Original article

International Journal of Public Health

, Volume 54, Issue 4, pp 250-259

First online:

Social inequalities in the use of health care services after 8 years of health care reforms – a comparative study of the Baltic countries

  • Jarno HabichtAffiliated withHead of Country Office, WHO Country Office in Estonia, World Health OrganizationDepartment of Public Health, University of Tartu Email author 
  • , Raul-Allan KiivetAffiliated withDepartment of Public Health, University of Tartu
  • , Triin HabichtAffiliated withDepartment of Economics, University of TartuDepartment of Health Economics, Estonian Health Insurance Fund
  • , Anton E KunstAffiliated withDepartment of Public Health, Erasmus MC, University Medical Center Rotterdam

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In nineties, Estonia, Latvia and Lithuania have implemented a wide range of changes to health systems. The objective of this paper was to assess social inequalities in utilisation of, and access to, health care services in the late nineties.


The comparative NORBALT Survey conducted in 1999 is used. Direct standardization and logistic regression was applied to analyse primary, out-patient and hospital care utilisation, and self reported financial barriers, by socio-demographic and geographical variables.


In all three countries social inequalities in utilization were large for out-patient specialist care, smaller or absent with regards to primary care or to hospitalisations. Inequalities were large and consistent in relationship to household income, less so in relationship to educational level. Inequalities in utilization of care were larger in Latvia as well in the self reported barriers to health care in absolute and relative terms were larger.


After 8 years of reforms, important pro-rich inequalities in the use of health services existed. In Latvia, these inequalities were largest, possibly due to higher ratio of cost sharing as compared to Estonia and Lithuania.


Health system reforms Inequalities Access to health care Baltic States Socioeconomic factor International comparison