Inequalities In Health Care Utilization Research Articles

Do Gatekeeping Schemes Influence Health Care Utilization Behavior Among Patients With Different Educational Background? An Analysis of 13 European Countries.

Gatekeeping has been introduced to regulate health care demand and to decrease existing educational inequalities in specialist utilization. This article aims to test whether these policy intentions are met effectively. By pooling two waves of the Survey of Health, Ageing, and Retirement in Europe (SHARE), this study performs a cross-country comparison of the impact of two different types of gatekeeping-obligatory referral and skip-and-pay schemes-on absolute and relative general practitioner and specialist utilization levels as well as their moderating effect on inequalities in health care utilization according to education. Results imply that skip-and-pay gatekeeping schemes are not successful in decreasing specialist use and, moreover, aggravate inequalities in health care use, according to education. These findings question the role of choice in health care and call for instruments other than gatekeeping to make health care more efficient and to buffer existing educational inequalities in health care use.

Factors predicting health services use among older people in China: An analysis of the China Health and Retirement Longitudinal Study 2013.

BackgroundRapid population ageing in China is increasing the numbers of older people who are likely to require health services in response to higher levels of poor perceived health and chronic diseases. Understanding factors influencing health services use at late life will help to plan for increasing needs for health care, reducing inequalities in health services use and releasing severe pressures on a highly variable health care system that has constrained public resources and increasing reliance on health insurance and user payments.MethodsDrawing on the nationally representative China Health and Retirement Longitudinal Study 2013 data, we apply the Andersen healthcare utilization conceptual model to binary logistic regression multivariate analyses to examine the joint predictors of physical examinations, outpatient and inpatient care among the middle-aged and elderly in China.ResultsThe multivariate analyses find that both physical examinations and inpatient care rates increase significantly by age when health deteriorates. Females are less likely to use inpatient care. Significant socio-economic variations exist in healthcare utilization. Older people with higher education, communist party membership, urban residence, non-agricultural household registration, better financial situation are more likely to have physical examinations or inpatient care. Factors influencing all three types of health care utilization are household expenditure, losing a partner, having multiple chronic diseases or perceiving poor health. With activities of daily living limitations or pain increases the probability of seeing a doctor while with functional loss increases the rates of having physical examinations, but being the ethnic minorities, no social health insurance, with depression, fair or poor memory could be a barrier to having physical examinations or seeing a doctor, which might delay the early diagnose of severe health problems among these groups. Not drinking, not smoking and regular physical exercises are adaptations after having health problems.ConclusionsAs a rapidly ageing society, in order to address the increasing needs and inequalities in health care utilization, China is facing a massive challenge to reform the current health care system, improve equitable access to health insurance and financial affordability for the most disadvantaged, as well as to provide more health education and information to the general public.

Inequality and inequity in healthcare utilization in urban Nepal: a cross-sectional observational study.

Inequality in access to quality healthcare is a major health policy challenge in many low- and middle-income countries. This study aimed to identify the major sources of inequity in healthcare utilization using a population-based household survey from urban Nepal. A cross-sectional survey was conducted covering 9177 individuals residing in 1997 households in five municipalities of Kathmandu valley between 2011 and 2012. The concentration index was calculated and a decomposition method was used to measure inequality in healthcare utilization, along with a horizontal inequity index (HI) to estimate socioeconomic inequalities in healthcare utilization. Results showed a significant pro-rich distribution of general healthcare utilization in all service providers (Concentration Index: 0.062, P < 0.001; HI: 0.029, P < 0.05) and private service providers (Concentration Index: 0.070, P < 0.001; HI: 0.030, P < 0.05). The pro-rich distribution of probability in general healthcare utilization was attributable to inequalities in the level of household economic status (percentage contribution: 67.8%) and in the self-reported prevalence of non-communicable diseases such as hypertension (36.7%) and diabetes (14.4%). Despite the provision of free services by public healthcare providers, our analysis found no evidence of the poor making more use of public health services (Concentration Index: 0.041, P = 0.094). Interventions to reduce the household economic burden of major illnesses, coupled with improvement in the management of public health facilities, warrant further attention by policy-makers.

Urbanization and Inequality in Hypertension Diagnosis and Medication in Indonesia

Urbanization has been progressing quickly in Indonesia and the consequences on health and health inequities are still not well understood. In this paper, we present new empirical evidence on the differences in the utilization of health care services between rural and urban areas as well as for the respective health inequities. Exploiting the rich data set of the Indonesian Family Life Survey, this paper measures the socioeconomic inequality of health care utilization for the case of the diagnosis of hypertension and its medication. In the Indonesian Family Life Survey, about 45% of all respondents over the age of 39 were found to suffer from hypertension (average systolic blood pressure higher than 140). However, more than half of the people with hypertension have never been diagnosed by a health care professional, and only a small fraction of the people suffering from hypertension are taking medicine for it. Our analysis further shows that diagnosis and medication rates are significantly higher in urban areas than in rural areas, implying that urban areas offer better access to health care services and medicines. Calculating concentration indices, we find that under-diagnosis of hypertension is more prevalent among the poor and this health inequality is more pronounced in rural areas. For the case of medication, we are unable to detect strong evidence of inequality either in rural or urban areas, as most Indonesians with hypertension do not take medicine irrespective of their socioeconomic status. Finally, decomposition analysis shows that the inequality in education, living standards, sanitary conditions, and the possession of vehicle and home appliances can explain a large fraction of the inequality of diagnosis and medication.

Income Inequities in Health Care Utilization among Adults Aged 50 and Older.

Equitable access to and utilization of health services is a primary goal for many health care systems, particularly in countries with universal publicly funded systems. Despite concerns regarding potentially adverse implications of the 1990s' health care policy and other reforms, whether and how income inequalities in service utilization changed remains unclear. This study addressed the impact of income on physician and hospital utilization from 1992-2002 among adults aged 50 and older in British Columbia. Those with lower incomes were found less likely to access general practitioner and specialist services but more likely to access hospital services. Income-related disparities in physician care increased over time; hospital care declined. Volume of GP and hospital care was inversely associated with income; these differences increased regarding GP services only. Findings of declines in hospital-care access, accompanied by increasing income-related disparities in physician-services access, show that inequities are increasing within Canada's health care system.

Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008

BackgroundTurkish health system showed major improvements in health outcomes since initiation of the Health Transition Programme (HTP) in 2003, however little is known regarding income-related inequalities in health care use. The aim of this study was to assess horizontal inequities in health care use in Turkey. MethodsWe used the data from Turkish Health Survey 2008 with 14,655 respondents. We calculated concentration index (C) and horizontal inequity index (HI) to measure the socioeconomic inequalities in utilization of general practitioner (GP) care, specialist care, inpatient care, dental care and emergency care. Contributions of each factor to the observed inequality in health care utilization were assessed through decomposition method. ResultsThere was a significant pro-rich inequality in specialist care and oral health care utilization among individuals as indicated by positive values of HI (=0.1149) and HI (=0.1137), respectively. However, the poor were more likely to utilize emergency care (HI=−0.0461) and inpatient care (HI=−0.0731). GP care was also slightly pro-poor distributed (HI=−0.0042). ConclusionPro-poor income-related inequalities in health care use were largely explained by greater health care need among low income groups, while non-need factors were the main determinants for pro-rich utilization (education, residence area). Inequalities in dental and specialist care linked to low income, low education level and rural areas should be given priority by decision makers to reduce the negative impact of utilization on health. Our results provide some evidence of inequity in 2008, after the introduction of HTP and provide a baseline against which the effects of the new reforms can be assessed.

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.

How do income and education affect health inequality: evidence from four developing countries

Using household survey data from four countries ‒ Albania, Nepal, Tajikistan and Tanzania ‒ this article calculates income-related inequality in health care utilization. We measure health disparity separately for generally and chronically ill individuals by constructing two models: one for the probability of a visit to a physician and another for the number of visits. Following model-based measurements, we decompose inequality into two major parts: one accounted for by identity-related factors and another by socioeconomic and other factors such as education, geography and distance to a clinic. We propose a new method to quantify the effect of changes in income and education on health disparity. One of our important findings suggests that health disparity is pro-rich in all our sample countries. The pro-rich disparity is prevalent among generally ill as well as chronically ill patients, in both visit probability and visit frequency models. Health inequality seems primarily driven by income differences followed by nonidentity factors. Further, the principle of equal treatment for equal need is not fulfilled in any of our countries. Among policy implications, increasing average income and education in a way that also reduces disparity in income and education, respectively, will substantially shrink inequality in health care utilization.

Health service use, out-of-pocket payments and catastrophic health expenditure among older people in India: The WHO Study on global AGEing and adult health (SAGE)

BackgroundHealthcare financing through out-of-pocket payments and inequities in healthcare utilisation are common in low and middle income countries (LMICs). Given the dearth of pertinent studies on these issues among older...

Socioeconomic inequities in health care utilization in China.

The study assessed the present degree of inequity in health care utilization as well as the contributions of the main determinants in the context of expending health insurance coverage in China. Data were obtained from the 2008 National Health Services Survey (NHSS) in China. A concentration index was used to quantify the degree of income-related inequity in health care utilization. The need-standardized concentration indexes of outpatient care and inpatient care were 0.015 and 0.197, respectively. Income made the largest contribution to inequity favoring the better-off in the use of health care. The impacts of health insurance schemes on overall inequity varied according to the insurance memberships as well as types of services. The study revealed a pro-rich distribution of the probability of health care across income groups in China. Increased financial protection ability of medical insurance system remains a vital cornerstone to tackle the health care utilization inequity.

Horizontal Inequity in Elderly Health Care Utilization: Evidence from India.

Against the backdrop of population aging, this paper presents the analysis of need-standardised health care utilization among elderly in India. Based on nationally representative morbidity and health care survey 2004, we demonstrate that the need for health care utilization is indeed pro-poor in nature. However, the actual health care utilization is concentrated among richer sections of the population. Further, the decomposition analysis reveals that income has a very strong role in shifting the distribution of health care away from the poor elderly. The impact of income on utilization is well-demonstrated even at the ecological-level as states with higher per capita incomes have higher elderly health care utilization even as the levels of need-predicted distribution across these states are similar. We also find that the distribution of elderly across social groups and their educational achievements favours the rich and significantly contributes to overall inequality. Nevertheless, contribution of need-related self-assessed health clearly favours pro-poor inequality. In concluding, we argue that to reduce such inequities in health care utilization it is necessary to increase public investments in health care infrastructure including geriatric care particularly in rural areas and underdeveloped regions to enhance access and quality of health care for the elderly.

Inequities in health care utilization by people aged 50+: Evidence from 12 European countries

The aim of this study is to describe the magnitude of educational inequities in the use of health care services, by people aged 50+, in 12 European countries, controlling for country-level heterogeneity. We consider four services: having seen or talked to 1) a general practitioner (GP) or 2) specialist, 3) having been hospitalized, and 4) having visited a dentist (only for prevention). Data derived from the SHARE (Survey of Health, Ageing and Retirement in Europe) project, a cross-national panel that collects information from individuals aged 50 and over. A Fixed Effects approach is applied, which is a valuable alternative to the application of conventional multilevel models in country-comparative analysis. The main findings of this study confirm that there is substantial educational inequity in the use of health care, although relevant differences arise between services. A clear pro-educated gradient is found for specialists and dentist visits, whereas no evidence of educational disparities was found for GP use. On the other hand, less clear results emerge regarding hospitalizations. However, the analysis shows that micro-level dimensions, i.e. individual needs and predisposing and enabling population characteristics, and macro level factors, i.e. health care system and welfare regime, interact to determine people's use of health services. It can be concluded that people with more education level have more resources (cognitive, communicative, relational) that allow them to make more informed choices and take more effective actions for their health goals, however, the institutional context may modify this relationship.

Does socioeconomic inequality in health care utilisation vary across different health care needs in low- and middle-income countries?

Background Despite recognition that universal health coverage should include a continuum of care, including for non-communicable diseases (NCDs), little is known about equality of care for chronic needs in low- and middle-income countries (LMICs). Past research has focused on maternal health care inequalities. Comparing equality of care for different care needs may identify priorities and generate new hypotheses about causal pathways. Methods This analysis uses data on 38 LMICs surveyed in the 2002-2004 World Health Survey. Wealth-related inequality in use …

Racial Inequities in Health Care Utilization and Costs for Immigrant Minorities With Pancreatic Disorders

Introduction: The pancreatic disorders (PDs) acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) are the leading causes of gastrointestinal hospital admissions and cancer death. PDs have a higher incidence and prevalence in blacks but there is a paucity of data on the impact of PD on other racial groups. Our aim is to further determine racial differences in health care utilization and outcomes of PD in the United States. Methods: Using the Nationwide Inpatient Sample, adult patients (≥18 years) with a primary discharge diagnosis of AP, CP or PDAC from 2011 were identified and studied. Results: A total of 340,231 discharges were identified with a primary diagnosis of AP (83%), CP (5%), or PDAC (12%). Racial distribution demonstrated that 65.5% were white (WH), 16.9% black (AA), 12.2% Hispanic (H), 1.7% Asian/Pacific Islander (AP), 0.7% Native American (NA) and 2.9% other race. Demographics were significantly different between populations. The majority of AA and NA populations were in the lowest income quartile. The majority of AP populations were in the top 2 income quartiles. On univariate analysis, NAs had the lowest mortality rate (0.5%; p<0.001), length of stay (LOS; 2.8 days; p<0.001) and total hospital charge ($15,646; p<0.001). APs had the highest total hospital charge ($32,836; p<0.001). On multivariate analysis (Table 1), compared to WHs, LOS was shorter for AAs, Hs, and NAs. Compared to WHs, hospital charges were less in AAs but higher in H and AP populations.Table 1: Multivariate Analysis of Race and Pancreatic Disease Health Care Utilization and OutcomesConclusion: Of the races evaluated, the immigrant minorities, Hispanic, and Asian/Pacific Islanders have different income demographics and length of stay yet have higher total hospital charges compared to Blacks, Native Americans, and Whites in pancreatic disorders. Our study demonstrates that significant pancreatic disorder health care utilization and outcome differences exist within minority groups that require additional investigation.

Measurement of Inequalities in Health Care Utilization in Korea Using Korea Health Panel

Measurement of Inequalities in Health Care Utilization in Korea Using Korea Health Panel

Comparing income inequalities in healthcare utilization in the low income community in suburban Kuala Lumpur and Malaysia

Background This paper aims to measure and compare income inequalities in healthcare utilization in the low income community in suburban Kuala Lumpur as compared to the national population level in Malaysia. The prevalence of those who sought outpatient treatment for acute and chronic illnesses and also prevalence of inpatient admission in both public and private health facilities were compared.

How affordable is health care in the United States and other countries?

How affordable is health care in the United States and other countries?

Equity in the Utilization of Healthcare Services in India: Evidence From National Sample Survey

Background: The pursuit of equity in health and healthcare has been the key feature of health policy in India. However, despite the policy significance, the volume of literature available on this issue is scarce. Therefore, this paper is an attempt to examine the horizontal inequities in healthcare utilization, consisting of outpatient and inpatient care in 15 major states and north-eastern region of India. Methods: Cross-sectional data were taken from the National Sample Survey Organization (NSSO) 60th round (2004), the survey on ‘morbidity and healthcare’. While outpatient care was assessed using the probability of outpatient visit 15 days prior to the survey date, the indicators of inpatient care utilization were based on the following variables: the probability of hospital admission and length of stay in hospital over a 12-month period. All these measures of healthcare utilization were standardized for need differences and controlled for socio-economic factors. Need standardized concentration indices were used to measure interstate and intrastate income-related inequities in healthcare utilization. Results: Absolute inequalities were found between states in the proportion of the population reporting a visit to an outpatient provider, in the range of 4.42% to 21.72%. Similarly, inpatient care varied from 1% to 10%. The magnitude of inequity for both outpatient and inpatient care was pro-rich across rural and urban areas of India and in majority of the states. In fact, in majority of the states, the horizontal inequity across types of curative care was noticeably higher within the rural population than in the urban population. The analysis demonstrated that high per capita government health spending was significantly associated with low inequity in utilization of inpatient care. Conclusion: The study concludes that it would be necessary to address the prevailing inequities in healthcare by substantially scaling up the public spending on health, and achieving effective universal coverage of healthcare in India.

Inequalities in public health care delivery in Zambia.

BackgroundAccess to adequate health services that is of acceptable quality is important in the move towards universal health coverage. However, previous studies have revealed inequities in health care utilisation in the favour of the rich. Further, those with the greatest need for health services are not getting a fair share. In Zambia, though equity in access is extolled in government documents, there is evidence suggesting that those needing health services are not receiving their fair share. This study seeks therefore, to assess if socioeconomic related inequalities/inequities in public health service utilisation in Zambia still persist.MethodsThe 2010 nationally representative Zambia Living Conditions and Monitoring Survey data are used. Inequality is assessed using concentration curves and concentrations indices while inequity is assessed using a horizontal equity index: an index of inequity across socioeconomic status groups, based on standardizing health service utilisation for health care need. Public health services considered include public health post visits, public clinic visits, public hospital visits and total public facility visits.ResultsThere is evidence of pro-poor inequality in public primary health care utilisation but a pro-rich inequality in hospital visits. The concentration indices for public health post visits and public clinic visits are −0.28 and −0.09 respectively while that of public hospitals is 0.06. After controlling for need, the pro-poor distribution is maintained at primary facilities and with a pro-rich distribution at hospitals. The horizontal equity indices for health post and clinic are estimated at −0.23 and −0.04 respectively while that of public hospitals is estimated at 0.11. A pro-rich inequity is observed when all the public facilities are combined (horizontal equity index = 0.01) though statistically insignificant.ConclusionThe results of the paper point to areas of focus in ensuring equitable access to health services especially for the poor and needy. This includes strengthening primary facilities that serve the poor and reducing access barriers to ensure that health care utilisation at higher-level facilities is distributed in accordance with need for it. These initiatives may well reduce the observed inequities and accelerate the move towards universal health coverage in Zambia.

Equity in the utilization of healthcare services in India: evidence from National Sample Survey

The pursuit of equity in health and healthcare has been the key feature of health policy in India. However, despite the policy significance, the volume of literature available on this issue is scarce. Therefore, this paper is an attempt to examine the horizontal inequities in healthcare utilization, consisting of outpatient and inpatient care in 15 major states and north-eastern region of India. Cross-sectional data were taken from the National Sample Survey Organization (NSSO) 60th round (2004), the survey on 'morbidity and healthcare'. While outpatient care was assessed using the probability of outpatient visit 15 days prior to the survey date, the indicators of inpatient care utilization were based on the following variables: the probability of hospital admission and length of stay in hospital over a 12-month period. All these measures of healthcare utilization were standardized for need differences and controlled for socio-economic factors. Need standardized concentration indices were used to measure interstate and intrastate income-related inequities in healthcare utilization. Absolute inequalities were found between states in the proportion of the population reporting a visit to an outpatient provider, in the range of 4.42% to 21.72%. Similarly, inpatient care varied from 1% to 10%. The magnitude of inequity for both outpatient and inpatient care was pro-rich across rural and urban areas of India and in majority of the states. In fact, in majority of the states, the horizontal inequity across types of curative care was noticeably higher within the rural population than in the urban population. The analysis demonstrated that high per capita government health spending was significantly associated with low inequity in utilization of inpatient care. The study concludes that it would be necessary to address the prevailing inequities in healthcare by substantially scaling up the public spending on health, and achieving effective universal coverage of healthcare in India.