Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries

Abstract

A key policy objective in OECD countries is to achieve adequate access to health care for all people on the basis of need. Previous studies have shown that there are inequities in health care services utilisation (HCSU) in the OECD area. In recent years, measures have been taken to enhance health care access. This paper re-examines income-related inequities in doctor visits among 18 selected OECD countries, updating previous results for 12 countries with 2006–2009 data, and including six new countries. Inequalities in preventive care services are also considered for the first time. The indirect standardisation procedure is used to estimate the need-adjusted HCSU and concentration indexes are derived to gauge inequalities and inequities. Overall, inequities in HCSU remain present in OECD countries. In most countries, for the same health care needs, people with higher incomes are more likely to consult a doctor than those with lower incomes. Pro-rich inequalities in dental visits and cancer screening uptake are also found in nearly all countries, although the magnitude of these varies among countries. These findings suggest that further monitoring of inequalities is essential in order to assess whether country policy objectives are achieved on a regular basis.

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Notes

  1. 1.

    Although the inclusion of private health insurance in the specification of the model may create an endogeneity problem due to selection effect, a sensitivity analysis showed that the findings were robust. We replicated the analysis without including insurance and found that the overall results for the measure of inequities were unchanged.

  2. 2.

    Detail on the construction of equalised income in Canada and EHIS countries is available on demand.

  3. 3.

    The analysis was also carried out with the Erreygers index. Results were broadly similar.

  4. 4.

    Only in England, Scotland and Wales.

  5. 5.

    For people with statutory health insurance.

  6. 6.

    In New Zealand, specialist visits, in contrast to GP visits, are exempted from co-payments.

  7. 7.

    The small sample size in the Czech Republic and Slovenia prevents detection of significant differences.

References

  1. 1.

    Hurst, J., Jee-Hughes, M.: Performance measurement and performance management in OECD health systems. Labour Mark. Soc. Policy Series, Occasional Paper No 47, OECD, Paris. (2001). doi: 10.1787/788224073713

  2. 2.

    Kelley, E., Hurst, J.: Health care quality indicators project: conceptual framework paper. OECD Health Working Papers No.23. OECD Publishing, Paris. http://www.oecd.org/health/health-systems/36262363.pdf (2006). Accessed 22 June 2013

  3. 3.

    OECD: Health at a glance 2011: OECD indicators, OECD Publishing, Paris. (2011)

  4. 4.

    Van Doorslaer, E., Koolman, X., Jones, A.M.: Explaining income-related inequalities in doctor utilisation in Europe. Health Econ. 13, 629–647 (2004)

    PubMed  Article  Google Scholar 

  5. 5.

    Van Doorslaer, E., Masseria, C.: Income-related inequality in the use of medical care in 21 OECD countries. OECD Health Working Paper No.14. OECD, Paris. http://www.oecd.org/health/health-systems/31743034.pdf (2004). Accessed 22 June 2013

  6. 6.

    Or, Z., Jusot, F., Yilmaz, E.: Impact of health care system on socioeconomic inequalities in doctor use. IRDES Working Paper No.17. IRDES, Paris. http://www.irdes.fr/EspaceAnglais/Publications/WorkingPapers/DT17ImpactHealthCareSystSocioeconomicInequalities.pdf (2008). Accessed 22 June 2013

  7. 7.

    Bago d’Uva, T., Jones, A.M., van Doorslaer, E.: Measurement of horizontal inequity in health care utilisation using European panel data. J. Health Econ. 28, 280–289 (2009)

    PubMed  Article  Google Scholar 

  8. 8.

    Palència, L., Espelt, S., Rodriguez-Sanz, M., Puigpinós, R., Pons-Vigués, M., Pasarín, M.I., Spadea, T., Kunst, A.E., Borrell, C.: Socioeconomic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program. Int. J. Epidemiol. 39, 757–765 (2010)

    PubMed  Article  Google Scholar 

  9. 9.

    Jusot, F., Or, Z., Sirven, N.: Variations in preventive care utilisation in Europe. Eur. J. Ageing 9, 15–25 (2012)

    Article  Google Scholar 

  10. 10.

    McKinnon, B., Harper, S.: Decomposing income-related inequality in cervical screening in 67 countries. Int. J. Pub. Health 56, 139–152 (2011)

    Article  Google Scholar 

  11. 11.

    Carrieri, V., Wübker, A.: Assessing inequalities in preventive care use in Europe. Ruhr Economic Papers 371. http://www.rwi-essen.de/publikationen/ruhr-economic-papers/499/ (2012). Accessed 22 June 2013

  12. 12.

    ECHIM European Community health indicators monitoring. Accessed on 20 June 2013: www.echim.org

  13. 13.

    OECD Health Statistics. doi:10.1787/health-data-en (2013). Accessed 05 October 2013

  14. 14.

    Mackenbach, J.P., Stirbu, I., Roskam, A.R., Schaap, M.M., Menvielle, G., Leinsalu, M., Kunst, A.E.: Socioeconomic inequalities in health in 22 European countries. N Eng J. Med. 358, 2468–2481 (2008)

    CAS  Article  Google Scholar 

  15. 15.

    O’Donnell, O., van Doorslaer, E., Wagstaff, A., Lingelow, M.: Analyzing health equity using household survey data. The World Bank, Washington (2008)

    Google Scholar 

  16. 16.

    Kakwani, N., Wagstaff, A., van Doorslaer, E.: Socioeconomic inequalities in health: measurement, computation, and statistical inference. J. Econom. 77, 87–103 (1997)

    Article  Google Scholar 

  17. 17.

    Wagstaff, A.: The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality. Health Econ. 14, 429–432 (2005)

    PubMed  Article  Google Scholar 

  18. 18.

    Erreygers, G.: Correcting the concentration index. J. Health Econ. 28, 504–515 (2009)

    PubMed  Article  Google Scholar 

  19. 19.

    Paris, V., Devaux, M., Wei, L.: Health Institutional Characteristics: A Survey of 29 OECD Countries, OECD Health Working Papers No. 50, OECD Publishing, Paris. doi:10.1787/5kmfxfq9qbnr-en (2010). Accessed 22 Nov 2013

  20. 20.

    OECD: Cancer care: assuring quality to improve survival, OECD Publishing, Paris. doi:10.1787/9789264181052-en (2013). Accessed 7 Dec 2013

  21. 21.

    Regidor, E., Martínez, D., Calle, M.E., Astasio, P., Ortega, P., Domínguez, V.: Socioeconomic patterns in the use of public and private health services and equity in health care. BMC Health Serv. Res. 8, 183 (2008)

    PubMed Central  PubMed  Article  Google Scholar 

  22. 22.

    Schopper, D., de Wolf, C: Breast cancer screening by mammography: international evidence and the situation in Switzerland, Krebsliga Schweiz. http://assets.krebsliga.ch/downloads/short_mammo_report_final_el_.pdf (2007). Accessed 22 June 2013

  23. 23.

    Wübker, A.: Explaining variations in breast cancer screening across European countries. Eur J Health Econ (2013). doi:10.1007/s10198-013-0490-3

    PubMed  Google Scholar 

  24. 24.

    National Center for Health Statistics: Health, United States, 2010: with special feature on death and dying. NCHS, Hyattsville (2011)

    Google Scholar 

  25. 25.

    Sirven, N., Or, Z.: Disparities in regular health care utilisation in Europe. IRDES Working Paper No. 37, IRDES, Paris. http://www.irdes.fr/EspaceAnglais/Publications/WorkingPapers/DT37DisparitiesRegularHealthCareUtilisationEurope.pdf (2010). Accessed 22 June 2013

  26. 26.

    Von Wagner, C., Baio, G., Raine, R., Snowball, J., Morris, S., Atkin, W., Obichere, A., Handley, G., Rainbow, S., Smith, S., Halloran, S., Wardle, J.: Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England. Int. J. Epidemiol. 40, 712–718 (2011)

    Article  Google Scholar 

  27. 27.

    Listl, S.: Income-related inequalities in dental service utilization by Europeans aged 50+. J. Dental Res. 90(6), 717–723 (2011)

    CAS  Article  Google Scholar 

  28. 28.

    Devaux, M., de Looper, M.: Income-related inequalities in health service utilisation in 19 OECD Countries, 2008–2009, OECD Health Working Papers no. 58, OECD Publishing, Paris. 10.1787/5k95xd6stnxt-en (2012). Accessed 22 Nov 2013.

  29. 29.

    Grasdal, A.L., Monstad, K.: Inequity in the use of physician services in Norway before and after introducing patient lists in primary care. Int J Equity Health 10, 25 (2011)

    PubMed Central  PubMed  Article  Google Scholar 

  30. 30.

    Nguyen, L., Häkkinen, U.: Income-related inequality in the use of dental services in Finland. Appl Health Econ Health Policy 3(4), 251–262 (2004)

    PubMed  Article  Google Scholar 

  31. 31.

    Grignon, M., Hurley, J., Wang, L., Allin, S.: Inequity in a market-based health system: evidence from Canada’s dental sector. Health Policy 98, 81–90 (2010)

    PubMed  Article  Google Scholar 

  32. 32.

    DeSalvo, K., Fan, V.S., McDonell, M.B., Fihn, S.D.: Predicting mortality and healthcare utilization with a single question. Health Serv. Res. 40, 1234–1246 (2005)

    PubMed Central  PubMed  Article  Google Scholar 

  33. 33.

    Idler, E.L., Benyamini, Y.: Self-rated health and mortality: a review of twenty-seven community studies. J. Health Soc. Behav. 38, 21–37 (1997)

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Bago d’Uva, T., Lindeboom, M., O’Donnell, O., van Doorslaer, E.: Education-related inequity in healthcare with heterogeneous reporting of health. J R Stat Soc Ser A Stat Soc 174(3), 639–664 (2011)

    Article  Google Scholar 

  35. 35.

    Tubeuf, S., Jusot F., Devaux M., Sermet C.: Social heterogeneity in self-reported health status and measurement of inequalities in health. IRDES Working Paper No. 12, IRDES, Paris. http://www.irdes.fr/EspaceAnglais/Publications/WorkingPapers/DT12SocialHeterogeSelfReportHealthStatus.pdf (2008). Accessed 22 June 2013

  36. 36.

    Van de Poel, E., van Doorslaer, E., O’Donnell, O.: Measurement of inequity in health care with heterogeneous response of use to need. J. Health Econ. 31, 676–689 (2012)

    PubMed  Article  Google Scholar 

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Acknowledgments

The author would like to thank Michael de Looper for his contribution at the initial stage of the work, and both anonymous reviewers for their helpful comments. The author also thanks data providers for supplying datasets, namely, Statistics Canada, the Finnish National Institute for Health and Welfare, the French Institute for Research and Information in Health Economics, the Robert Koch Institute for German data, the Irish Social Science Data Archive, the New Zealand Ministry of Health, the Spanish National Statistics Institute, the Swiss Federal Statistical Office, the Institute for Social and Economic Research for UK data, the American Agency for Healthcare Research and Quality, and Eurostat for EHIS. All data computations were prepared by the author, and the responsibility for the use and interpretation of these data is entirely that of the author.

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Correspondence to Marion Devaux.

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Devaux, M. Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries. Eur J Health Econ 16, 21–33 (2015). https://doi.org/10.1007/s10198-013-0546-4

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Keywords

  • Inequality
  • Inequity
  • Doctor visit
  • Preventive care
  • Health care access

JEL Classification

  • I10
  • I14