Inequality In Service Utilization Research Articles

Geographical inequality in service utilization for primary aldosteronism screening: spatial epidemiological study in Southern Thailand

BackgroundPrimary aldosteronism (PA), the most common cause of secondary hypertension is considered as a “major public health issue” due to higher risk of cardiovascular complications compared to blood-pressure-match hypertension and increase in prevalence around the world. In Thailand, though PA screening is provided under the universal health coverage, the service can be offered only at some centers. Hence, the service availability affects an accessibility of health care in patients. Our study aimed to evaluate the service utilization in PA screening and diagnosis in terms of geographical inequality in health resources in Southern Thailand.MethodsData of 688 patients who underwent PA screening from 2011 to 2017 were obtained from the electronic database of Songklanagarind Hospital, a super-tertiary center in this region. The patients’ residence in the province, district and subdistrict were transformed to a 6-digit numbers corresponding to the global one (GADM©). The areas with PA screening and diagnosis were visualized by disease mapping procedures. A general log linear model was used to identify the factors affecting patient’s service accessibility.ResultsFrom the geographic distribution, patients living in or near the area of the super-tertiary center (Songkhla) had high probability of receiving PA screening. The analysis of factors contributing to PA screening by multivariate log-linear model demonstrated that the distance from the super-tertiary center was a predictive factor for screening while the presence of endocrinologists and cultural differences were not. The chance of patients living in Songkhla, living less than 200 km, and more than 200 km from Songkhla to receive PA screening was 100, 82, and 66%, respectively. The crude incidence rate of PA in Southern Thailand was 1.66/106 person-years. The provinces located adjacent to the Andaman Sea had the highest incidences of PA (3.62-5.17 patients/106 person-years).ConclusionsThere is still geographical inequality and the strategy to decrease the barrier should be resolved. The policymaker should develop a transfer system of blood tests for PA investigation from the local hospital to reduce the burden such as transportation costs in patients who live far away from the super-tertiary hospital. In addition, PA screening should be implemented in hypertension care plan.

Can the implementation of family doctor contracted service enable the elderly to utilize primary health care services more equally? empirical evidence from Shandong, China

BackgroundWhile the elderly are facing greater health risks, they also face more serious inequalities in utilization of medical services. The family doctor contracted service is the core policy of the Chinese government to cope with aging and to achieve the outcome that everyone has the right to primary health care. However, previous research has neither revealed the degree of inequality in the use of contracted services among the elderly in China, nor has it revealed what factors are related to the inequality in the use of services.ObjectiveAssess and decompose the inequality in the use of family doctors contracted services in the elderly population in China.MethodsA cross-sectional study of 1037 elderly people was conducted in Shandong Province, China. According to the first consultation rate of family doctors, the physical examination rate, the healthy lifestyle guidance rate and the chronic disease management rate, the situation of elderly people’s utilization of family doctor contracted service was investigated. The concentration index is used to measure the degree of inequality in the use of family doctors contracted services by the elderly. In order to test the contribution of different factors to the inequality of utilization of family doctors contracted services, the concentration index was also decomposed.ResultsThe first consultation rate of family doctors for the elderly in Shandong Province was 24.6%, the physical examination rate was 65.8%, the healthy lifestyle guidance rate was 13.7%, and the chronic disease management rate was 52.2%. The horizontal inequality index of the healthy lifestyle guidance rate and the chronic disease management rate were 0.451 and 0.573, respectively, indicating that there is an inequality of pro-wealth. The concentration index of physical examination rate and chronic disease management rate is negative (− 0.260, − 0.518), which means inequality to the poor. Education level is the most important factor affecting the unequal utilization of health services for the elderly, followed by income.ConclusionThe family doctor contracted service has had a positive impact on alleviating the health inequality in the utilization of basic medical and health services for the elderly. Although there is still inequality in terms of pro-wealth for the elderly, the utilization of family doctor contracted service has weakened the inequality of service utilization brought about by income. Enhancing the health literacy of the elderly, narrowing the gap between the rich and the poor, bridging the gap between urban and rural areas, and building a harmonious family relationship can promote the realization of basic medical and health care services for every elderly.

Inequities in the Uptake of Reproductive and Maternal Health Services in the Biggest Regional State of Ethiopia: Too Far from "Leaving No One Behind".

BackgroundDespite improvement in the coverage of most maternal, newborn, and child health services, inequality in the uptake of services still remains the challenge of health systems in most developing countries. This study was conducted to examine the degree of inequities and potential predictors of inequity in reproductive and maternal health services utilization in the Oromia region, Ethiopia.MethodsThe 2016 Ethiopian demographic and health survey data set was used. Utilization rate of four maternal health service categories (family planning, antenatal care, facility based delivery and postnatal care) was considered in the analysis. Equity in each of these indicators was assessed by residence (urban/rural), wealth index, and educational status. Inequality in service utilization was estimated using rate ratios, concentration curve, and concentration indices.ResultsOverall data of 5701 women were used in this analysis. The concentration index to all of the maternal health service utilization indicators showed significance. The concentration index of family planning, antenatal care, facility based delivery, and postnatal care was 0.136 (95% CI=0.099–0.173), 0.106 (95% CI=0.035–0.177), 0.348 (95% CI=0.279–0.418), and 0.348 (95% CI=0.279–0.418), respectively. Maternal age and all of the three socio-demographic factors (residence, education, and wealth) showed inequitable distribution of maternal health service utilization in the Oromia region. The majority of women who were in the favored groups utilized the key reproductive and maternal health services.ConclusionThe utilization of maternal health services in the study area is grossly skewed to those who are well off, educated, and live in urban areas. Any action intended to improve utilization of maternal and child health services should aim to reduce the unnecessary and avoidable disparity demonstrated in our analysis. This of course demands multisectoral intervention to impact on the determinants.

Wealth stratified inequalities in service utilisation of breast cancer screening across the geographical regions: a pooled decomposition analysis

BackgroundBreast cancer is the most commonly occurring cancer among women in low-resourced countries. Reduction of its impacts is achievable with regular screening and early detection. The main aim of the study was to examine the role of wealth stratified inequality in the utilisation breast cancer screening (BCS) services and identified potential factors contribute to the observed inequalities.MethodsA population-based cross-sectional multi-country analysis was used to study the utilisation of BCS services. Regression-based decomposition analyses were applied to examine the magnitude of the impact of inequalities on the utilisation of BCS services and to identify potential factors contributing to these outcomes. Observations from 140,974 women aged greater than or equal to 40 years were used in the analysis from 14 low-resource countries from the latest available national-level Demographic and Health Surveys (2008–09 to 2016).ResultsThe population-weighted mean utilisation of BCS services was low at 15.41% (95% CI: 15.22, 15.60), varying from 80.82% in European countries to 25.26% in South American countries, 16.95% in North American countries, 15.06% in Asia and 13.84% in African countries. Women with higher socioeconomic status (SES) had higher utilisation of BCS services (15%) than those with lower SES (9%). A high degree of inequality in accessing and the use of BCS services existed in all study countries across geographical areas. Older women, access to limited mass media communication, being insured, rurality and low wealth score were found to be significantly associated with lower utilisation of BCS services. Together they explained approximately 60% in the total inequality in utilisation of BCS services.ConclusionsThe level of wealth relates to the inequality in accessing BCS amongst reproductive women in these 14 low-resource countries. The findings may assist policymakers to develop risk-pooling financial mechanisms and design strategies to increase community awareness of BCS services. These strategies may contribute to reducing inequalities associated with achieving higher rates of the utilisation of BCS services.

Sex-specific prevalence, inequality and associated predictors of hypertension, diabetes, and comorbidity among Bangladeshi adults: results from a nationwide cross-sectional demographic and health survey

ObjectivesTo determine the sex-specific prevalence, inequality and factors associated with healthcare utilisation for diabetes mellitus (DM), hypertension and comorbidity among the adult population of Bangladesh.Study designThis study analysed cross-sectional nationwide...

Global Inequality in Maternal Health Care Service Utilization: Implications for Sustainable Development Goals.

Purpose: Globally, low-middle-income countries continue to account for almost all of the pregnancy-related mortalities that are largely preventable through adequate utilization of essential maternal health care services such as antenatal care (ANC) and skilled birth assistance (SBA). Promoting the use of ANC and SBA services are hindered by numerous policy- and capacity-related barriers along with widespread inequality in utilization of the existing services that further exacerbates the scenario. In an attempt to better understand the geography of inequality in service utilization, we conducted this brief descriptive study by using World Health Organization (WHO) data on ANC and SBA utilization among the member states.Methods: This was a descriptive study based on open access data on ANC and SBA use between 2012 and 2015 available through the Global Health Observatory of WHO. Country-level data were collected for Asia (41 countries), Africa (35 countries), Europe (35 countries), North America (10 countries), Latin America and the Caribbean (25 countries), and Oceania (16 countries). Cross-country and continent comparisons were made using dot and bar charts.Results: The overall prevalence of ANC and SBA use were, respectively, 78.17% and 88.33%. Considerable disparities were found in terms of ANC and SBA use across the continents, especially in Asia and Africa. Globally, the poorest performing countries included Afghanistan, Somalia, and South Sudan where more than three-quarters of the women remain deprived of ANC and SBA services during the period of 2012 and 2015. The greatest inequality in ANC use was observed in Africa (9.4% in Somalia and 99.9% in Libya), whereas that of SBA use was observed in Asia (17.8% in Afghanistan vs. 100% in Bahrain). Europe was the most equal of all regions in terms of both ANC (66.8% in Albania vs. 99.7% in Belarus) and SBA (94.4% in Denmark vs. 100% in Lithuania) use.Conclusion: Although in the majority of countries more than three-quarters of the women receive ANC and SBA services, the extent of intraregional inequality remains overwhelming especially for Asia and Africa. Progress toward maternal health-related targets should be interpreted in terms of the disparities to ensure a more even and sustainable outcome at both national and global level.

Utilization and out of pocket (OOP) payment for physiotherapy services in public hospitals of Shahid Beheshti University of Medical Sciences.

Background: Physiotherapy services constitute a principle part of health care systems, and interest in their use has increased in the recent decades. This study was conducted to investigate the utilization and OOP payment for physiotherapy services in public hospitals of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Methods: This cross-sectional study was conducted using the data of physiotherapy department of three public hospitals. The study sample included 6528 patients who had received 7257 episodes of care. Data were extracted through hospital information systems and analyzed using multivariate regression analysis by SPSS17. Results: The average episode per patient was 1.11 and 12.6 session per episode. The average cost of each episode and treatment session was 1 784 660 IRR (USD 59) and 142 023 IRR (USD 4.7), respectively. The OOP payment share for physiotherapy was 31%. Age, OOP amount, having insurance coverage, insurance type, and service type significantly affected physiotherapy utilization. Number of treatment sessions, having insurance coverage, type of insurance coverage, and gender were related to OOP payment. Conclusion: There is a large variety in utilization and OOP payment in the insurance funds, which could restrict the accessibility and utilization of services by patients, leading to inequalities in utilization. Therefore, policymakers should conduct an overall review on the tariffs and service packages of insurer organizations to provide better conditions for the elderly, unhealthy, and vulnerable population to mitigate inequality in service utilization and decrease OOP payment.

Explaining inequity in the use of institutional delivery services in selected countries.

Wealth-related disparities in the use of reproductive health services remain a substantial problem in many low- and middle-income countries. Very few studies have attempted to explain such inequalities through decomposition of the contributions made by various individual- and household-level factors. This study aims to: (1) assess the degree of wealth-related inequality and inequity in the use of institutional delivery services in selected low- and middle-income countries, and (2) to explain wealth-related inequity through decomposition by the contributions made by various components, including health insurance coverage. Data come from Demographic and Health Surveys in three countries: Ghana, Rwanda, and the Philippines. Concentration indices are used to calculate inequality and horizontal inequity in service utilization. Multivariate methods are used to decompose inequity. Findings indicate a moderate to high degree of inequity in institutional delivery service use in all study countries. The study provides some evidence of the contribution of health insurance to increased wealth-related inequity in the use of institutional delivery services, although having health insurance was also associated with increased utilization of services. Results suggest that increased health insurance coverage does not automatically translate to lower wealth-related inequity in service utilization. Inequities in service utilization exist if there are still inequities in the health insurance status. The study advocates for expanding health insurance coverage, particularly among the poor to reduce inequity in insurance coverage and increase service utilization.

Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey.

BackgroundAntenatal Care (ANC), use of skilled delivery attendants and postnatal care (PNC) services are key maternal health services that can significantly reduce maternal mortality. Understanding the factors that affect service utilization helps to design appropriate strategies and policies towards improvement of service utilization and thereby reduce maternal mortality. The objective of this study was to identify factors that affect utilization of maternal health services in Ethiopia.MethodsData were drawn from the 2011 Ethiopia Demographic and Health Survey. The dependent variables were use of ANC, skilled delivery attendants and PNC services. The independent variables were categorized as socio-cultural, perceived needs and accessibility related factors. Data analysis was done using SPSS for windows version 20.0. Bivariate and multivariate logistic regression models were used in the analysis.ResultsThirty four percent of women had ANC visits, 11.7% used skilled delivery attendants and 9.7% of women had a postnatal health checkup. Education of women, place of residence, ethnicity, parity, women’s autonomy and household wealth had a significant association with the use of maternal health services. Women who completed higher education were more likely to use ANC (AOR = 3.8, 95% CI = 1.8-7.8), skilled delivery attendants (AOR = 3.4, 95% CI = 1.9-6.2) and PNC (AOR = 3.2, 95% CI = 2.0-5.2). Women from urban areas use ANC (AOR = 2.3, 95% CI = 1.9-2.9), skilled delivery attendants (AOR = 4.9, 95% CI = 3.8-6.3) and PNC services (AOR = 2.6, 95% CI = 2.0-3.4) more than women from rural areas. Women who have had ANC visits during the index pregnancy were more likely to subsequently use skilled delivery attendants (AOR = 1.3, 95% CI = 1.1-1.7) and PNC (AOR = 3.4, 95% CI = 2.8-4.1). Utilization of ANC, delivery and PNC services is more among more autonomous women than those whose spending is controlled by other people.ConclusionMaternal health service utilization in Ethiopia is very low. Socio-demographic and accessibility related factors are major determinants of service utilization. There is a high inequality in service utilization among women with differences in education, household wealth, autonomy and residence. ANC is an important entry point for subsequent use of delivery and PNC services. Strategies that aim improving maternal health service utilization should target improvement of education, economic status and empowerment of women.

Equity in Maternal Health in South Africa: Analysis of Health Service Access and Health Status in a National Household Survey

BackgroundSouth Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources.MethodsAnalysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data.FindingsPoorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2–6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group.ConclusionsAside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.

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.

Change in determinants of use of physician services in Finland between 1987 and 1996

The determinants of use of physician services in Finland in 1987 and 1996 were studied to evaluate how the utilisation altered over this period, which saw fairly radical changes in Finnish health care and the entire economy. We used econometric methods to describe the changes in structure and level of utilisation. The study was based on the Finnish Health Care Surveys of 1987 and 1996, which were nationally representative cross-sectional samples of the total non-institutionalised population. Visits to a doctor were analysed using a two-part model (logit +truncated negative binomial regression). Structural changes were tested by a Chow-type test and changes in utilisation level by a dummy variable indicating the year of study. Analyses were made separately for four different age groups: children aged 0–6 and 7–17, and adults aged 18–64 and over 64 years. The change in utilisation of physician services over the nine-year period was a product of both structural and level changes. Except in the youngest age group, both types of changes occurred in the second part of the utilisation model, which implies that they were more associated with supply side factors than demand factors. Among young children, the type of day-care seems to have been an important determinant of physician utilisation. Although its effect decreased considerably over the period, the total number of visits to a doctor in 1996 was still about 30% greater among children in nursery care than those at home. The rise in self-reported chronic illness was an important explanation of the increase in utilisation of doctors’ services, especially among children. Among adults aged 18–64, the most important structural change was an increase of the effect of self-rated health status variables on utilisation. Inequity in utilisation of services persisted with respect to income. In conclusion it can be stated that Finland's tax-based and locally decentralised health care system adapted quite well to the radical changes experienced during the study period.

Beyond Equity in the Delivery of Alcohol and Drug Abuse Treatment Services

Equity in service utilization has become an important policy goal of federally-, state-, and locally-funded alcohol and drug treatment programs. A number of conceptual and methodological issues surrounding equity, including its strengths and limitations as a policy goal, are addressed. Among the many issues discussed is the observation that inequity in service utilization carries evaluative connotations in that a service system is likely to be judged as unsatisfactory, inadequate, or inappropriate when the inequity is modest, and as morally reprehensible when the inequity is significant. Violation of the norm of equity is a prescription for institutional reform and political action. On the other hand, policies that would increase the equity in service utilization may be incompatible with the goal of “service on demand” and they may have no consequent effect of increasing service efficacy. Moreover, there are some arrangements in which maintaining or even increasing inequity would be cost-effective. Other methodological, conceptual and policy-related issues are addressed.