ECuity project
! Group of health economists who study the relationship between health,
health care and income.
! Groups has used ECHP for many papers on
! Income related variation in health
! Income related variation in health care
Equity in access to health care in Europe
Xander Koolman
Erasmus University Medical Center
Health care system evaluation;
What do we want from our health care system?
! WHO:
! Health
! Responsiveness
! Fairness in financing
! Equity and efficiency about equally important (WHO WHR2000)
Equity in health care is instrumental
! Policy documents state preference for equal access for equal need
(Wagstaff and Van Doorslaer)
Equity
Not all unmet need is inequitable
!
equal access but unequal preference for consuming care
Unmet need is ‘inequitable’ if access isn’t equal for equal need (health)
!
Empirical definition inequity: systematic variation in access with
irrelevant characteristics such as
! income;
! education;
! region of residence;
! ethnicity.
Equity under threat due to cost-containment efforts
Rationing might affect different groups differently
! Price rationing through co-payment
! Co-insurance
! Out of pocket payments
! Limited coverage (100% co-payment)
! Non-price rationing through limiting supply
! Limited number doctors
! Limited number health care facilities
! Limited opening hours
! Limited quality
Empirical evidence equity in health care in the EU
! Many studies show:
! overall physician visits are distributed according to need (most
countries) or pro rich (some):
! GP utilisation is distributed according to need or pro poor;
! specialist visits are distributed pro rich.*
! But, these studies were all based on utilisation, not access
! “inequities” might be due to different preferences
*Based on work together with Eddy van Doorslaer, Andrew Jones, Cristina
Masseria, Frank Puffer, a OECD-team and the ECuity project team, see:
http://www.eur.nl/ecuity)
EU-SILC: new data on health care access
Unmet need for medical examination or treatment during the last 12
months (yes at least once; no)
Main reason for unmet need for medical examination or treatment
! Could not afford to (too expensive)
! Waiting list
! Could not take time because of work, care for children or for
others
! Too far to travel/no means of transportation
! Fear of doctor/hospitals/examination/ treatment
! Wanted to wait and see if problem got better on its own
! Didn’t know any good doctor or specialist
! Other reasons
Variation in unmet need by country (%)
Unmet
need
EU14
5.2
BE
2.0
DK
1.3
GR
5.3
ES
6.8
EE
10.7
FR
4.7
IE
2.4
IT
7.7
LU
5.0
NO
2.6
AT
2.0
PT
5.4
FI
4.6
SE
13.1
Variation in unmet need by country and reason (%)
Unmet
need
toexpen
waitlist
notime
toofar
fear
watchful
nogood
other
EU14
5.2
33
15
10
5
4
14
2
18
BE
DK
GR
ES
EE
FR
IE
IT
LU
NO
AT
PT
FI
SE
2.0
1.3
5.3
6.8
10.7
4.7
2.4
7.7
5.0
2.6
2.0
5.4
4.6
13.1
64
1
13
0
3
13
1
5
16
11
4
0
0
18
2
49
58
7
7
10
5
9
0
2
7
32
28
4
3
11
2
12
34
27
5
6
2
5
8
14
31
5
18
1
12
23
1
9
50
24
5
2
2
9
0
7
47
20
3
1
4
10
1
13
6
2
12
1
8
23
2
45
23
3
0
35
2
3
5
28
19
10
25
2
5
15
1
21
64
17
8
1
3
4
1
3
30
38
0
1
0
3
0
27
5
14
9
1
2
45
4
20
Measures of inequity
! Absolute inequality
! Slope index of inequality (SII) = outcome best of – outcome worst
of
! Relative inequality
! Relative index of inequality (RII) = outcome worst of/outcome best
of
1
y − 2 SII
RII =
y + 12 SII
! Concentration index
C=
SII
2Cov( y, r )
= 2σ r2
y
y
Relative inequity (OR≈
≈RII) and absolute (SII = APE)
EU14
Income
Education
OR
2.3
OR
1.0
SII(%)
3.6
SII(%)
-0.1
Degree
urbanisation
OR
SII(%)
0.8
-1.0
Foreign
OR
1.1
SII(%)
0.6
EU14
AT
BE
DK
EE
ES
FI
FR
GR
IE
IT
LU
NO
PT
SE
Income
Education
OR
2.3
SII(%)
3.6
OR
1.0
SII(%)
-0.1
2.1
5.8
2.7
2.8
1.1
3.0
3.0
3.5
1.9
3.4
1.7
0.7
2.6
1.5
1.3
3.2
1.3
9.1
0.8
4.5
4.7
5.6
1.4
8.2
2.4
-0.8
4.5
4.0
0.8
1.4
1.0
0.8
1.0
1.2
1.1
1.1
1.1
1.1
0.5
1.1
2.5
0.8
-0.4
0.6
0.0
-2.0
0.1
0.7
0.4
0.3
0.2
0.3
-3.5
0.1
4.2
-2.5
Degree
urbanisation
OR
SII(%)
0.8
-1.0
Foreign
OR
1.1
SII(%)
0.6
0.5
1.2
0.6
0.5
0.7
0.9
0.6
0.7
0.6
0.7
1.7
1.2
1.0
1.1
0.7
1.1
1.2
1.3
1.1
0.7
1.1
1.1
1.2
0.9
0.8
2.1
1.3
1.5
-0.7
0.2
0.2
2.2
0.4
-1.3
0.6
0.6
0.4
-0.5
-0.9
1.7
1.1
4.1
-1.5
0.3
-0.6
-5.6
-2.5
-0.6
-2.1
-1.9
-1.0
-2.2
2.5
0.4
-0.1
0.6
Concentration index (Cy)
EU-
AT
BE
DK
EE
-0.16
-0.32
-0.18
-0.19
ES
FI
FR
GR
IE
IT
LU
NO
PT
SE
-0.22
-0.20
-0.26
-0.18
-0.20
-0.03
-0.09
-0.26
-0.11
14
Cy
-0.17
-0.03
Health corrected concentration index (C*)
EU-
AT
BE
DK
EE
ES
FI
FR
GR
IE
IT
LU
NO
PT
SE
14
Cy
-0.17
-0.16
-0.32
-0.18
-0.19
-0.03
-0.22
-0.20
-0.26
-0.18
-0.20
-0.03
-0.09
-0.26
-0.11
C*
-0.11
-0.09
-0.26
-0.16
-0.11
0.00
-0.14
-0.16
-0.15
-0.08
-0.17
-0.02
0.04
-0.15
-0.04
Decomposition of Cy
Wagstaff et al., have shown that if
(1)
y = λ0 + λ1 x1 + λ2 x2 + ... + λk xx + υ
then
(2)
Cov( y, r ) = Cov(λ1 x1 , r ) + Cov(λ2 x2 , r ) + ... + Cov(λk xk , r ) + Cov(υ , r )
Decomposition of CI
Equation 2 can be used to decompose the CI
(3)
2Cov ( y, r )
Cy =
y
2Cov( x1 , r ) x1 2Cov ( x2 , r ) x2
2Cov( xk , r ) xk
=
+
+ ... +
+ GCυ
x1
y
x2
y
xk
y
Which can be rewritten as
(4)
C y = C x1S x1 + C x 2 S x 2 + ... + C xk S xk + GCυ
Where Cx1 is the concentration index of X1 and Sx1 is the share of unmet
need due to X1
Contributions to C*
EU-
AT
BE
DK
EE
ES
FI
FR
GR
IE
IT
LU
NO
PT
SE
14
Cy
-0.17
-0.16
-0.32
-0.18
-0.19
-0.03
-0.22
-0.20
-0.26
-0.18
-0.20
-0.03
-0.09
-0.26
-0.11
C*
-0.11
-0.09
-0.26
-0.16
-0.11
0.00
-0.14
-0.16
-0.15
-0.08
-0.17
-0.02
0.04
-0.15
-0.04
toexpen
159
78
136
63
138
1028
77
79
126
95
102
223
-119
149
51
waitlist
35
-3
2
11
-11
308
37
1
2
69
10
37
-2
17
16
notime
-53
-41
-12
3
6
-630
-1
1
-6
-4
2
-35
0
-7
-16
toofar
35
14
1
0
19
435
-1
3
37
7
2
-17
-25
1
9
fear
12
22
-1
0
5
199
1
14
3
-2
5
-49
-41
2
6
watchful
13
43
-7
34
-1
-3
10
11
3
27
3
-17
-9
1
92
nogood
-9
-2
-1
-1
-1
-107
0
0
0
2
-1
-10
-17
-3
12
other
13
65
0
-6
2
-27
29
10
-2
23
-6
31
5
0
58
-105
-76
-17
-5
-57
-1102
-51
-19
-63
-116
-16
-63
307
-61
-126
residual
Conclusions (I)
!
5.2% Of the people in an EU member state claim unmet need for
medical examination or treatment during the last 12 months.
!
Unmet need for medical examination or treatment during the last 12
months varies between 1% of the population for Denmark and 13% of
the population for Sweden.
!
Costs of care are the most important reason provided for unmet need,
followed by waiting lists, no time and watchful waiting.
Conclusions (II)
! Unmet need is for all countries (strongly) concentrated among the lower
income households and less related to degree of urbanisation,
education and being a foreigner.
! Decomposition of income related inequity shows that the expense of
health care is still the most important barrier for lower income groups.
! Waiting lists and distance to health care also contribute importantly to
income related inequity.
! Based on the results from the RAND health insurance experiment it is
quite likely that these obstacles to access have adverse consequences
on health for the poor with chronic conditions.
! Because the causes for inequity vary dramatically from country to
country, so should policies to address these inequities.
Recommendations (I)
Relationship between socioeconomic factors and health
! Lost to follow up: attrition is
often health related but health
state of the person lost to follow
up was mostly unknown.
! Health related sample selection
! Inclusion of health vignettes
could make self assessed health
more comparable.
Relationship between socioeconomic factors and health care
! Ethnic sample selection:
monitor the response rate of
ethnic groups
! Information about health care
expenditure
Recommendations (II)
Studies in regional inequality in
health and health care were
seriously hampered by privacy
considerations.
Studies in regional inequality in
ethnic differences were seriously
hampered by privacy
considerations.
Studies of both supply and demand
for health care were hampered due
to difficulty of linking data with
other databases (privacy
considerations).
!Suggestion:
Allow researchers access to full
data without giving the data to
the researchers.
On-site or remote access
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