International Journal for Quality in Health Care 2001; Volume 13, Number 2: 117–125
Social class inequalities in the use of and
access to health services in Catalonia,
Spain: what is the influence of
supplemental private health insurance?
CARME BORRELL1, ESTEVE FERNANDEZ2, ANNA SCHIAFFINO2, JOAN BENACH3, LUIS RAJMIL4,
JOAN R. VILLALBÍ1,5 AND ANDREU SEGURA5
1
Institut Municipal de Salut Pública. Barcelona, 2Institut Català d’Oncologia, 3Universitat Pompeu Fabra. Barcelona,
Agència d’Avaluacio de Tecnologia i Recerca Mèdiques de Catalunya and 5Institut de Salut Pública de Catalunya, Spain
4
Abstract
Objective. To analyse social class inequalities in the access to and utilization of health services in Catalonia (Spain), and the
influence of having private health insurance supplementing the National Health System (NHS) coverage.
Design. 1994 Catalan Health Interview Survey, a cross-sectional survey conducted in 1994.
Setting. Catalonia (Spain).
Study participants. The participants were a representative sample of people aged over 14 years from the non-institutionalized
population of Catalonia (n=12 245).
Main outcome measures. Health services utilization, perceived health, having only NHS or NHS plus a private health
insurance, and social class.
Results. Although one-quarter of the population of Catalonia had a supplemental private health insurance, percentages were
very different according to social class, ranging from almost 50% for classes I and II to 16% for classes IV and V in both
sexes. No inequalities by social class were observed for the utilization of non-preventive health care services (consultation
with a health professional in the last 2 weeks and hospitalization in the last year) among persons with poor self-perceived
health status, i.e. those in most need. However, social inequalities still remain in the use of health services provided only
partially by the NHS, and when characteristics of last consultation are taken into account. Subjects who paid for a private
service waited an average of 18.8 minutes less than those attending the NHS. Within the NHS, social classes IV and V
waited longer (35.5 minutes) than social classes I and II (28.4 minutes).
Conclusion. The NHS in Catalonia, Spain, has reduced inequalities in the use of health services. Social inequalities remain
in the use of those health services provided only partially by the NHS.
Keywords: Catalonia, health services utilization, inequalities in health, preventive services, social class, Spain, waiting time
Equity in access to and utilization of health care services for
equal health needs has not been achieved in industrialized
countries. Barriers exist which limit the equitable access to
and utilization of health care services by disadvantaged social
classes (those in lower social categories), particularly in countries such as the USA where an important percentage of the
population is uninsured [1,2]. In Sweden, with a National
Health Service, the existence of barriers of access has appeared
during the 1990s mainly because of market reforms and
spending cuts [3].
In Spain, under a socially-minded government, the 1986
General Health Service Act established a National Health
System (NHS) with 17 regional health services [4,5], financed
mainly by taxes, which provides universal and free health
coverage including primary, specialized and hospital health
care. Coverage of dental care is, however, only partial, leaving
Address reprint requests to C. Borrell, Institut Municipal de Salut Pública de Barcelona, Pl. Lesseps 1, 08023 Barcelona,
Spain. E-mail: [email protected]
 2001 International Society for Quality in Health Care and Oxford University Press
117
C. Borrell et al.
Table 1 Distribution of 5641 males and 6604 females according to age, social class, health insurance coverage and
self-perceived health status. Catalan Health Interview Survey,
1994
Males
Females
................................ ................................
n
(%)
n
(%)
............................................................................................................
1
6604
[53.9]1
Total
5641
[46.1]
Age (years)
15–24
25–34
35–44
45–54
55–64
65–74
[–75
1239
880
894
832
856
635
305
(22.0)
(15.6)
(15.8)
(14.8)
(15.2)
(11.3)
(5.4)
1259
978
1077
1010
926
831
524
(19.1)
(14.8)
(16.3)
(15.3)
(14.0)
(12.6)
(7.9)
Social class
I
II
III
IV
V
Unknown
352
843
1108
2938
330
71
(6.2)
(14.9)
(19.6)
(52.1)
(5.8)
(1.3)
229
935
1164
3252
815
209
(3.5)
(14.2)
(17.6)
(49.2)
(12.3)
(3.2)
Health insurance coverage
Only NHS
4224
NHS and private 1403
(75.1)
(24.9)
4949
1648
(75.0)
(25.0)
Self-perceived health
Good health
4428
Poor health
1213
(78.5)
(21.5)
4636
1968
(70.2)
(29.8)
1
Percentage among the total sample (row percentage).
NHS, National Health System.
out orthodontics [6]. In 1995, it was estimated that only 1.0%
of the population was not covered by the NHS, mainly welloff people who had never been on salary [4,7].
Part of the Spanish population (about 11% overall) has
some private insurance coverage in addition to NHS; this
double coverage is much higher in Catalonia (about 25%) [4,
7], for wealth and historical reasons. Private health insurance
may provide services beyond those offered by the NHS (e.g.
dental care, elective surgery) and more personalized care for
low cost services (greater convenience in primary health care
or specialized care).
In Spain, interest in the study of social inequalities in
health has increased notably in the 1990s. Among the studies
reported [8], most are based on mortality data [9,10]. Few
studies, however, have analysed the influence of having a
private health insurance supplementing the NHS in social
inequalities. The purpose of this investigation was to analyse
social class inequalities in the access to and utilization of
health services in Catalonia, taking into account the factor
of having private health insurance supplementing the NHS
using data from the 1994 Catalan Health Interview Survey.
Subjects and methods
Study population and sample
The 1994 Catalan Health Interview Survey is a cross-sectional
survey based on a representative sample of the non-institutionalized population of Catalonia, which has about
six million inhabitants. The survey included self-reported
information on morbidity, health status, health-related behaviours and use of health care services as well as sociodemographic data.
Fifteen thousand subjects were selected randomly by using
a multiple stage random sampling strategy. For each of the
eight health areas of Catalonia, the first sampling stage
consisted of selecting municipalities (or municipal districts in
the case of the city of Barcelona) according to their population
size (eight strata). In each of these strata, cluster random
sampling was used to select individuals by using proportional
probabilities according to the weight of the municipality (or
district). Trained interviewers administered the questionnaires
at the subjects’ homes in face-to-face interviews from January
to December 1994 (to avoid a potential seasonal bias). Only
5.4% of subjects were substituted due to refusal or absence
of those initially selected [11]. For the present study, only
subjects aged over 14 years and able to respond for themselves
(5641 males and 6604 females) were included for analysis
(Table 1).
Measuring social class
Figure 1 Health insurance coverage by social class and sex.
Catalan Health Interview Survey, 1994.
118
Social class was obtained from a Spanish adaptation of the
1980 British Registrar General (BRG) classification [12]. Class
I includes managerial and senior technical staff and free-lance
professionals; class II includes intermediate occupations and
managers in commerce; class III, skilled non-manual workers;
class IV, skilled (IVa) and partly-skilled (IVb) manual workers;
Inequalities in use and access to health services
Table 2 Age-standardized proportions and prevalence odds ratios (and 95% confidence intervals) of having visited a health
professional in the past 2 weeks, an ophthalmologist in the past year, a dentist in the past year, and having been hospitalized
in the past year according to sex and social class. Catalan Health Interview Survey, 1994
Males
Females
......................................................
......................................................
1
2
%
OR (95% CI)
%1
OR (95% CI)2
.............................................................................................................................................................................................................................
Visit to a health professional (last 2 weeks)
Social class I–II
Social class III
Social class IV–V
15.0
18.1
19.3
13
1.2 (0.9–1.5)
1.2 (1.0–1.5)
23.8
21.8
26.0
13
0.8 (0.7–1.1)
0.9 (0.8–1.1)
6.1
6.8
8.8
13
1.0 (0.7–1.4)
1.3 (1.0–1.7)
6.6
5.3
6.7
13
0.9 (0.6–1.3)
0.9 (0.7–1.2)
Visit to an ophthalmologist (last year)
Social class I–II
Social class III
Social class IV–V
23.3
21.9
19.1
13
0.9 (0.8–1.2)
0.8 (0.7–1.0)
27.9
24.3
22.5
13
0.9 (0.7–1.1)
0.7 (0.6–0.8)
Visit to a dentist (last year)
Social class I–II
Social class III
Social class IV–V
29.4
25.7
20.8
13
0.9 (0.7–1.0)
0.7 (0.6–0.8)
37.7
36.0
26.7
13
0.9 (0.8–1.1)
0.6 (0.5–0.7)
Hospitalization (last year)
Social class I–II
Social class III
Social class IV–V
1
Age-standardized by the direct method. 2Odds ratio and 95% confidence interval, adjusted for age, area of residence, self-perceived
health, and health insurance coverage. 3Reference category.
and class V, unskilled manual workers. For analysis purposes,
classes were grouped as I–II, III, and IV–V. Subjects in an
unpaid work (e.g. women working at home and students) were
assigned to the same social class as the head of the household
(558 males and 1418 females), with the exception of those
who had previously worked (including retired and unemployed
subjects), who were classified according to their last occupation.
In 2.3% of the sample, social class was missing or could not be
defined. Although the BRG classification has been validated
in Spain [13], it has been criticized because it does not fully
take into account the social aspects of production [14]. Future
surveys in this context are including another social class classification based on the E.O. Wright approach [15].
Health service utilization and health variables
analysed
Health insurance coverage was analysed in two categories: (i)
only NHS or (ii) NHS and a supplementary private insurance,
as reported in a non-exclusive question. Consultation with a
health professional over the past 2 weeks prior to the interview
(no/yes) included either in-person visits or telephone consultations with a primary health care physician, a specialist
doctor, a nurse, or other health professionals. Variables on
the last consultation during the 15 days prior to the interview
were: waiting time at the place of the visit (in minutes);
location of visit (private clinic, public clinic, emergency
services); type of visit (diagnostic, prescription, diagnosis plus
prescription preventive examination; administrative procedure) and service funding, defined as private if the patient
paid the physician out-of-pocket or through a private health
insurance, and NHS funding if only NHS physicians were
used. Funding of the last visit is not the same as health
insurance coverage status.
Consultation with an ophthalmologist or a dentist during
the year prior to the interview was specifically elicited, as
well as hospitalization in the year prior to the interview for
a minimum stay of at least one night. The reason for
hospitalization was elicited for the most recent episode.
Hospitalizations for pregnancy and delivery were excluded
from the analysis (WONCA codes: 633-, 640-, 6466, 642-,
636-, 634, 648-, 650-) [16].
As a measure of need, ratings of self-perceived health were
obtained using the question ‘In general, how would you say
your health is?’ with response options of excellent, very good,
good, fair, or poor. This measure of morbidity has shown
validity across numerous studies and is a strong predictor of
mortality [17]. For analysis purposes, answers were grouped
into two categories: ‘good health’ (excellent, very good and
good) and ‘poor health’ (fair and poor).
Data analysis
As sex differences in the use of health services were found
in a previous study [18], all analyses were carried out separately
119
C. Borrell et al.
Table 3 Age-standardized proportions and prevalence odds ratios (and 95% confidence intervals) of having visited a health
professional in the past 2 weeks, an ophthalmologist in the past year, a dentist in the past year, and having been hospitalized
in the past year according to sex, social class and self-perceived health status. Catalan Health Interview Survey, 1994
Males
Females
Self-perceived health
Self-perceived health
............................................................................... ...............................................................................
Excellent,
Excellent,
Fair or poor
very good or good
Fair or poor
very good or good
%1 OR (95% CI)2 %1 OR (95% CI)2 %1 OR (95% CI)2 %1 OR (95% CI)2
.............................................................................................................................................................................................................................
Visit to a health professional
(past 2 weeks)
Social class I–II
Social class III
Social class IV–V
31.4 13
32.6 1.0 (0.6–1.6)
31.4 1.0 (0.7–1.4)
12.8 13
14.5 1.2 (0.9–1.6)
15.7 1.4 (1.1–1.7)
38.1 13
37.1 0.9 (0.6–1.3)
35.9 0.9 (0.6–1.2)
19.4 13
19.0 0.9 (0.7–1.2)
20.4 1.0 (0.8–1.3)
Hospitalization (past year)
Social class I–II
Social class III
Social class IV–V
13.7 13
13.8 1.1 (0.6–1.9)
16.0 1.1 (0.7–1.8)
5.1 13
5.5 0.9 (0.6–1.4)
6.5 1.3 (0.9–1.9)
11.7 13
13.8 1.0 (0.5–1.8)
11.4 1.0 (0.7–1.6)
5.1 13
4.8 0.9 (0.6–1.4)
4.5 0.8 (0.6–1.2)
Visit to an ophthalmologist (past year)
Social class I–II
18.4 13
Social class III
30.0 1.3 (0.8–2.0)
Social class IV–V
20.3 1.0 (0.7–1.5)
23.2 13
20.2 0.9 (0.7–1.2)
18.0 0.9 (0.7–1.1)
31.3 13
30.4 0.8 (0.5–1.3)
26.8 0.9 (0.6–1.2)
26.8 13
24.1 0.9 (0.8–1.2)
19.7 0.7 (0.6–0.9)
Visit to a dentist (past year)
Social class I–II
Social class III
Social class IV–V
29.8 13
25.7 0.9 (0.7–1.1)
20.4 0.7 (0.6–0.8)
30.6 13
41.4 1.3 (0.9–2.0)
27.9 0.8 (0.6–1.1)
38.7 13
33.4 0.9 (0.7–1.0)
26.1 0.6 (0.5–0.8)
28.9 13
29.3 0.9 (0.6–1.6)
22.3 1.0 (0.7–1.5)
1
Age-standardized by the direct method. 2Odds ratio and 95% confidence interval, adjusted for age, area of residence, and health insurance
coverage. 3Reference category.
for males and females. In addition, direct standardization by
age (in decades) based on the 1991 Catalan census was used
to obtain age-adjusted proportions of subjects for each of
the dependent variables in each social class [19]. Age-adjusted
means for the waiting time at the place of the visit were also
computed by the direct method.
Prevalence odds ratios (OR) and their corresponding 95%
confidence intervals were computed by means of logistic
regression to estimate the association between social class
and utilization of health care services variables [20]. The
regression equations included terms for age (in decades), area
of residence (the eight health areas), self-perceived health
(good/poor) or health insurance coverage (having only NHS
or NHS plus a supplementary private health insurance).
Stratified analysis by self-reported health and health insurance
coverage were also performed. Other variables potentially
related to health services utilization (nationality of origin,
immigration status, ethnic group) were not analysed because
they represent a small proportion of our sample.
All analyses included the weights derived from the sample
design using standard statistical packages (SPSS and EGRET).
In this survey, the weights accounted for the extra variability
from the complex sample design, as shown elsewhere [21].
120
Results
Although one-quarter of the population of Catalonia had
supplemental private health insurance, percentages were very
different by social class, ranging from almost 50% for classes
I and II to 16% for classes IV and V in both sexes (Figure
1).
Overall, no inequalities in the use of health services by
social class were found. Table 2 shows no social class inequalities either in having visited a health professional in the
2 weeks prior to the interview or in having been hospitalized
during the previous year. Likewise, no social class differences
were evident when the analysis was stratified by health status
(Table 3) or health insurance coverage (Table 4).
In contrast, subjects in social classes IV and V were less
likely to have visited an ophthalmologist or a dentist during
the past year (Table 2), especially in the case of people with
good health status (Table 3). The proportion of males and
females that visited an ophthalmologist or a dentist during
the past year was higher among subjects with both NHS and
private health insurance as compared with those with only
NHS coverage. Classes IV and V were less likely to have
visited a dentist, regardless of their having a private health
Inequalities in use and access to health services
Table 4 Age-standardized proportions and prevalence odds ratios (and 95% confidence intervals) of having visited a health
professional in the past 2 weeks, an ophthalmologist in the past year, a dentist in the past year, and having been hospitalized
in the past year according to sex, social class and health insurance coverage. Catalan Health Interview Survey, 1994
Males
Females
Health insurance coverage
Health insurance coverage
............................................................................... ...............................................................................
NHS
NHS and private
NHS
NHS and private
%1 OR (95% CI)2 %1 OR (95% CI)2 %1 OR (95% CI)2 %1 OR (95% CI)2
.............................................................................................................................................................................................................................
Visit to a health professional
(past 2 weeks)
Social class I–II
15.1 13
15.1 13
21.7 13
26.5 13
Social class III
18.3 1.2 (0.9–1.6)
15.7 1.1 (0.7–1.6)
21.5 1.0 (0.8–1.3)
22.4 0.8 (0.5–1.0)
Social class IV–V
19.3 1.2 (1.0–1.6)
20.2 1.3 (0.9–1.8)
26.4 1.1 (0.9–1.4)
24.4 0.8 (0.6–1.2)
Hospitalization (past year)
Social class I–II
Social class III
Social class IV–V
5.9 13
7.0 1.0 (0.7–1.6)
9.0 1.3 (0.9–1.9)
7.0 13
6.8 0.8 (0.5–1.5)
8.2 1.3 (0.8–2.1)
6.6 13
4.4 0.7 (0.4–1.2)
6.9 0.9 (0.6–1.3)
6.1 13
7.2 1.3 (0.8–2.2)
5.7 0.9 (0.5–1.5)
Visit to an ophthalmologist (past year)
Social class I–II
21.2 13
Social class III
18.9 0.9 (0.7–1.2)
Social class IV–V
18.1 0.9 (0.7–1.1)
26.1 13
28.4 1.1 (0.8–1.5)
24.5 1.0 (0.7–1.3)
25.2 13
22.2 0.9 (0.7–1.2)
21.1 0.7 (0.6–0.9)
30.6 13
28.7 0.9 (0.7–1.2)
29.8 0.9 (0.7–1.2)
Visit to a dentist (past year)
Social class I–II
Social class III
Social class IV–V
33.7 13
34.3 1.0 (0.7–1.3)
25.1 0.7 (0.5–0.9)
32.6 13
33.6 1.0 (0.8–1.3)
25.0 0.7 (0.6–0.8)
43.8 13
41.9 0.8 (0.6–1.1)
35.0 0.7 (0.5–0.9)
25.4 13
22.1 0.9 (0.7–1.1)
20.1 0.8 (0.6–0.9)
1
Age-standardized by the direct method. 2Odds ratio and 95% confidence interval, adjusted for age, area of residence, and self-perceived
health, 3Reference category.
insurance supplementing the NHS. Findings showed the
same direction for visiting an ophthalmologist, although
patterns were less apparent (Table 4).
Table 5 shows the time waiting at the last visit by social
class and the service funding of the visit. Subjects who paid
for a private service waited an average of 18.8 minutes less
than those attending the NHS. Within the NHS, social classes
IV and V waited longer (35.5 minutes) than social classes I
and II (28.4 minutes). In contrast, there were no social class
inequalities in time waiting in private services. Results were
similar both for males and females. Subjects of advantaged
classes (classes I and II) visited private clinics more often
(around half of the visits), took many more preventive
examinations, and paid for private services more frequently
(Table 6), while for classes IV and V the opposite pattern
was observed.
Discussion
In this study no inequalities by social class were found in
Catalonia for the utilization of non-preventive health care
services among persons with poor self-perceived health status,
i.e. those in most need. However, social inequalities still
remain in the use of those health services provided only
partially by the NHS and when quality of care is taken into
account.
Studies on health care inequalities have shown different
results. In the 1970s in the UK, visits to the family doctor
were more frequent among people in disadvantaged social
classes, but when measures of ‘utilization/need’ were considered, the gradient between social classes reversed, and the
working classes actually are consulting less, suggesting that,
for the same level of need, disadvantaged classes might have
less access to the family doctor [22]. More recently, other
authors did not find variations according to social class in
the use of general practitioners, although they did not stratify
the analysis by any measure of need [23,24]. Studies on trends
of access inequality, combining general practitioners and
outpatient visits between 1984–1985 and 1993–1994, have
shown few inequalities in access to care after adjusting for
health status [3]. In 1993–1994 in Sweden, inequalities in
access to care (proportion of people visiting the doctor)
appeared for the first time since 1960 [3]. Some studies in
Denmark and Germany have found that general practice use
was higher in less well-off areas and in people with lower
121
C. Borrell et al.
Table 5 Age-standardized means (and 95% confidence intervals) of waiting time at the last visit (minutes) according
to service funding, sex and social class. Subjects who visited
a health professional (2 weeks prior to interview). Catalan
Health Interview Survey, 1994
Funding
NHS
Private
.................................. ..................................
Mean1 (95% CI) Mean1 (95% CI)
............................................................................................................
Both sexes
Social class I–II
Social class III
Social class IV–V
33.1
28.4
26.2
35.5
(31.1–35.1)
(24.0–32.8)
(22.5–29.8)
(33.0–38.1)
14.3
13.7
17.1
13.5
(12.4–16.1)
(10.9–16.4)
(12.2–22.1)
(11.0–16.1)
Males
Social class I–II
Social class III
Social class IV–V
33.9
29.8
23.3
36.7
(30.3–37.5)
(23.1–36.5)
(18.3–28.4)
(32.4–41.0)
14.6
17.7
12.5
15.2
(12.3–23.4)
(12.0–23.4)
(8.8–16.2)
(9.6–20.5)
Females
Social class I–II
Social class III
Social class IV–V
32.8
27.1
27.4
34.5
(30.6–35.1)
(21.6–32.6)
(22.6–32.2)
(31.6–37.4)
14.2
11.6
19.3
12.6
(11.6–16.9)
(8.7–14.5)
(12.1–26.5)
(9.2–16.0)
1
Age-standardized by the direct method.
occupational income, while the opposite trend was seen for
use of specialists [25,26]. Another study in Denmark, however,
did not show inequalities in the utilization of general practice
by social class [27]. In Canada, income level has been reported
to have a positive effect on hospital utilization [28,29], while
other studies, adjusting by health status, showed that Ontario
and USA inhabitants with fair or poor health had lower
hospital admissions rates than people with excellent or good
health [30].
A number of studies carried out in Spain in recent years
have not found social class inequalities with regard to visits
or hospitalizations [31–34]. In earlier studies with data collected in the 1980s however, differences by social class were
evident when the level of need was taken into account, with
persons of disadvantaged classes and with poor self-perceived
health consulting less [35,36].
Two main factors may be suggested to explain this change.
First, the implementation in the late 1980s of the General
Health Service Act with a quasi-universal coverage is likely
to have reduced health care inequalities [4]. The system is
financed through taxes, most health facilities are public, and
access is free of charge. Second, the broadening reforms of
primary care services were initiated in 1984 following the
principles of the Alma Ata Conference. The new primary
health care services in the NHS are based on the concept of
health care centres in which professionals work in teams [37];
the location of hospitals and other health centres is designed
to make specialist and in-patient services geographically accessible. Currently, the reform has been implemented to
different degrees in different regions of Spain. In Catalonia,
122
it has reached 70% of the population, with priority given to
deprived and rural areas [38].
Double coverage does not seem to change the social
pattern of inequalities in having visited a health professional
in the 2 weeks prior to the interview, or in having been
hospitalized during the last year, as was also observed in the
Netherlands [39,40]. However, visits to an ophthalmologist
or to a dentist were more frequent among people with double
coverage, which is much more frequent in advantaged classes.
Those in disadvantaged social classes, particularly those subjects with good health status, made fewer visits to the dentist.
These observations may be explained as part of an overall
pattern, where subjects in less advantaged classes undertake
fewer preventive practices such as prenatal monitoring, visits
to the dentist [22,41] or breast or cervical cancer screening
[42].
The importance has been emphasized of analysing the
quality of services in health care inequalities research [22,43],
urging that studies should not only be based on the number
of visits and admissions, but that their nature should also be
considered. In this study, health care quality was approximated
through mean waiting times at the place of the visit and the
type of visits made. In the future, qualitative studies are
needed to identify and characterize the quality of medical
care received. Disadvantaged social classes made more visits to
NHS, had longer waiting times, and received fewer preventive
examinations than advantaged classes. Subjects with private
health insurance have some advantages in the quality of care
received and have fewer financial barriers to health care
[44–46]. These findings are likely to be related to the fact
that having a private insurance is more common for subjects
in the advantaged classes [47].
Other Spanish studies seem to support the same hypothesis.
Use of NHS primary health care services follows a social
class pattern, with about 60% of people in advantaged social
classes using a NHS centre when visiting a doctor, while
more than 90% of working class individuals use NHS centres
[10]. Similar social inequalities in waiting time both at consultation and for hospital admission have been reported in
Spain [31] with waiting times being greater among people
with a lower educational level. Likewise, a clear gradient has
been found by social class in the use of dental services
[10] and visits to the gynaecologist [31]. In Barcelona and
Catalonia, it was found that women with double coverage
and those from advantaged social classes were more likely
to receive regular cervical smears and mammograms [48,49].
Among the limitations of this study, the possibility of
differential recall bias of health service utilization according
to social class deserves attention [50]. However, in a validation
study performed in Barcelona no meaningful differences were
observed [51]. In addition, it should be mentioned that the
measurement of the majority of variables used in this study
has been validated previously [52,53]. For example, selfreported hospitalization (with a recall period of 12 months),
and ambulatory physician visits over a 2-week period [54–56].
The low use of NHS services by the most advantaged has
policy implications. If a wide sector of the advantaged classes
does not use publicly funded services, they are likely to receive
Inequalities in use and access to health services
Table 6 Age-standardized percentages for locations of the last visit, type of visit and service
funding by sex and social class. Subjects who visited a health professional (2 weeks prior to
interview). Catalan Health Interview Survey, 1994
Males
Females
................................................. .................................................
I–II
III
IV–V
I–II
III
IV–V
............................................................................................................................................................................
Visit location
Private clinic
51.1
31.2
18.5
45.2
45.6
19.9
Public clinic
44.5
62.1
72.4
50.9
49.0
74.7
Emergency centre
4.3
6.7
9.1
3.9
5.4
5.4
Type of visit
Diagnostic
Prescription
Diagnostic plus prescription
Preventive exam
Administrative procedure
Other
59.8
5.0
11.6
9.3
14.2
62.8
5.8
9.3
6.5
2.2
13.4
56.9
8.8
12.2
4.3
5.6
12.0
52.0
10.8
8.3
14.7
2.0
12.1
61.7
2.2
8.8
14.6
2.2
10.4
53.1
8.2
13.8
8.8
3.5
12.5
Service funding
Private
NHS
52.1
47.9
33.6
66.4
18.9
81.1
46.1
53.9
46.8
53.2
20.2
79.8
less political priority and funding. In fact, over recent years,
policies aiming at expanding the market for private services
and refunding the costs of private insurance have been put
forward [57]. Only a NHS which offers services valued by all
can resist such pressures in times of budget cutting.
This study has shown the existence of social class inequalities in the use of those services not provided fully by
the NHS, as well as in quality of care and in the accessibility
to some NHS services. These findings indicate that double
coverage benefits more those people who already have higher
levels of health suggesting the need to improve current health
care services as well as to avoid service duplication. The
analysis and monitoring of the evolution of inequalities in
the quality of health services should be a matter of concern
for both social epidemiologists and policy makers. Thus,
there is a need to analyse the potential impact of primary
health care reform on health care inequalities according to
social class. Providing equitable access and utilization in all
health care services in relation to health needs regardless of
the type of insurance and the social class of their citizens
should be a priority for the health care system in Catalonia.
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Accepted for publication 29 November 2000
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