more recent data. Second, these results are difficult to generalize to individual behavior. Future research should examine the extent and individual determinants of cross-system use.     

Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala

OBJECTIVE: To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care. METHODS: The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure. FINDINGS: Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector. CONCLUSION: Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.     

Pakistan's health policy: appropriateness and relevance to women's health needs

The interface between national health policy and women's health needs is complex in developing countries like Pakistan. This paper aims to assess if Pakistan's national health policy 2001 is relevant and appropriate to women's health needs. Through review of existing data on women, a profile of women's health needs was developed which was transformed into framework of analysis. This framework indicates that Pakistani women's health needs are determined by gender disparities in health and health-related sectors. Comparison of national health policy with women's health needs framework reveals that although policy focuses on women's health through prioritization of gender equity, it is however addressed as an isolated theme without acknowledging the vital role gender inequalities in health and health-related sectors play in defining women's health needs. Moreover, gender equity is translated as provision of reproductive health services to married mothers, ignoring various critical overarching issues of women's life such as sexual abuse, violence, induced abortion, etc. Health systems strengthening strategies are though suggested but these fails to recognize main obstacles of utilization of healthcare services by women including non-availability of female healthcare providers and gender-based obstacles to healthcare utilization such as illiteracy, lack of empowerment to make decisions related to health, etc. In order to be relevant and appropriate to women's health needs the policy should: (1) use gender equity in health and health-related sectors as an approach to develop a healthy policy (2) expand the focus from reproductive health to life cycle approach to address all issues around women's life (3) strengthen health systems through creation of gender equity among all cadres of health providers (4) tailoring health interventions to counter gender-based obstacles to utilization of healthcare services and (5) dissemination interventions for behavior change.     

Pakistan's health policy: Appropriateness and relevance to women's health needs

The interface between national health policy and women's health needs is complex in developing countries like Pakistan. This paper aims to assess if Pakistan's national health policy 2001 is relevant and appropriate to women's health needs.Through review of existing data on women, a profile of women's health needs was developed which was transformed into framework of analysis. This framework indicates that Pakistani women's health needs are determined by gender disparities in health and health-related sectors.Comparison of national health policy with women's health needs framework reveals that although policy focuses on women's health through prioritization of gender equity, it is however addressed as an isolated theme without acknowledging the vital role gender inequalities in health and health-related sectors play in defining women's health needs. Moreover, gender equity is translated as provision of reproductive health services to married mothers, ignoring various critical overarching issues of women's life such as sexual abuse, violence, induced abortion, etc. Health systems strengthening strategies are though suggested but these fails to recognize main obstacles of utilization of healthcare services by women including non-availability of female healthcare providers and gender-based obstacles to healthcare utilization such as illiteracy, lack of empowerment to make decisions related to health, etc.In order to be relevant and appropriate to women's health needs the policy should: (1) use gender equity in health and health-related sectors as an approach to develop a healthy policy (2) expand the focus from reproductive health to life cycle approach to address all issues around women's life (3) strengthen health systems through creation of gender equity among all cadres of health providers (4) tailoring health interventions to counter gender-based obstacles to utilization of healthcare services and (5) dissemination interventions for behavior change.     

昭通市农村居民两周患病卫生服务需求与利用现状及影响因素分析

[目的]了解农村居民卫生服务需求与利用现状,并找出相关的影响因素,为卫生政策的制定提供参考依据。[方法]采用分层随机整群抽样方法,对昭通市3个县(区)共3645户10,584个居民进行入户调查。通过两周就诊率、两周就诊次数、两周患病就诊率了解农村居民两周患病卫生服务需求与利用现况,运用二分类Logistic回归、零膨胀泊松模型等方法进行影响因素分析。[结果]昭通市农村居民两周就诊率为4.72%,两周患病就诊率为73.49%。卫生服务需求受年龄、性别、职业、婚姻状况、人均收入的影响;卫生服务利用的影响因素有性别、职业、文化程度,人均收入。[结论]昭通市农村居民卫生服务需求和卫生服务利用均低于国家农村平均水平。农民卫生服务需求高,但卫生服务利用不足;低收入人群和男性就诊可能性低,就诊时疾病严重程度高。应更加关注男性、农民和低收入人群的卫生服务需求和利用情况。     

Health policy reform in the People's Republic of China

With very limited resources, China has developed perhaps the world's largest network of health care services. The health status of its peoples has risen dramatically during the past 40 years. The reasons for these achievements are complex and include an ideology of equity for all citizens, the near universal availability of adequate food, education, housing, jobs, and transport, and the universal availability of accessible and affordable treatment and preventive health services. Despite these achievements China is facing new problems. These include the aging of the population, continued growth of the population leading to ever increasing demands on all sectors of the economy including health services, urban-rural inequalities, low productivity in the health services, lack of legal safeguards for health protection, a continued burden of infectious and endemic diseases, weak infrastructure for prevention and primary health care, and an increasing burden of chronic diseases associated with tobacco smoking and atherosclerotic circulatory diseases and trauma due to traffic accidents and occupational hazards. Decentralized management, financial incentives for health workers, privatization of medical practitioners, health legislation, and changes to health insurance arrangements have been introduced as a means of addressing the issues. The outcomes have been uneven, with little or no improvements in some problems and good progress in others. Changes in the health system appear to be reflecting not only health reform measures but also general economic reforms.     

HIV/AIDS and home-based health care

This paper highlights the socio-economic impacts of HIV/AIDS on women. It argues that the socio-cultural beliefs that value the male and female lives differently lead to differential access to health care services. The position of women is exacerbated by their low financial base especially in the rural community where their main source of livelihood, agricultural production does not pay much. But even their active involvement in agricultural production or any other income ventures is hindered when they have to give care to the sick and bedridden friends and relatives. This in itself is a threat to household food security. The paper proposes that gender sensitive policies and programming of intervention at community level would lessen the burden on women who bear the brunt of AIDS as caregivers and livelihood generators at household level. Improvement of medical facilities and quality of services at local dispensaries is seen as feasible since they are in the rural areas. Other interventions should target freeing women's and girls' time for education and involvement in income generating ventures. Two separate data sets from Western Kenya, one being quantitative and another qualitative data have been used.     

The dually entitled elderly Medicare and Medicaid population living in the community.

This study shows that the elderly living in the community and covered by Medicare and Medicaid have a higher proportion of older persons, of minority races, and of women and are in poorer health than other aged persons covered only by Medicare. The noninstitutionalized poor elderly population use more health care services (especially inpatient hospital care) and have much higher per capita health care expenses compared to those covered by Medicaid. There were also large disparities in education and income. The study indicates that the Medicare program provides substantially more financial protection for all elderly persons living in the community than for the total elderly population.     

Income inequality,illiteracy rate,and life expectancy in Brazil

OBJECTIVES: The link between income disparities and health has been studied mostly in developed nations. This study assesses the relationship between income disparities and life expectancy in Brazil and measures the impact of illiteracy rates on the association. METHODS: The units of analysis (n = 27) are all the Brazilian states and the federal capital. Simple and multiple linear regressions were performed to measure the association between income disparity, measured by the Gini coefficient, gross domestic product (GDP) per capita, and illiteracy rate. Data came from publicly available sources at the Brazilian Ministry of Health and the Brazilian Institute of Geography and Statistics. RESULTS: Income disparities and illiteracy rates were negatively associated with life expectancy in Brazil. GDP per capita was positively associated with life expectancy. The inclusion of illiteracy rates in the regression model removed the effect of income disparities. CONCLUSIONS: Illiteracy rate is strongly associated with life expectancy in Brazil. This finding is in accord with reports from the United States and has implications for health policy and planning for both developed and developing countries.     

Determinants of healthcare utilization in Greece: Implications for decision-making

Objective: To explore factors influencing the utilization of primary and secondary healthcare in Greece. Methods: A national, geographically stratified sample was randomly selected. From November 2001 to March 2002, 5000 questionnaires were mailed, 4427 were actually received, and 1819 were completed and returned (response rate 41%). The questionnaire investigated respondents’ characteristics and their health services utilization. A number of potential utilization determinants were explored, such as region, gender, age, education, income, insurance coverage, number of family members, self-rated health status, country of birth, and parents’ country of birth. Results: The utilization of primary healthcare services depended on self-rated health status, age, income, gender, and region. Individuals with moderate and poor self-rated health, older people, women, and residents of the region of Epirus showed increased utilization of primary healthcare services. Income was a factor affecting the utilization of primary healthcare only at lower income levels. The frequency of visits for primary healthcare was negatively correlated with self-rated health status and increased as self-evaluation of health status worsened. Hospitalization was associated with self-rated health and insurance coverage for primary healthcare. Individuals with better self-rated health status, as well as those who were covered by health insurance for primary care, showed decreased hospital care utilization. The frequency of hospitalization depended on region and lower evaluations of health status.

Conclusion: The findings of our research are encouraging, since they suggest that the utilization of health services in Greece is mostly determined by health status rather than other socioeconomic factors. It is believed that similar studies should be conducted in the country, since they can improve health service planning and reinforce decision-making towards healthcare resource allocation according to healthcare needs.     

Promoting the private sector: a review of developing country trends

Two questions are addressed in this article: (i) How can itbe ensured that private sector resources promote national healthgoals? and; (ii) What can be learnt from the private sectorto enhance operations in the public sector? There is a surprisingdegree of private sector activity in both the finai icing andprovision of services, despite the fact that few countries haveadopted wide-reaching privatization programmes. In some countriespressure upon government budgets for health has led to privatesector expansion - in others rapid income growth accompaniedby increased demand for health care is a causal factor. A number of problems related to private for-profit providersare evident; often quoted are supplier-induced demand and excessiveinvestment in high technology equipment, the equity implicationsof private health care, and the availability of manpower forthe public sector. Governments have tried to tackle these problemsthrough a range of innovative interventions, however littleproper evaluation of these policies has been carried out. Whilesuch problems are less likely to arise with the private, not-for-profitsector, the financial sustainability of their activities ismore worrying. There is also a need to define more clearly therelationships between governments and not-for-profit organizations. The paper considers market-oriented reforms in industrializedcountries, and their implications for the health sector in developingcountries. The measures taken in industrialized countries appearto be of limited direct applicability in developing countries,due to factors such as the sparse coverage of health facilitiesin the latter. However the principles on which the reforms arebased are relevant, in particular the need for greater transparencyin the activities of public and private sector providers andin the use of con tracting out services. Finally it is suggestedthat too much research in this area has focused on defendingone or other side of the privatization debate. Not enough workhas considered the health sector as a whole, and the complicatedinteractions between public and private sectors as providers,buyers, financ ing agents and regulators of health care services.     

Health care utilization among women on O'ahu: implications for Native Hawaiian women

Women generally seek and use more health care services than do men. Women are also more likely to encounter financial and non-financial barriers to care than do their male counterparts. These differences are accentuated among low income and minority women. We examined health care utilization patterns among women on O'ahu using survey data, and compared those patterns among Native Hawaiian and other ethnic groups. We also provide prevalence rates for several critical women's health issues by ethnic group and explore demographic predictors for health care utilization. Although the vast majority of women have seen health care providers in the last year, ethnic and socioeconomic disparities were identified, especially with respect to our Native Hawaiian female population. A pattern for Native Hawaiian women reveals among the highest rates of depression, as well as sexual/physical/emotional abuse. Alarmingly, Native Hawaiian women are also less likely to have seen a provider in the last year, less likely to have insurance coverage, and more likely to visit emergency departments. Differences by provider type served to reinforce these disparities. In order to reduce barriers to health care utilization for Native Hawaiian women--and for all women in Hawai'i--we recommend universal insurance coverage that includes screening and counseling services. Additionally, training for health care providers is essential in order to improve culturally competent, psychological assessments of health issues for women, particularly Native Hawaiian women.     

Utilization of health services in Indonesia

This paper examines the utilization patterns of traditional and modern health services in Indonesia, using household sample survey socio-economic data in conjunction with community-level data on availability of services. The results strongly suggest that low household income is a barrier to the utilization of modern health services, even where they are publicly provided. The relatively well-to-do use the services of trained practitioners and physicians more and spend more on these services than do the poor. That is, income has a qualitative effect shown as a shift to more expensive and sophisticated practitioners and services rather than increased expenditures on the same type of services. Nevertheless, public facilities do make a difference; where they are available people prefer them to indigenous practitioners. Despite limitations of data and method of estimation, it is clear that both income and availability of services matter and hence that public services are more important to the poor than to the rich. The results further suggest that exposure to modern services that may involve health education brings about the right kinds of substitutions from an efficiency viewpoint: paramedics for traditional practitioners as well as physicians.     

Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey

Objectives. We compared health status, access to care, and utilization of medical services in the United States and Canada and compared disparities according to race, income, and immigrant status.

Methods. We analyzed population-based data on 3505 Canadian and 5183 US adults from the Joint Canada/US Survey of Health. Controlling for gender, age, income, race, and immigrant status, we used logistic regression to analyze country as a predictor of access to care, quality of care, and satisfaction with care and as a predictor of disparities in these measures.

Results. In multivariate analyses, US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines. Disparities on the basis of race, income, and immigrant status were present in both countries but were more extreme in the United States.

Conclusions. United States residents are less able to access care than are Canadians. Universal coverage appears to reduce most disparities in access to care.

     

健康与卫生服务利用的不平等：来自省级数据的证据

目的:了解中国各经济发展水平地区的健康以及卫生服务使用的差异,为改善与经济相关的健康不平等提供参考。方法:对省级面板数据的组间差异进行分解。结果:不同经济发展水平地区存在健康和卫生服务利用的不平等,其中新生儿健康以及卫生服务利用的不平等仍在扩大。结论:在改善新生儿健康水平中,应对高收入地区进行重点关注,在促进卫生服务利用的平等中,需要对低收入地区和农村地区进行重点关注。