Equity in the delivery of health care in Europe and the US
Introduction
Over the last three decades, most of the OECD countries — the exception is the United States — have achieved close to universal coverage of their population for the majority of health care services (OECD, 1993). However, they have often adopted very different mixes of public and private financing and delivery of services, and there is a growing body of evidence showing that, despite such universal coverage, not all population groups are treated equally when in equal need. Violations of the horizontal equity principle that equals ought to be treated equally irrespective of other characteristics have mainly been reported with respect to income.1 In trying to establish systematic differences in the treatment of individuals with similar needs but at different income levels, it seems worth pursuing this objective in an international perspective for at least two reasons. One, it may help to find out whether the relative magnitude of any inequity is a serious cause for concern; and two, it may help to address the question which particular system characteristics contribute to inequitable outcomes.
In van Doorslaer et al. (1992) — hereafter DWEA — we have presented estimates for eight OECD countries of the extent to which violations of the principle of ‘equal treatment for equal need’ in the delivery of health care were systematically related to income. This paper extends and develops that work in a number of respects. First, results are presented for five new countries — Belgium, Finland, the former East and West Germany, and Sweden and for more recent years for the other six countries that were included in DWEA.2 Secondly, we have made greater efforts to apply a common methodology in all countries in an attempt to make the results more comparable and more meaningful. Third, we have not only looked at aggregate health care utilization but also present disaggregated results for GP, outpatient and inpatient care separately. This allows us to examine whether patterns of (in)equity differ across types of care. Finally, we have modified the methodology used in DWEA in a number of ways by replacing the direct standardization by an indirect standardization method. This implies the use of a new index and a new method of testing for inequity.
The paper is organized as follows. Section 2 outlines the methods. Section 3 describes the data used and Section 4 presents the results. In Section 5, we consider the association between inequity findings and system characteristics. The final section — Section 6 — contains a summary and conclusions.
Section snippets
Methods
The objective of the study is, as in DWEA, to quantify and test for violations of the principle of ‘equal treatment for equal need’ that are related to socioeconomic status as reflected by income. In DWEA, we used the index of horizontal inequity proposed by Wagstaff et al. (1991). Here we use another index that has been proposed by Wagstaff and van Doorslaer (2000a). Instead of (directly) standardizing medical care utilization for need differences and comparing the resulting distribution with
Data and variable definitions
The surveys used are listed in Table 1.8 All samples comprise all
Results
The results for all doctor visits (to a GP and a medical specialist), for GP and specialist visits separately, for inpatient care, and for aggregate utilization are presented in Table 3, Table 4, Table 5, Table 6, Table 7, respectively. Two general points are worth making. First, it can be seen from the unstandardized concentration indices presented in the first column of each table (CM values) that the distribution of care is generally heavily concentrated towards the lower-income groups. Most
Discussion: Is there a link with delivery system features?
The obvious question that arises is whether any of these (few) cross-country differences in equity can be traced back to characteristics of the health care delivery systems. Table 9, Table 10 summarize some potentially equity-relevant characteristics that may help to explain why in some countries higher- and lower-income groups appear to be treated differently at the same level of need. Table 9 relates to potential barriers to access such as the extent of public and private cover and the use of
Conclusion
The results from this study update those from an earlier international comparison of inequity in health care utilization (DWEA). New methods have been applied to more recent data from a larger set of countries and at a lower level of aggregation. We also believe that we have achieved a higher level of comparability of results. Nevertheless, in some instances, some important differences, e.g. in need standardization, have remained, and the number of countries is still relatively small for
Acknowledgements
This paper derives from the project “Equity in the finance and delivery of health care in Europe” (the ECuity project), which is funded by the European Union's Biomed Programme (contract BMH1-CT92-608). It was jointly coordinated by Eddy van Doorslaer and Adam Wagstaff.
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