Inequality In Health Service Utilization Research Articles

The role of regional health policy for socioeconomic inequality in health services utilization

Abstract Background “J1” is a preventative routine examination in Germany recommended for adolescents at the age of 12-14 years. In contrast to the well-established U1-U9 examinations for younger children, with participation rates above 90%, the attendance of the J1 examination is approximately only 40%. The most frequent reason for not attending J1 is the unawareness of this examination. “Ticket to J1” is an intervention including an information leaflet introduced in Bavaria in 2017 to inform adolescents about J1. The aims of the present analysis are to investigate (1) if the regional policy was effective in increasing the attendance in J1, (2) if the effects vary by family socioeconomic status (SES), and (3) which meso-level characteristics of the healthcare system correlate with attendance rates in J1. Methods We used anonymised data of a large statutory health insurance in Germany for the timeframe of 2016-2018. To investigate the effect of the policy, a difference-in-differences design at the individual level was used. Assuming a parallel trend at the level of federal states, the likelihood of attendance in J1 of 13- and 14-year-olds was compared between Bavaria and other federal German states before and after policy introduction. All analyses were additionally stratified by SES. Results The introduction of “Ticket to J1” increased participation in J1 by 1% after controlling for all confounders. Furthermore, the effect was stronger for children from families with lower SES (an increase of 5%). Density of pediatricians was positively significantly correlated with participation in J1. Discussion Regional health policy intervention had a significant positive impact on attendance of J1 and appears to have the potential to reduce socioeconomic inequalities in healthcare utilization. Informing adolescents about J1 seems to increase the attendance, in particular for children from families with lower SES.

Utilization of health services among the elderly in Iran during the COVID-19 outbreak: A cross-sectional study.

Background and AimsElderly people are potentially vulnerable with a higher need for health services, and utilization of Essential Public Health Services (EPHS) among this group is of high importance. This study aimed to examine the utilization of health services among the elderly in Iran during the coronavirus disease 2019 outbreak.MethodsThis was a cross‐sectional study conducted in 21 public health centers in Sirjan, Southern Iran, from May to December 2020. A total of 420 elderly patients were selected through a systematic random sampling method. Data were collected using a questionnaire and were analyzed using SPSS v22.0. The binary logistic regression was used to examine the effect of demographic, socioeconomic and morbidity status on inpatient and outpatient healthcare utilization.ResultsOur results showed that 56% of the elderly had a history of hospitalization during the last year. Although 60% of the elderly reported they had a perceived need for outpatient services, only 49% of them reported that they utilized outpatient services. 51% and 35.5% of the elderly reported that their inpatient and outpatient costs were covered by health insurance, respectively. Others reported their health spending was financed through out‐of‐pocket payments. Male gender aged 80 and above, urban residents, higher socioeconomic and supplemental insurance coverage were associated with an increase in health services utilization. The elderly with Cancer, mental disorders, kidney disease, and cardiovascular diseases (CVDs) were more likely to be hospitalized.ConclusionThere were demographic and socioeconomic inequalities in health services utilization among the elderly. Therefore, appropriate interventions and strategies are needed to reduce these inequalities in health services utilization among the elderly. In addition, given that the hospitalization rate was significantly higher among the elderly with chronic diseases than those without, it is crucial and necessary to take interventions to reduce the burden of chronic diseases in the future.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China.

BackgroundThe Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.MethodsA total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.ResultsThe horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.ConclusionsThe findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

Assessing Income-Related Inequality on Health Service Utilization among Chinese Rural Migrant Workers with New Co-Operative Medical Scheme: A Multilevel Approach.

Background: Eliminating inequality in health service utilization is an explicit goal of China’s health system. Rural migrant workers with New Rural Cooperative Medical Insurance (NCMS) still face the dilemma of limited health service; however, there is a lack of analysis or measurement on the income-related inequality of health service utilization. Method: The nationally representative data of the China Labor-Force Dynamic Survey in 2016 were used for analysis. Multilevel regressions were used to obtain robust estimates and to account for various covariates associated with health service utilization of rural migrant workers with NCMS. The concentration index and its decomposition method were applied to quantify the income-related inequality of health service utilization of rural migrant workers. Result: The multilevel model analysis indicated that influencing factors of health service utilization were diversified, including gender, city service quality index, type of industry, the per capita annual income, marital status, health self-assessment, the community health index and the number of friends. The concentration indices of the total cost of inpatient and OOP cost of inpatient were 0.102 (95%CI: 0.031, 0.149), and the CI of OOP cost of inpatient was 0.094 (95%CI: 0.007, 0.119), respectively. The horizontal inequality indices of the total cost of inpatient and OOP cost of inpatient were 0.051 and 0.009, respectively. Conclusion: Our study presented a unique opportunity to examine the potential influence factors of health service utilization of rural migrant workers with NCMS, and highlighted that unequal health service utilization is evident among rural migrant workers with NCMS. This study provides important corroborative evidence to take full account of the contribution of each determinant to the inequality and health service needs among rural migrant workers with NCMS, in order to improve the basic medical insurance and social security systems—particularly for some marginal groups in China.

Inequality in health service utilization among migrant and local children: a cross-sectional survey of children aged 0\u201314\u2009years in Shenzhen, China

BackgroundShenzhen is characterized with the largest scale of migrant children among all the cities in China. Unequal access to health services among migrant and local children greatly affects health equity and has a profound impact on the quality of human capital. This study aimed to investigate differences in using community-based healthcare between local and migrant children and to identify the influencing factors in Futian District of Shenzhen.MethodsHouseholds in 12 communities in Futian District of Shenzhen were randomly sampled. Children aged 0–14 years were investigated using self-administered questionnaire - the 2018 Survey of Health Service Needs of Chinese Residents. Differences in healthcare including physical examination, feeding guidance, development guidance, disease prevention guidance, injury prevention guidance, oral health guidance, and mental health guidance, were tested between local and migrant children. Binary logistic regressions were used in identifying potential influencing factors which affected the use in the above healthcare items.ResultsA total of 936 participants from1512 families were sampled and 508 of them were included. Compared with local children, migrant children had less use of development guidance (OR = 0.417, 95% CI: 0.279–0.624) and oral health care guidance (OR = 0.557, 95% CI: 0.381–0.813). Children whose father received higher education level enjoyed a better use of disease prevention guidance as compared to whose father stopped at junior high school education or below (senior high vs junior high and below, OR = 1.286, 95% CI: 0.791–2.090; bachelor and above vs junior high and below, OR = 2.257, 95% CI: 1.417–3.595). Children whose fathers were blue-collar workers had less use of injury prevention guidance (OR = 0.750, 95% CI: 0.334–1.684) and mental health guidance (OR = 0.784, 95% CI: 0.295–2.080) as compared to whose father were white collar workers.ConclusionsExcept feeding guidance, healthcare utilization were lower among migrant children than among local children. Generally, fathers have a stronger influence on children’s use of community-based healthcare than mothers do. The potential influence of fathers in promoting children’s healthcare use behaviors should be carefully considered, and fathers’ attention to children’s health should be increased.

The effects of poverty reduction policy on health services utilization among the rural poor: a quasi-experimental study in central and western rural China

BackgroundChina poverty reduction policy (PRP) addresses two important elements: the targeted poverty reduction (TPA) project since 2015 in line with social assistance policy as national policy; and reducing inequality in health services utilization by making provision of medical financial assistance (MFA). Therefore, this study aims to assess the effects of the PRP in health services utilization (both inpatient and outpatient services) among the central and western rural poor of China.MethodsThe study conducted household survey and applied propensity score matching (PSM) method to assess the effects of the PRP on health services utilization among the rural poor of Central and Western China. A sensitivity test was also performed on the PSM results to test their robustness.ResultsKey findings showed 17.6% of respondents were the beneficial of PRP. The average treatment effects on the treated (ATT) of the PRP on the inpatient visits within one year was found significantly positive (P = 0.026).ConclusionThere has been relationship between PRP with medical financial assistance and reduction of inequality in health services utilization by the poorer, in particular to accessing the inpatient services from the county or township hospitals of China. Policy makers should pay attention for making provision of improving responsiveness of supply, when subsidizing on the demand side.

Equitable realization of the right to health in Haiti: how household data inform health seeking behavior and financial risk protection.

BackgroundThough the right to health is included in Haiti’s constitution, little progress has been made to expand universal health coverage nationwide, a strategy to ensure access to health services for all, while preventing financial hardship among the poor. Realizing universal health coverage will require a better understanding of inequities in health care utilization and out-of-pocket payments for health. This study measures inequality in health services utilization and the determinants of health seeking behavior in Haiti. It also examines the determinants of catastrophic health expenditures, defined by the Sustainable Development Goal Framework (Indicator 3.8.2) as expenditures that exceed 10% of overall household expenditures.MethodologyThree types of analysis were conducted using the 2012 and 2013 Household Surveys (Enquête sur les Conditions de Vie des Ménages Après Séisme (ECVMAS I (2012) and ECVMAS II (2013)) to measure: 1) outpatient services as a measure of inequalities using the 2013 Concentration Index; 2) drivers of health seeking behavior using a logistic regression model for 2013; and 3) determinants of catastrophic health expenditures using Seemingly Unrelated Regressions for both 2012 and 2013.ResultsThe rate of catastrophic health expenditures increased nationwide from 9.43% in 2012 to 11.54% in 2013. This increase was most notable among the poorest wealth quintile (from 11.62% in 2012 to 18.20% in 2013), yet declined among the richest wealth quintile (from 9.49% to 4.46% during the same period). The increase in the rate of catastrophic health expenditures among the poorest coincides with a sharp decrease in external donor funding for the health sector. Regression analysis indicated that the rich wealth quintiles were less likely than poor wealth quintiles to incur catastrophic health expenditures. Interestingly, households were less likely to incur catastrophic health expenditures when they accessed care from Community Health Workers than when they received care from other types of providers, including public and private health care facilities. This study also shows that Community Health Worker-provided services have a negative concentration index (− 0.22) and are therefore most utilized by poor quintiles. In contrast, both public and private outpatient services had positive concentration indexes (0.05 and 0.12 respectively) and are most utilized by the rich wealth quintiles. Seeking care from traditional healers was found to be pro-poor in Haiti (concentration index of − 0.18) yet was also associated with higher catastrophic health expenditures albeit the coefficient was not significant.ConclusionThe expansion of universal health coverage in Haiti is evolving in a ‘pro-rich’ manner. Realizing Haiti’s right to health will require a course-correction supported by national policies that protect the poor wealth quintiles from catastrophic health expenditures. Such policies may include Community Health Worker service delivery expansion in underserved areas. Evidence-based interventions may also be required to lower outpatient user fees, subsidize drug costs and promote efficiencies in pro-poor disaster relief programming.

Socio-economic inequalities in health services utilization: a cross-sectional study

PurposeDeveloping country workers mainly face important challenges when examining equality in health services utilization among the population and identifying influential factors. The purpose of this paper us to: understand health service use among households with different socio-economic status in Isfahan province; and to investigate probable inequality determinants in service utilization.Design/methodology/approachAlmost 1,040 households living in Isfahan province participated in this cross-sectional study in 2013. Data were collected by a questionnaire with three sections: demographic characteristics; socio-economic status; and health services utilization. The concentration index was applied to measure inequality. Analysts used STATA 11.FindingsEconomic status, educational level, insurance coverage and household gender were the most influential factors on health services utilization. Those with a high socio-economic level were more likely to demand and use such services; although self-medication patterns showed an opposite trend.Practical implicationsFemale-headed families face with more difficulties in access to basic human needs including health. Supportive policies are needed to meet their demands.Originality/valueThe authors used principle component analysis to assess households’ economic situation, which reduced the variables into a single index.

Determining the Socio-Economic Inequalities in Health Services Utilization among Ischemic Heart Disease Patients; Case of Falavarjan City

Determining the Socio-Economic Inequalities in Health Services Utilization among Ischemic Heart Disease Patients; Case of Falavarjan City

Inequalities of general physicians and specialists visits’ utilization and its determinants in Iran: a population based study

Purpose – The purpose of this paper is to study, inequalities between general physicians’ and specialists’ visits in Shiraz. Also, the factors effecting the utilization of visits were determined. Design/methodology/approach – Concentration index and curves, ranked by income and quality of life were used to estimate the amount of inequality in the utilization of services. Health utilization data which had been gathered already were used for this purpose. Poisson regression was used to construct the models. Findings – Results of the study showed that, inequalities in specialists’ visits were higher than GPs’. Complementary insurances users and females used more specialist services. People with higher quality of life utilized fewer GPs’ and specialists’ services. Originality/value – New evidences about inequality in health services utilization and its components in Iran was surveyed.

Income-related inequalities in health care utilization in Mongolia, 2007/2008-2012.

BackgroundAlthough health strategies and policies have addressed equitable distribution of health care in Mongolia, few studies have been conducted on this topic. Rapid socio-economic changes have recently occurred; however, there is no evidence as to how horizontal inequity has changed. The aim of this paper is to evaluate income related-inequalities in health care utilizations and their changes between 2007/2008 and 2012 in Mongolia.MethodsThe data used in this study was taken from the nationwide cross-sectional data sets, the Household Socio-Economic Survey, collected in 2007/2008 and 2012 by the National Statistical Office of Mongolia. We employed the Erreygers’ concentration index to measure inequality in health service utilization. Horizontal inequity was estimated by a difference between actual and predicted use of health services using the indirect standardization method.ResultsThe results show that the concentration indices for tertiary level, private outpatient and inpatient services were significantly positive, the contrary for family group practice/soum hospital outpatient services, in both years. After controlling for need, pro-rich inequity (p < 0.01) was observed in the tertiary level, private outpatient, and general inpatient, services in both years. Pro-poor inequity (p < 0.01) existed in family group practice/soum hospital outpatient services in both years. Degrees of inequity in tertiary level hospital and private hospital outpatient services became more pro-rich, whereas in family group practice/soum hospital outpatient services became more pro-poor from 2007/2008 to 2012. Pro-rich inequity in inpatient services remained the same from 2007/2008 to 2012.ConclusionsEquitable distribution of health care has been well documented in health strategies and policies; however, the degree of inequity in delivery of health services has a tendency to increase in Mongolia. Therefore, there is a need to consider implementation issues of the strategies and refocus on policy prioritizations. It is necessary to strengthen primary health care services, particularly by diminishing obstacles for lower income and higher need groups.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-015-0185-8) contains supplementary material, which is available to authorized users.

Identifying determinants of socioeconomic inequality in health service utilization among patients with chronic non-communicable diseases in China.

BackgroundPeople with chronic non-communicable diseases (NCD) are particularly vulnerable to socioeconomic inequality due to their long-term expensive health needs. This study aimed to assess socioeconomic-related inequality in health service utilization among NCD patients in China and to analyze factors associated with this disparity.MethodsData were taken from the 2008 Chinese National Health Survey, in which a multiple stage stratified random sampling method was employed to survey 56,456 households. We analyzed the distribution of actual use, need-expected use, and need-standardized usage of outpatient services (over a two-week period) and inpatient services (over one-year) across different income groups in 27,233 adult respondents who reported as having a NCD. We used a concentration index to measure inequality in the distribution of health services, which was expressed as HI (Horizontal Inequity Index) for need-standardized use of services. A non-linear probit regression model was employed to detect inequality across socio-economic groups.ResultsPro-rich inequity in health services among NCD patients was more substantial than the average population. A higher degree of pro-rich inequity (HI = 0.253) was found in inpatient services compared to outpatient services (HI = 0.089). Despite a greater need for health services amongst those of lower socio-economic status, their actual use is much less than their more affluent counterparts. Health service underuse by the poor and overuse by the affluent are evident. Household income disparity was the greatest inequality factor in NCD service use for both outpatients (71.3%) and inpatients (108%), more so than health insurance policies. Some medical insurance schemes, such as the MIUE, actually made a pro-rich contribution to health service inequality (16.1% for outpatient and 12.1% for inpatient).ConclusionsInequality in health services amongst NCD patients in China remains largely determined by patient financial capability. The current insurance schemes are insufficient to address this inequity. A comprehensive social policy that encompasses a more progressive taxation package and redistribution of social capital as well as pro-poor welfare is needed.

Growing old before growing rich: inequality in health service utilization among the mid-aged and elderly in Gansu and Zhejiang Provinces, China

BackgroundChina’s recent growth in income has been unequally distributed, resulting in an unusually rapid retreat from relative income equality, which has impacted negatively on health services access. There exists a significant gap between health care utilization in rural and urban areas and inequality in health care access due to differences in socioeconomic status is increasing. We investigate inequality in service utilization among the mid-aged and elderly, with a special attention of health insurance.MethodsThis paper measures the income-related inequality and horizontal inequity in inpatient and outpatient health care utilization among the mid-aged and elderly in two provinces of China. The data for this study come from the pilot survey of the China Health and Retirement Longitudinal Study in Gansu and Zhejiang. Concentration Index (CI) and its decomposition approach were deployed to reflect inequality degree and explore the source of these inequalities.ResultsThere is a pro-rich inequality in the probability of receiving health service utilization in Gansu (CI outpatient = 0.067; CI inpatient = 0.011) and outpatient for Zhejiang (CI = 0.016), but a pro-poor inequality in inpatient utilization in Zhejiang (CI = −0.090). All the Horizontal Inequity Indices (HI) are positive. Income was the dominant factor in health care utilization for out-patient in Gansu (40.3 percent) and Zhejiang (55.5 percent). The non-need factors’ contribution to inequity in Gansu and Zhejiang outpatient care had the same pattern across the two provinces, with the factors evenly split between pro-rich and pro-poor biases. The insurance schemes were strongly pro-rich, except New Cooperative Medical Scheme (NCMS) in Zhejiang.ConclusionsFor the middle-aged and elderly, there is a strong pro-rich inequality of health care utilization in both provinces. Income was the most important factor in outpatient care in both provinces, but access to inpatient care was driven by a mix of income, need and non-need factors that significantly differed across and within the two provinces. These differences were the result of different levels of health care provision, different out-of-pocket expenses for health care and different access to and coverage of health insurance for rural and urban families. To address health care utilization inequality, China will need to reduce the unequal distribution of income and expand the coverage of its health insurance schemes.

Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban-rural inequality in health service utilization among the elderly. A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference-in-differences model was employed and estimated by the random-effect probit method. The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.