Equity in Health and Health Care11This chapter was written when Marc Fleurbaey was research associate at CORE. We thank Chiara Canta, Tom McGuire, Tom van Ourti and Fred Schrogen for their useful comments

Equity in vaccine coverage in Uganda from 2000 to 2016: revealing the multifaceted nature of inequity

BACKGROUND

This study analyses vaccine coverage and equity among children under five years of age in Uganda based on the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Understanding equity in vaccine access and the determinants is crucial for the redress of emerging as well as persistent inequities.

METHODS

Applied to the UDHS for 2000, 2006, 2011, and 2016, the Vaccine Economics Research for Sustainability and Equity (VERSE) Equity Toolkit provides a multivariate assessment of immunization coverage and equity by (1) ranking the sample population with a composite direct unfairness index, (2) generating quantitative measure of efficiency (coverage) and equity, and (3) decomposing inequity into its contributing factors. The direct unfairness ranking variable is the predicted vaccination coverage from a logistic model based upon fair and unfair sources of variation in vaccination coverage. Our fair source of variation is defined as the child's age - children too young to receive routine immunization are not expected to be vaccinated. Unfair sources of variation are the child's region of residence, and whether they live in an urban or rural area, the mother's education level, the household's socioeconomic status, the child's sex, and their insurance coverage status. For each unfair source of variation, we identify a "more privileged" situation.

RESULTS

The coverage and equity of the Diphtheria-Pertussis-Tetanus vaccine, 3rd dose (DPT3) and the Measles-Containing Vaccine, 1st dose (MCV1) - two vaccines indicative of the health system's performance - improved significantly since 2000, from 49.7% to 76.8% and 67.8% to 82.7%, respectively, and there are fewer zero-dose children: from 8.4% to 2.2%. Improvements in retaining children in the program so that they complete the immunization schedule are more modest (from 38.1% to 40.8%). Progress in coverage was pro-poor, with concentration indices (wealth only) moving from 0.127 (DPT3) and 0.123 (MCV1) in 2000 to -0.042 and -0.029 in 2016. Gains in overall equity (composite) were more modest, albeit significant for most vaccines except for MCV1: concentration indices of 0.150 (DPT3) and 0.087 (MCV1) in 2000 and 0.054 and 0.055 in 2016. The influence of the region and settings (urban/rural) of residence significantly decreased since 2000.

CONCLUSION

The past two decades have seen significant improvements in vaccine coverage and equity, thanks to the efforts to strengthen routine immunization and ongoing supplemental immunization activities such as the Family Health Days. While maintaining the regular provision of vaccines to all regions, efforts should be made to alleviate the impact of low maternal education and literacy on vaccination uptake.

Impact of the new rural social pension insurance on the health of the rural older adult population: based on the China health and retirement longitudinal study

The health issues of China's older adult population in rural areas have been receiving increasing attention with the continuous expansion of the nation's ageing population and the continuous promotion of urban-rural integration. The impact of the new rural social pension insurance (NRSPI) on the health of the rural older adult population, the mechanism of its action and how old-age service can be improved and optimised according to the health needs of the rural older adult population are urgent and realistic challenges. Based on survey data from the China Health and Retirement Longitudinal Study in 2015 and 2018, this study applies a multivariate ordered logistic regression model to explore the impact mechanism and effect of the NRSPI on the older adult population health in rural China while controlling for endogeneity. The results show that participation in the NRSPI can significantly improve the health of the rural older adult population at a 1% level. The results of the heterogeneity test reveal that the NRSPI has a significant impact on the self-reported health of the rural older adult at a 1% level, with a significantly positive impact on the mental and physical health of rural female older adult, whereas the impact on male older adult is not significant. The mediating effect test results show that medical services, food access and entertainment activities have a mediating effect on the new rural social endowment insurance. The results of the moderating effect test indicate that the NRSPI regulates 7.8% of the effect of physical health on mental health and 10.7% of the effect of mental health on physical health. Based on these findings, this study proposes to strengthen the construction of healthy lifestyle guidance and emotional support systems while improving the NRSPI's participation rate and treatment level to meet the diverse health service needs of different older adult groups.

Unmet healthcare needs and health inequalities in people with spinal cord injury: a direct regression inequality decomposition

BACKGROUND

Inequality in health is a prevalent and growing concern among countries where people with disabilities are disproportionately affected. Unmet healthcare needs explain a large part of the observed inequalities between and within countries; however, there are other causes, many non-modifiable, that also play a role.

AIM

This article explores the difference in health across income levels in populations with spinal cord injury (SCI). SCI is of special interest in the study of health systems, as it is an irreversible, long-term health condition that combines a high level of impairment with subsequent comorbidities.

METHODS

We estimated the importance of modifiable and non-modifiable factors that explain health inequalities through a direct regression approach. We used two health outcomes: years living with the injury and a comorbidity index. Data come from the International Spinal Cord Injury Survey (InSCI), which has individual data on people with SCI in 22 countries around the world. Due to the heterogeneity of the data, the results were estimated country by country.

RESULTS

On average, the results exhibit a prevalence of pro-rich inequalities, i.e., better health outcomes are more likely observed among high-income groups. For the years living with the injury, the inequality is mostly explained by non-modifiable factors, like the age at the time of the injury. In contrast, for the comorbidity index, inequality is mostly explained by unmet healthcare needs and the cause of the injury, which are modifiable factors.

CONCLUSIONS

A significant portion of health inequalities is explained by modifiable factors like unmet healthcare needs or the type of accident. This result is prevalent in low, middle, and high-income countries, with pervasive effects for vulnerable populations like people with SCI, who, at the same time are highly dependent on the health system. To reduce inequity, it is important not only to address problems from public health but from inequalities of opportunities, risks, and income in the population.

HIGHLIGHTS

• Better health status is evident among high-income groups, which is reflected in pro-rich inequalities. • Age at the time of the injury is the most important factor to explain inequalities in years living with the injury. • Unmet health care needs are the most important factor to explain inequalities in comorbidities. • The inequality in health varies by country dependent upon socioeconomic factors.

Multivariate Assessment of Vaccine Equity in Nigeria: A VERSE Tool Case Study using Demographic and Health Survey 2018

Nigeria experiences wide heterogeneity in vaccination rates by vaccine and region. However, inequities in vaccination status extend beyond just geographic covariates. Traditionally, inequity is represented by a single metric pertaining to socioeconomic status. A growing body of literature suggests that this view is limiting, and a multi-factor approach is necessary to comprehensively evaluate relative disadvantage between individuals. The Vaccine Economics Research for Sustainability and Equity (VERSE) tool produces a composite equity metric, which accounts for multiple factors influencing inequity in vaccination coverage. We apply the VERSE tool to Nigeria's 2018 Demographic and Health Survey (DHS) to cross-sectionally evaluate equity in vaccination status for national immunization program (NIP) vaccines over the following contributing covariates: age of child, sex of child, maternal education level, socioeconomic status, health insurance status, state of residence, and urban or rural designation. We also assess equity for zero-dose, fully immunized for age, and completion of NIP. Results show that socioeconomic status contributes substantially to variation vaccination coverage, but it is not the most substantial factor. For all vaccination statuses, except for NIP completion, maternal education level is the greatest contributor towards a child's immunization status among model variables. We highlight the outputs for zero-dose, fully immunized at infancy, MCV1 and PENTA1. The percentage point gap in vaccination status between the top and bottom quintiles of disadvantage, as ranked by the composite indicator is 31.1 (29.5-32.7) for zero-dose status, 53.1 (51.3-54.9) for full immunization status, 48.9 (46.9-50.9) for MCV1, and 67.6 (66.0-69.2) for PENTA1. Though concentration indices indicate inequity for all statuses, full immunization coverage is very low at 31.5% suggesting significant gaps in reaching children after initial doses for routine immunizations. Applying the VERSE tool to future Nigeria DHS surveys can allow decisionmakers to track changes in vaccination coverage equity, in a standardized manner, over time.

Comparing Multivariate with Wealth-Based Inequity in Vaccination Coverage in 56 Countries: Toward a Better Measure of Equity in Vaccination Coverage

INTRODUCTION

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study applies the Vaccine Economics Research for Sustainability and Equity (VERSE) vaccination equity toolkit to measure national-level inequity in immunization coverage using a multidimensional ranking procedure and compares this with traditional wealth-quintile based ranking methods for assessing inequity. The analysis covers 56 countries with a most recent Demographic & Health Survey (DHS) between 2010 and 2022. The vaccines examined include Bacillus Calmette-Guerin (BCG), Diphtheria-Tetanus-Pertussis-containing vaccine doses 1 through 3 (DTP1-3), polio vaccine doses 1-3 (Polio1-3), the measles-containing vaccine first dose (MCV1), and an indicator for being fully immunized for age with each of these vaccines.

MATERIALS & METHODS

The VERSE equity toolkit is applied to 56 DHS surveys to rank individuals by multiple disadvantages in vaccination coverage, incorporating place of residence (urban/rural), geographic region, maternal education, household wealth, sex of the child, and health insurance coverage. This rank is used to estimate a concentration index and absolute equity coverage gap (AEG) between the top and bottom quintiles, ranked by multiple disadvantages. The multivariate concentration index and AEG are then compared with traditional concentration index and AEG measures, which use household wealth as the sole criterion for ranking individuals and determining quintiles.

RESULTS

We find significant differences between the two sets of measures in almost all settings. For fully-immunized for age status, the inequities captured using the multivariate metric are between 32% and 324% larger than what would be captured examining inequities using traditional metrics. This results in a missed coverage gap of between 1.1 and 46.4 percentage points between the most and least advantaged.

CONCLUSIONS

The VERSE equity toolkit demonstrated that wealth-based inequity measures systematically underestimate the gap between the most and least advantaged in fully-immunized for age coverage, correlated with maternal education, geography, and sex by 1.1-46.4 percentage points, globally. Closing the coverage gap between the bottom and top wealth quintiles is unlikely to eliminate persistent socio-demographic inequities in either coverage or access to vaccines. The results suggest that pro-poor interventions and programs utilizing needs-based targeting, which reflects poverty only, should expand their targeting criteria to include other dimensions to reduce systemic inequalities, holistically. Additionally, a multivariate metric should be considered when setting targets and measuring progress toward reducing inequities in healthcare coverage.

Inequality of opportunity in health service utilization among middle-aged and elderly community-dwelling adults in China

BACKGROUND

The inequality caused by circumstances is known as "inequality of opportunity" (IOp). Many scholars have studied IOp in the health field, but few studies have quantified contributors to the IOp of health service utilization among middle-aged and elderly people. This study measured the IOp of health service utilization and decomposed the contributors to IOp present among Chinese middle-aged and elderly people.

METHODS

Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015 and 2018. A mean-based regression method was adopted to measure the IOp of health service utilization. Shapley-Shorrocks decomposition was used to analyze the main contributors to IOp seen among the middle-aged and elderly.

RESULTS

Although the absolute IOp of health service utilization decreased over time, IOp still explains the total inequality to a large extent. The absolute IOp and relative IOp were greatest in the areas of self-treatment and inpatient care utilization, respectively. Shapley decomposition results showed that the out-of-pocket (OOP) ratio contributed most to the IOp of outpatient care utilization; and the residence area highly explains the IOp of inpatient service utilization. Meanwhile, social and economic factors such as work status and income contribute more to the IOp of inpatient care utilization than outpatient and self-treatment.

CONCLUSIONS

Strategies aimed at achieving equal opportunities remain necessary to ensure the fairness of health service utilization. Policies and measures should further adjust the medical insurance compensation policies, and pay more attention to the middle-aged and elderly residents in rural areas, optimize health resource allocation, improve the social security systems, and narrow the socioeconomic gap between urban and rural areas in China.

Coverage and Equity of Childhood Vaccines in China

IMPORTANCE

Measuring vaccination coverage rates and equity is crucial for informing immunization policies in China.

OBJECTIVES

To estimate coverage rates and multidimensional equity for childhood vaccination in China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted via a survey in 10 Chinese provinces between August 5 and October 16, 2019, among children ages 6 months to 5 years and their primary caregivers. Children's vaccination records and their primary caregivers' demographics and socioeconomic status were collected. Data were analyzed from November 2019 to March 2022.

MAIN OUTCOMES AND MEASURES

Vaccine coverage rates were measured as a percentage of National Immunization Program (NIP) and non-NIP vaccines administered before the day on which the child was surveyed. A multidimensional equity model applied a standardized approach to ranking individuals from least to most unfairly disadvantaged by estimating differences between observed vaccination status and estimated vaccination status as function of fair and unfair variation. Fair sources of variation in coverage included whether the child was of age to receive the vaccine, and unfair sources of variation included sex of the child and sociodemographic characteristics of caregivers. Absolute equity gaps (AEGs), concentration index values, and decompositions of factors associated with vaccine equity were estimated in the model.

RESULTS

Vaccine records and sociodemographic information of 5294 children (2976 [52.8%] boys and 2498 [47.2%] girls; age range, 6-59 months; 1547 children aged 12-23 months) and their primary caregivers were collected from 10 provinces. Fully immunized coverage under the NIP was 83.1% (95% CI, 82.0%-84.1%) at the national level and more than 80% in 7 provinces (province coverage ranged from 77.8% [95% CI, 74.3% to 81.3%] in Jiangxi to 88.4% [95% CI, 85.7%-91.1%] in Beijing). For most non-NIP vaccines, however, coverage rates were less than 50%, ranging from 1.8% (95% CI, 1.3%-2.2%) for the third dose of rotavirus vaccine to 67.1% (65.4% to 68.8%) for the first dose of the varicella vaccine. The first dose of Haemophilus influenzae type b vaccine had the largest AEG, at 0.603 (95% CI, 0.570-0.636), and rotavirus vaccine dose 3 had the largest concentration index value, at 0.769 (95% CI, 0.709-0.829). The largest share of non-NIP vaccine inequity was contributed by monthly family income per capita, followed by education level, place of residence, and province for caregivers. For example, the proportion of explained inequity for pneumococcal conjugate vaccine dose 3 was 40.94% (95% CI, 39.49%-42.39%), 22.67% (95% CI, 21.43%-23.9%), 27.15% (95% CI, 25.84%-28.46%), and 0.68% (95% CI, 0.44%-0.92%) for these factors, respectively.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that NIP vaccination coverage in China was high but there was inequity for non-NIP vaccines. These findings suggest that improvements in equitable coverage of non-NIP vaccination may be urgently needed to meet national immunization goals.

A standardized approach for measuring multivariate equity in vaccination coverage, cost-of-illness, and health outcomes: Evidence from the Vaccine Economics Research for Sustainability & Equity (VERSE) project

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study outlines a standardized approach for measuring multivariate equity in vaccine coverage, economic impact, and health outcomes. The Vaccine Economics Research for Sustainability & Equity (VERSE) composite vaccination equity measurement approach is derived from literature on the measurement of socioeconomic inequality combined with measures of direct unfairness in healthcare access. The final metrics take the form of a concentration index for vaccination coverage where individuals are ranked by multivariate unfairness in access and an absolute equity gap representing the difference in coverage between the top and bottom quintiles of individuals ranked by multivariate unfairness in access. Regression decomposition is applied to the concentration index to determine each factor's relative influence on observed inequity. These methods are applied to India's National Family Health Survey (NFHS) from 2015 to 2016 to assess the equity in being fully-immunized for age vaccination coverage and zero-dose status. The multivariate absolute equity gap is 0.120 (SE: 003) and 0.371 (SE: 0.008) for zero-dose status and fully-immunized for age, respectively. Therefore, the most disadvantaged quintile is 12 percentage points more likely to be zero-dose than the most advantaged quintile and 37.1 percentage points less likely to be fully immunized. The primary correlate of unfair disadvantage for both outcomes is maternal education accounting for 27.4% and 19.1% of observed inequality. The VERSE model provides a standardized approach for measuring multivariate vaccine coverage equity. It also allows policymakers to determine the relative magnitude of factors influencing multivariate equity rather than only the correlates of socioeconomic or bivariate equity. This framework could be adapted to track equitable progress toward Universal Health Coverage (UHC) or outcomes beyond the vaccine space.

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This study outlines a standardized approach and toolkit for measuring multivariate inequality in vaccination coverage.

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The model isolates unfair from fair correlates of inequality in coverage.

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Application to India shows maternal education is the factor most associated with vaccine inequity.

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Greater inequality exists for being fully-immunized for age than being zero-dose in India.

Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt

BACKGROUND

The Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees' access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable.

METHODS

A cross-sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors.

RESULTS

We found pro-rich inequality and horizontal inequity in the probability of refugees' outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures.

CONCLUSION

Our results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

Decomposing Differences of Health Service Utilization among Chinese Rural Migrant Workers with New Cooperative Medical Scheme: A Comparative Study

The New Rural Cooperative Medical Insurance (NCMS) in China has provided benefits for rural migrant workers’ health service utilization, but the financial coordination and mutual aid of NCMS is mainly based on the county or district as a unit, leading NCMS with the characteristics of regional segmentation. Our study aims to explore their health service utilization, as well as to decompose differences of the health service utilization into contributors. Data from the China Labor-Force Dynamic Survey in 2016 and Urban Statistical Yearbook in 2016 were used. We used coarsened exact matching to control the confounding factors in order to enhance the comparison of two groups. The Fairlie decomposition method was used to analyze the differences and the sources of health service utilization. Influencing factors of health service utilization for rural migrant workers with NCMS were diversified, especially contextual characteristic and individual characteristics. The proportion of ethnic minorities, the number of medical institutions for 10,000 people in the community, the number of beds for 10,000 people in the city, and the urban service quality index were the major contributors of the differences. The proportion of difference in the health service utilization of rural migrant workers with NCMS caused by health service need were −54.73% and 6.92%, respectively. The inequities of the probability of two weeks outpatient, and the probability of inpatients, were −0.006 and −0.007, respectively. There were substantial differences in the health service utilization between rural migrant workers with NCMS in the county/district and rural migrant workers with NCMS across the county/district. Our results illustrated the inequity from the differences on basis of characteristic effect and the discrimination effect. Our studies clarified that health service needs of should be fully considered, contributing to a more reliable understanding of the health service utilization of rural migrant workers.

Urban-Rural Inequality of Opportunity in Health Care: Evidence from China

(1) Background: We aim to measure the urban-rural inequality of opportunity in healthcare in China based on the theory of Equality of Opportunity (EOp). (2) Methods: Following the compensation principle, we establish a decomposition strategy for the fairness gap, which we use for the measurement of the inequality of opportunity in urban-rural healthcare utilization. We then use China Health and Nutrition Survey (CHNS) data from 1997 to 2006 to calculate the fairness gap. (3) Results: Empirical analysis using CHNS data shows that the ratio of the fairness gap to the directly observed average urban-rural difference in healthcare was 1.167 for 1997-2000 and 1.744 for 2004-2006. The average urban-rural difference observed directly from original statistical data may have underestimated the degree of this essential inequity. (4) Conclusions: Our findings suggest that upgrading urban-rural reimbursement ratios may not be sufficient in eliminating the inequality of opportunity in healthcare utilization between urban and rural residents. Within the context of an urban-rural dualistic social structure and widening of the urban-rural income gap, a shift to a pro-disadvantaged policy will be a more effective approach in promoting equality of opportunity in healthcare.

Investigating the geographic disparity in quality of care: the case of hospital readmission after acute myocardial infarction in Italy

Unwarranted variation in the quality of care challenges the sustainability of healthcare systems. Especially in decentralised healthcare systems, it is crucial to understand the drivers behind regional differences in hospital qualities such as unplanned readmissions. This paper examines the factors that influence the risk of unplanned hospital readmission and the geographic disparity of readmission rate in Italy. We use hospital discharge data from 2010 to 2015 for patients above 65 years old admitted with Acute Myocardial Infarction. Employing hierarchical models, we identified the patient and hospital-level determinants for unplanned readmission. In line with the literature, the risk of readmission increases with age and being male, while hospitals with higher patient volume and capacity tend to have lower unplanned readmission. In particular, we find that after patient risk-adjustments, there are differential effects of hospitalisation length-of-stay on the probability of readmission across the hospitals that are governed by different payment systems. For hospitals under a prospective payment system, the effect of length-of-stay in reducing the probability of readmission is weaker than hospitals under an ex-post global budget, but the overall readmission rates are the lowest. Moreover, there are substantial geographic variations in readmission rate across Local Health Authority and regions, and these variations of unplanned readmission are explained by differences in hospital length-of-stay and surgical procedures used. Our results demonstrate that differential hospital behaviours can be one of the potential mechanisms that drive geographic quality disparities.

Horizontal inequity in the utilisation of healthcare services in Australia

The Australian universal healthcare system aims to ensure affordable and equitable use of healthcare services based on individual health needs. This paper presents empirical evidence on the extent of horizontal inequity (HI) in healthcare services (unequal utilisation by income for equal need) in Australia during the period of promoting reliance on private healthcare financing. Using data from the most recent Australian National Health Survey of 2011-12 and 2014-15, we examined and measured the extent of HI in eight indicators of out-of-hospital services and hospital-related care. Contrary to earlier studies, our results show a small but pro-rich inequity in the probability of general practitioner visits. Inequity in the distribution of specialist and dentist visits was in favour of richer people, a result that is commonly found in other developed countries and is also consistent with existing Australian evidence. Hospital-related care was equitably distributed compared to the pro-poor pattern found in earlier studies. Despite the universal health insurance system in Australia, there was inequity in the utilisation of needed healthcare services. Our evidence is relevant to similar health systems as governments move to higher out-of-pocket payments and other private sources to reduce pressure on public healthcare expenditure.

Inequality of opportunity in healthcare expenditures: evidence from China

BACKGROUND

The theory of equality of opportunity attributes total inequality to effort levels and circumstance factors. Inequality attributable to circumstance is defined as inequality of opportunity (IOp), namely inequity. Many studies have been pursued in this area but few concerning health care, especially in China. Despite Chinese health system reforms, healthcare inequity remains. This study explores the extent and sources of IOp in outpatient and inpatient expenditures in China.

METHODS

We used three waves (2011, 2013 and 2015) of data from the China Health and Retirement Longitudinal Study that offer a nationally representative sample of Chinese residents aged 45 and older. Based on a pooled regression model, we estimated the contribution of circumstance factors to the inequality in outpatient and inpatient expenditures by defining a counterfactual distribution. The "circumstance-free effort" was introduced to deal with the correlation between circumstance and effort.

RESULTS

We report a decline in inequity from 2011 to 2015, and the IOp ratio to total inequality in outpatient and inpatient expenditures decreased 9.4% (from 28.6 to 25.9%) and 3.3% (from 49.1 to 47.5%), respectively. Social background, medical supply-side factors, including the type of basic medical insurance, region and community medical resources were important sources of IOp in outpatient and inpatient expenditures.

CONCLUSIONS

These findings provide information on which to base policies designed to reduce inequity in healthcare expenditures. It is necessary to transfer more subsidies to the New Co-operative Medical System, and to address the uneven regional distribution of medical resources. Additionally, increasing access to quality primary community clinics may be a pro-poor policy to alleviate inequity in the use of outpatient care. Compared to outpatient services, policies protecting vulnerable populations need to pay more attention to the financing and design of inpatient services.

Inequity in physician visits: the case of the unregulated fee market in Australia

Equity is one of the key goals of universal healthcare coverage (UHC). Achieving this goal does not just depend on the presence of UHC, but also on its design and organisation. In Australia, out-of-hospital medical services are provided by private physicians in a market where fees are unregulated. This makes an interesting case to study equity. Using data from the Australian National Health Survey of 2014-15, we distinguish between the probability of any visit and the number of visits conditional on having any visit to analyse income-related inequity in general practitioner (GP) and specialist visits. We apply the horizontal inequity approach to measure the extent of inequity, and the decomposition method to explain the factors accounting for inequity. Our results show a small pro-rich inequity in the probability of any GP visit, but the distribution of conditional GP visits was concentrated among the poor. Inequity in the probability of any specialist visit was pro-rich. However, there was almost no inequity in conditional specialist visits. We find holding a concession card explained pro-poor inequity while income, education, and private health insurance contributed to pro-rich inequity in specialist visits. Although Australia has a universal health insurance system, there is unequal use (adjusted for health need) of physician services by socioeconomic status. This has implications for insurance design in other countries.

Socioeconomic inequalities in mental health in Australia: Explaining life shock exposure

BACKGROUND

Recent research suggests that there exists a strong link between life shocks and mental health. However, research on the distributional aspects of these shocks on mental health status is limited. In the health inequality literature no Australian studies have examined this relationship.

OBJECTIVE

This study examines the distributional impact of life shocks (negative life events and financial hardships) on mental health inequality among different socioeconomic groups in a longitudinal setting in Australia.

METHODS

This study analysed the data of 13,496 individuals from the Household, Income and Labour Dynamics in Australia (HILDA) survey, waves 12-17 (2012-2017). Using concentration index and Blinder-Oaxaca approaches, the study decomposed socioeconomic inequalities in mental health and changes in inequalities in mental health over the study period. The study used frailty indices to capture the severity of life shocks experienced by an individual.

RESULTS

The results suggest that exposure to just one life shock will result in a greater risk of mental disorder in the most disadvantaged socioeconomic groups. The results also indicate that 24.7%-40.5% of pro-rich socioeconomic mental health inequality are due to life shocks. Financial hardship shocks contributes to 21.6%-35.4% of inequality compared with 2.3%-5.4% inequality generated by negative life event shocks across waves.

CONCLUSIONS

Lower SES groups experience more life shocks than higher SES groups and in turn generate higher socioeconomic mental health inequality. Policies aimed at reducing socioeconomic inequality in mental health should account for these shocks when designing interventions.

Effects of a reimbursement change and travel times on the delivery of private and public radiology services in Norway: a register-based longitudinal study of Norwegian claims data

BACKGROUND

The variation in the impact of the 2008 reimbursement change for Norwegian radiology providers, depending on the travel times to private and public providers in different municipalities, was examined. The activity-based fund allocation for radiology providers was reduced from approximately 50% to 40%, which was compensated by an increased basic grant. The hypothesis was that the Norwegian population would be affected by the reimbursement change unevenly depending on their distances to different types of the providers.

METHODS

The study of the effect of the reimbursement change and travel time difference between private and public radiology providers in Norway (Time_difference) on the number of the services was performed using fixed-effects regressions applied to panel data at the municipality level with monthly observations for the period 2007-2010.

RESULTS

After the reimbursement change, the number of private services decreased more than the number of public services. Private services declined after 2008, but the absolute value of the effect was smaller as the Time_difference became greater. The number of public services increased as the Time_difference grew. The total number of services decreased until the Time_difference was equal to 40 min and increased for time differences greater than 40 min.

CONCLUSIONS

The messages for policymakers are as follows. Populations that only had private providers nearby were more affected by the reimbursement change in terms of a reduced number of services. The reimbursement change contributed to the reallocation of patients from private to public providers. The difference between the centralities of municipalities in their consumption patterns was reduced and the difference between different Regional Health Authorities was increased due to the reimbursement change.

Does the critical illness insurance reduce patients' financial burden and benefit the poor more: a comprehensive evaluation in rural area of China

BACKGROUND

Critical illness insurance (CII) is one kind of health insurance that is gradually gaining attention worldwide. China implemented CII in 2012 to decrease patients' out-of-pocket (OOP) medical payments. The aims of this study were to determine if the project had positive impacts on relieving financial burden and improving health equity.

METHODS

A series of questionnaire surveys were undertaken in two counties before and after the intervention in rural China. OOP expenditure, catastrophic Health Expenditure (CHE) incidence, and associated average gap (AG) were assessed across different income groups and project durations, measuring short-term direct medical cost. Medical debt rate and amount were used to measure long-term financial burden; concentration index (CI) was calculated for equity. All data were evaluated by descriptive statistics and multi-variate variance analysis. The linear regression and logit regression with random effect analysis upon area was used to evaluate the effect of CII.

RESULTS

Six hundred and thirteen and 834 patients were surveyed at baseline and final evaluation. After the program, the OOP payments of hospitalizations sharply decreased from RMB 39,363.2 to RMB 28,426.1 (p < 0.001), with the largest decrease for lowest income patients (from RMB 44,507.6 to RMB 29,214.2). With longer duration of CII, more OOP medical payments decreased. The amount of medical debt was decreased by RMB 7,209.4 among all the patients, and the decrease was highest in the highest income group (RMB 8,119.9). The CI of AG changed a lot (from -0.858 to -0.670).

CONCLUSION

The CII has effectively reduced the financial burden of patients with high medical cost, whether in the short-term or a longer length of time. It also improved health equity in health service utilization and expenditure. However, rich householders still receive more benefits from the policy, government health insurance financing is increased, and the policy needs to further benefit the poor.

Allocating health care resources: a questionnaire experiment on the predictive success of rules

Background

The topic of this paper is related to equity in health within a country. In public health care sectors of many countries decisions on priority setting with respect to treatment of different types of diseases or patient groups are implicitly or explicitly made. Priorities are realized by allocation decisions for medical resources where moral judgments play an important role with respect to goals and measures that should be applied. The aim of this study is to explore the moral intuitions held in the German society related to priorities in medical treatment.

Methods

We use an experimental questionnaire method established in the Empirical Social Choice literature. Participants are asked to make decisions in a sequence of distributive problems where a limited amount of treatment time has to be allocated to hypothetically described patients. The decision problems serve as an intuition pump. Situations are systematically varied with respect to patients’ initial health levels, their ability to benefit from treatment time, and the amount of treatment time available. Subjects are also asked to describe their deliberations. We focus on the acceptance of different allocation principles including equity concepts and utilitarian properties. We investigate rule characteristics like order preservation or monotonicity with respect to resources, severity, or effectiveness. We check the consistency of individual choices with stated reasoning.

Results

The goals and allocation principles revealed show that the moral intuitions held by our experimental subjects are much more complex than the principles commonly applied in health economic theory. Especially, cost-utility principles are rarely applied, whereas the goal of equality of health gain is observed more often. The principle not to leave any patient untreated is very dominant. We also observe the degrees to which extent certain monotonicity principles, known from welfare economics, are followed. Subjects were able to describe their moral judgments in written statements. We also find evidence that they followed their respective intuitions very consistently in their decisions.

Conclusions

Findings of the kind presented in this paper may serve as an important input for the public and political discussion when decisions on priorities in the public health care sector are formed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-017-0611-1) contains supplementary material, which is available to authorized users.

The impact of rural health care accessibility on cancer-related behaviors and outcomes

BACKGROUND

This research seeks to identify the relationship between economic factors related to the ability to receive and pay for health services and adverse cancer outcomes, as well as preventative screening and behavioral factors that influence the risk of cancer. We focus on the Northern High Plains region, where we are able to compare regions with extremely low access to health services with those with relatively high levels of access.

OBJECTIVE

This study aims to identify health disparities in rural communities, particularly among Native American populations, and, thereby, begin to determine the most effective means by which to deliver health services to areas where geography, economics, and culture might prevent traditional models of health delivery from providing sufficient incentives for the prevention of adverse cancer-related outcomes.

METHODS

The Health Care Accessibility Index (HCAI) is computed through the use of principal component analysis and includes economic variables as well as variables concerning institutional and geographic access to health care. Index values are then regressed onto cancer outcomes, cancer-prevention outcomes, and cancer-related risk, using weighted least squares and quantile regressions.

RESULTS

Counties with relatively poor access to health care (low HCAI) also have statistically (1) lower breast cancer screening rates, (2) higher smoking prevalence, (3) higher obesity prevalence, and (4) higher cancer-related mortality rates. Breast cancer screening is found to be especially sensitive to areas of low health accessibility.

CONCLUSIONS

Empirical results provide support for policy efforts to increase the accessibility of health care services that are targeted to areas with low mammography screening rates, high obesity rates, high smoking prevalence, as well as areas near Native American reservation territories.