Explaining inequalities in Health Care Utilization among Turkish adults: Findings from Health Survey 2008

From inequalities to solutions: an explanatory sequential study on type 2 diabetes health services utilization

BACKGROUND

Health inequities are a significant issue. This study aimed to measure and decompose socioeconomic inequality in the utilization of type 2 diabetes (T2D) services and propose solutions to mitigate these inequalities.

METHODS

This explanatory sequential mixed-method study was conducted in two phases: quantitative and qualitative. A total of 2000 T2D patients from health centers, hospitals, and diabetes clinics in Isfahan and Khuzestan provinces, Iran, were selected. In the quantitative phase, the existence of inequality in the utilization of T2D services was examined using the Concentration Index (CI) approach. To determine the contribution of each explanatory variable to T2D inequality, we used concentration index decomposition analysis. In the qualitative phase, based on the main contributors identified in the quantitative phase, we conducted semi-structured interviews with purposefully selected key experts to identify solutions for reducing inequality in the utilization of T2D services.

RESULTS

The sample consisted of 65.3% men, with 40% of T2D patients being over 60 years old. The CI values were 0.31 (p < 0.05) for outpatient services, -0.10 (p > 0.05) for inpatient services, and 0.11 (p < 0.05) for pharmaceutical services. This indicates an inequality in the utilization of outpatient and pharmaceutical services among T2D patients, while the inequality in inpatient services was not significant. The main variables contributing to inequality in outpatient services were health status (33.54%), basic insurance (27.43%), and socioeconomic status (24.08%). For pharmaceutical services, the contributing variables were health status (22.20%), basic insurance (13.63%), and socioeconomic status (34.35%). Experts' solutions to reduce socioeconomic inequalities in Iran were classified into three main themes: socioeconomic status, health status, and basic insurance, with 29 sub-themes.

CONCLUSION

The results suggest that targeted health interventions for poor T2D patients are recommended. Efforts towards universal coverage in outpatient care and commonly used pharmaceutical items, such as: Antidiabetic Drugs, Triglyceride Control Drugs, Cardiovascular Drugs, Neuropathy Drugs, and Nephropathy Drugs, should be considered.

Socioeconomic inequity in the utilization of healthcare among people with eating disorders in Australia

BACKGROUND

Little is known about socioeconomic equity in access to healthcare among people with eating disorders in Australia. This study aims to measure the extent of inequity in eating disorder-related healthcare utilization, analyze trends, and explore the sources of inequalities using New South Wales (NSW) administrative linked health data for 2005 to 2020.

METHODS

Socioeconomic inequities were measured using concentration index approach, and decomposition analysis was conducted to explain the factors accounting for inequality. Healthcare utilization included: public inpatient admissions, private inpatient admissions, visits to public mental health outpatient clinics and emergency department visits, with three different measures (probability of visit, total and conditional number of visits) for each outcome.

RESULTS

Private hospital admissions due to eating disorders were concentrated among individuals from higher socioeconomic status (SES) from 2005 to 2020. There was no significant inequity in the probability of public hospital admissions for the same period. Public outpatient visits were utilized more by people from lower SES from 2008 to 2020. Emergency department visits were equitable, but more utilized by those from lower SES in 2020.

CONCLUSIONS

Public hospital and emergency department services were equitably used by people with eating disorders in NSW, but individuals from high SES were more likely to be admitted to private hospitals for eating disorder care. Use of public hospital outpatient services was higher for those from lower SES. These findings can assist policymakers in understanding the equity of the healthcare system and developing programs to improve fairness in eating disorder-related healthcare in NSW.

Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics

Unequal utilization in healthcare can potentially affect the right to health. Access to healthcare services and achieving positive health outcomes and health equity are essential principles in promoting human rights. This study aims to assess and analyze socioeconomic-related inequalities in outpatient health services utilization (OHSU) among various socio-demographic subgroups to inform policies that foster health equity. Data were collected through a cross-sectional survey of 1200 households in Tehran, Iran. Inequality in OHSU among the socio-demographic subgroups was calculated by concentration, Wagstaff, and Erigers indices. Decomposition was used to identify the factors contributing to inequality in OHSU. Marginal effect and elasticity were used to calculate the relative absolute shares of socio-demographic variables in the inequality. The rate of OHSU was 63.61% (CI: 60-66.80) which concentrated among households with better socioeconomic status. Based on the results, living in an affluent neighborhood (Relative share (RS): 85.48) and having a disabled member in the household (RS: 6.58) were the most important factors in the concentration of OHSU in favor of the privileged groups. In contrast, very low levels of health knowledge (RS: -83.79) and having basic insurance coverage (RS: -3.92) concentrated OHSU in favor of the lower socioeconomic households. The study was conducted based on survey data, and this may lead to some limitations. Given that this study was a cross-sectional study, we were unable to establish causal relationships between explanatory variables and outpatient health service utilization and its relevant predictors. Households with disabled member(s), as well as a member(s) with chronic diseases, may experience severe inequalities in access to healthcare services. Policies that facilitate access to health services for these households can play a significant role in improving health equity.

Scoping review of outpatient health services utilization among women

BACKGROUND

Health services utilization, as one of the mechanisms of the health system, guarantees a healthy life and improves well-being for everyone.

AIMS

The aim of this study was to identify factors affecting the use of outpatient health services among women.

METHODS/DESIGNS

This scoping review examined the studies related to outpatient health services utilization (OHSU) and its determinants among women. This review was conducted on English language studies published between 2010 and 2023 (All searches were conducted on 20 January 2023). Studies available in databases such as Web of Science, MEDLINE (PubMed), Scopus, Wiley library, Proquest, and Google Scholar were searched manually. Selected keywords and their equivalents were used to search for related articles in each database.

RESULTS

A total of 18 795 articles were identified, of which 37 met the inclusion criteria. Findings showed that age, marital status, level of education, employment status, income level, socioeconomic status, rape experience, health insurance, health status, ethnicity, living in rural areas, quality of services, area of residence, having a purpose in life and access to health services affect OHSU among women.

CONCLUSIONS

The results of the present review showed that in order to achieve the universal goals of health services coverage and health service utilization, it is necessary for countries to provide insurance coverage to the maximum number of people. Also, policies should change in favor of the elderly, poor and low-income, low-educated, rural, ethnic minority, and chronically ill women and provide them with free preventive health services.

The link between out-of-pocket costs and inequality in specialist care in Australia

Objective Out-of-pocket (OOP) costs could act as a potential barrier to accessing specialist services, particularly among low-income patients. The aim of this study is to examine the link between OOP costs and socioeconomic inequality in specialist services in Australia. Methods This study is based on population-level data from the Medicare Benefits Schedule of Australia in 2014-15. Three outcomes of specialist care were used: all visits, visits without OOP costs (bulk-billed services), and visits with OOP costs. Logistic and zero-inflated negative binomial regression models were used to examine the association between outcome variables and area-level socioeconomic status after controlling for age, sex, state of residence, and geographic remoteness. The concentration index was used to quantify the extent of inequality. Results Our results indicate that the distribution of specialist visits favoured the people living in wealthier areas of Australia. There was a pro-rich inequality in specialist visits associated with OOP costs. However, the distribution of the visits incurring zero OOP cost was slightly favourable to the people living in lower socioeconomic areas. The pro-poor distribution of visits with zero OOP cost was insufficient to offset the pro-rich distribution among the visits with OOP costs. Conclusions OOP costs for specialist care might partly undermine the equity principle of Medicare in Australia. This presents a challenge to the government on how best to influence the rate and distribution of specialists' services.

Utilization of health services among the elderly in Iran during the COVID-19 outbreak: A cross-sectional study

Background and Aims

Elderly people are potentially vulnerable with a higher need for health services, and utilization of Essential Public Health Services (EPHS) among this group is of high importance. This study aimed to examine the utilization of health services among the elderly in Iran during the coronavirus disease 2019 outbreak.

Methods

This was a cross-sectional study conducted in 21 public health centers in Sirjan, Southern Iran, from May to December 2020. A total of 420 elderly patients were selected through a systematic random sampling method. Data were collected using a questionnaire and were analyzed using SPSS v22.0. The binary logistic regression was used to examine the effect of demographic, socioeconomic and morbidity status on inpatient and outpatient healthcare utilization.

Results

Our results showed that 56% of the elderly had a history of hospitalization during the last year. Although 60% of the elderly reported they had a perceived need for outpatient services, only 49% of them reported that they utilized outpatient services. 51% and 35.5% of the elderly reported that their inpatient and outpatient costs were covered by health insurance, respectively. Others reported their health spending was financed through out-of-pocket payments. Male gender aged 80 and above, urban residents, higher socioeconomic and supplemental insurance coverage were associated with an increase in health services utilization. The elderly with Cancer, mental disorders, kidney disease, and cardiovascular diseases (CVDs) were more likely to be hospitalized.

Conclusion

There were demographic and socioeconomic inequalities in health services utilization among the elderly. Therefore, appropriate interventions and strategies are needed to reduce these inequalities in health services utilization among the elderly. In addition, given that the hospitalization rate was significantly higher among the elderly with chronic diseases than those without, it is crucial and necessary to take interventions to reduce the burden of chronic diseases in the future.

Do changes in primary care service use over time differ by neighbourhood income? Population-based longitudinal study in British Columbia, Canada

Background

Strong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia.

Methods

We used linked administrative databases to track annual primary care visits, continuity of care, emergency department (ED) visits, specialist referrals, and prescriptions dispensed over time. We use generalized estimating equations to examine differences in the magnitude of change by neighbourhood income quintile, adjusting for age, sex/gender, and comorbidity, and stratified by urban/rural location of residence. We also compared the characteristics of physicians providing care to people living in low- and high-income neighbourhoods at two points in time.

Results

Between 1999/2000 and 2017/8 the average number of primary care visits per person, specialist referrals, and continuity of care fell in both urban and rural settings, while ED visits and prescriptions dispensed increased. Over this period in urban settings, primary care visits, continuity, and specialist referrals fell more rapidly in low vs. high income neighbourhoods (relative change in primary care visits: Incidence Rate Ratio (IRR) 0.881, 95% CI: 0.872, 0.890; continuity: partial regression coefficient -0.92, 95% CI: -1.18, -0.66; specialist referrals: IRR 0.711, 95%CI: 0.696, 0.726), while ED visits increased more rapidly (IRR 1.06, 95% CI: 1.03, 1.09). The percentage of physicians who provide the majority of visits to patients in neighbourhoods in the lower two income quintiles declined from 30.6% to 26.3%.

Conclusion

Results raise concerns that equity in access to primary care has deteriorated in BC. Reforms to primary care that fail to attend to the multidimensional needs of low-income communities may entrench existing inequities. Policies that tailor patterns of funding and allocation of resources in accordance with population needs, and that align accountability measures with equity objectives are needed as part of further reform efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01679-4.

Distributive Pattern of Health Services Utilization Under Public Health Reform and Promotion in Turkey

OBJECTIVES

Inclusive health policies and health promotion to ensure strong primary healthcare systems are main tenets of health reforms in developing countries, such as Turkey. Nevertheless, there has been a lack of interest regarding the assessment of equity in health services utilization under public health reform and promotion of primary care. This study aims to analyze equity by measuring deviations from proportionality in the relationship between the utilization of health services and income using indices and curve approaches.

METHODS

A cross-sectional national Turkey Health Survey used the years 2008, 2010, 2012, and 2014. Gini and Kakwani indices and concentration curves were estimated, and the degree of regressivity was analyzed to understand the sources of equity in health services utilization.

RESULTS

Health services utilization for inpatient and outpatient services and family medicine and general practitioner services were regressive between the years 2008 and 2014. The most regressive pattern was observed in the year 2014 regarding medicine usage (Kakwani index = -0.1808904).

CONCLUSIONS

Differences in the utilization of health services have increased, hurting the poorest during the health reform in Turkey. Policies focused on health promotion to strengthen the primary health system and continuous monitoring of health services utilization by vulnerable groups are essential for ensuring a fairer health service usage in developing countries.

Health care use in response to health shocks: Does socio-economic status matter?

We investigate how utilization of primary care, specialist care, and emergency department (ED) care (and the mix across the three) changes in response to a change in health need. We determine whether any changes in utilization are impacted by socio-economic status. The use of a unique Australian data set that consists of a large survey linked to multiple years of detailed administrative records enables us to better control for individual heterogeneity and allows us to exploit changes in health that are related to the onset of two health shocks: a new diagnosis of diabetes and heart disease. We extend the analysis by also examining changes to patient out-of-pocket costs. We find significant differences in the mix between primary and specialist care use according to income and type of health shock but no evidence of using ED as a substitute for other care. Our results indicate that low- and high-income patients navigate very different pathways for their care following the onset of diabetes and to a lesser extent heart disease. These pathways appear to be chosen on the basis of ability to pay, rather than the most effective or efficient bundle of care delivered through a combination of GP and specialist care.

Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt

BACKGROUND

The Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees' access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable.

METHODS

A cross-sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors.

RESULTS

We found pro-rich inequality and horizontal inequity in the probability of refugees' outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures.

CONCLUSION

Our results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

Income-related inequality in distribution of health human resource among districts of Pakistan

BACKGROUND

Solving inequality of health human resource (HHR) is one of the motives of Pakistan health policies, however, there is still exists a massive quantity of HHR inequality in almost every district of Pakistan. The main goal of this research is to scrutinize the disparity in allocation of human health resources among 114 regions of Pakistan from the year 2012 to 2016 and to expose the foundations and aspects of HHR inequality.

METHODS

The data regarding this research has been obtained from Pakistan Statistical Bureau from the year 2012 to 2016. The statistics had also been collected from United Nation Development Program (UNDP) Pakistan 2017, Pakistan economic surveys, Ministry of finance Islamabad, Pakistan, Pakistan Social and Living standards Measurement (PSLM) Surveys from 2012 to 2016. The information incorporates district wise; the number of specialists and medical caretakers those are doctors and nurses, number of hospitals, number of beds, number of dispensaries, number of beds in dispensaries, urbanization, total estimated GNI per capita, infant mortality rate, geographical area, and population size. The concentration index is used to compute the extent of disparity in allocation of human health resources and decomposition analysis is also carried out to enumerate the contribution of each variable towards total inequality. Furthermore, the horizontal concentration was used to measure the participation of the need variable.

RESULTS

7. The consequent Concentration Indexes (CI) of the doctors and nurses for the year 2016 are 0.60 (95% CI= 0.42, 0.78) and 0.67 (95% CI= 0.42, 0.92) respectively. Decomposition of the concentration indexes exposed that the monetary status accounts are the leading percentage contributor in doctors disparity (77.5, 44.9, 30.6, - 11.6% and 13%) and population size (- 20.7,-10.5%, 4.6, 49.8, 19.7%). Furthermore, the monetary status formulates the superior contribution HHR disparity from nurses inequality (104.5, 75.1, 59.2, - 54.3%, - 40.1%), and population size (- 53.7, - 53.6%, - 36.3, 83.8, 65.3%). Moreover, after the identification of the need variable the Horizontal Concentration Index (HCI) values of doctors from the year 2012 to 2016 are 0.62, 0.64, 0.63, 0.62 and 0.61 and HCI of the nurses are 0.69, 0.70, 0.69, 0.68 and 0.67.

CONCLUSION

The pro-rich disparity in allocation of HHR has been scrutinized from the year 2012 to 2016 among 114 districts of Pakistan. The hard concern of HHR disparity should be concentrated by the complete procedures from a multidisciplinary approach.

Determinants of Outpatient Health Service Utilization according to Andersen's Behavioral Model: A Systematic Scoping Review

BACKGROUND

The present review focuses on identifying factors contributing to health service utilization (HSU) among the general adult population according to Anderson's behavioral model.

METHODS

Published articles in English on factors related to HSU were identified by systematically probing the Web of Science, MEDLINE (via PubMed research engine), and Scopus databases between January 2008 and July 2018, in accordance with the PRISMA guidelines. The search terms related to HSU were combined with terms for determinants by Boolean operators AND and OR. The database search yielded 2530 papers. Furthermore, we could find 13 additional studies following a manual search we carried out on the relevant reference lists.

RESULTS

Thirty-seven eligible studies were included in this review, and the determinants of HSU were categorized as predisposing, enabling, and need factors according to Andersen's model of HSU. The results demonstrated that all predisposing, enabling, and need factors influence HSU. In most studies, the female gender, being married, older age, and being unemployed were positively correlated with increased HSU. However, evidence was found regarding the associations between education levels, regions of residence, and HSU. Several studies reported that a higher education level was related to HSU. Higher incomes and being insured, also, significantly increased the likelihood of HSU.

CONCLUSION

This review has identified the importance of predisposing, enabling, and need factors, which influence outpatient HSU. The prediction of prospective demands is a major component of planning in health services since, through this measure, we make sure that the existing resources are provided in the most efficient and effective way.

Tracking socio-economic inequalities in healthcare utilization in Iran: a repeated cross-sectional analysis

Background

Although some healthcare reforms such as Health Transformation Plan (HTP) were implemented in Iran to provide required healthcare services, few studies have been conducted to track the impacts of these reforms on socio-economic inequality in healthcare utilization. This study aims to track socio-economic inequalities in healthcare utilization and their changes between 2008 and 2016 in Iran.

Methods

Required data were obtained from two of Iran’s utilization of healthcare services survey conducted in 2008 and 2016. Erreygers concentration index (EI) was used to measure inequality in the utilization of outpatient and inpatient healthcare services (UOH and UIH). The decomposition of EI (DEI) was used to explain healthcare utilization inequality. Oaxaca decomposition (OD) was also employed to track the changes in EI in this period.

Result

Inequality in UOH increased from 0.105 to 0.133 in the studied years, indicating the pro-rich distribution of UOH. Inequality in UIH decreased from 0.0558 to − 0.006. DEI showed that economic status was the main factor that contributed to inequality in the UOH and UIH. OD showed that residence in rural areas and supplementary insurance were the main contributing factors in the increased inequality of UOH. Moreover, OD also showed that economic status was the main contributing factor in the reduced inequality of UIH.

Conclusion

While Iran still suffers from significant socio-economic inequalities in UOH, it seems that healthcare reforms, especially HTP, have reduced UIH inequality. Expanding healthcare reforms into the outpatient sector and also implementing effective health financing policies could be recommended as a remedy against UOH inequality.

Health-Seeking Behaviors and its Determinants: A Facility-Based Cross-Sectional Study in the Turkish Republic of Northern Cyprus

Background: Understanding health-seeking behaviors and determining factors help governments to adequately allocate and manage existing health resources. The aim of the study was to examine the health-seeking behaviors of people in using public and private health facilities and to assess the factors that influence healthcare utilization in Northern Cyprus.

Methods: A cross-sectional study was conducted in 2 polyclinics among 507 people using a structured intervieweradministered questionnaire. Health-seeking behaviors were measured using four indicators including routine medical check-ups, preferences of healthcare facilities, admission while having health problems, and refusal of health services while ill. Descriptive statistics and multivariable logistic regression analyses were done to explore factors influencing the use of health services.

Results: About 77.3% of the participants reported to have visited health centers while they had any health problems. More than half (51.7%) of them had a routine medical check-up during the previous year, while 12.2% of them had refused to seek healthcare when they felt ill during the last five years. Of all, 39.1% of them reported preferring private health services. Current smokers (adjusted odds ratio [AOR]=1.92, 95% CI: 1.17-3.14), having chronic diseases (AOR=2.05, 95% CI: 1.95-2.16), having poor perceptions on health (AOR=2.33; 95% CI: 1.563.48), and spending less on health during the last three months (AOR=2.08, 95% CI: 1.43- 3.01) had about twice the odds of having routine checkups. Higher education (AOR=1.87, 95% CI: 1.38-2.55) was shown to be a positive predictor for the health-seeking behaviors, whereas having self-care problems (AOR=0.18, 95% CI: 0.08-0.40) and having a moderate-income (AOR=0.68, 95% CI: 0.57-0.81) were inversely associated with seeking healthcare.

Conclusion: The utilization of public and private health sectors revealed evident disparities in the socio-economic characteristics of participants. The health-seeking behaviors were determined by need factors including chronic disease status and having poor health perception and also by enabling factors such as education, income, insurance status and ability to pay by oneself. These findings highlight the need for further nationwide studies and provide evidence for specific strategies to reduce the socioeconomic inequalities in the use of healthcare services.

Assessing Horizontal Equity in the Utilization of Mental Healthcare Services in Turkey: A Gender Perspective

BACKGROUND

Equity in healthcare services utilization is on the agenda for both research and policy makers, especially after the Millennium Development Goals. Despite the recognition of the importance of mental health services utilization, equity in terms of access has not been widely researched.

OBJECTIVE

This study aims to investigate the degree and progress of equity in mental healthcare services utilization in Turkey from a gender perspective.

METHODS

The Horizontal Inequity (HI) index is calculated using a nationally representative dataset from the Health Surveys (2014 and 2016) conducted by the Turkish Statistical Institute. The index is calculated for males, females, and all individuals separately to identify gender differences.

RESULTS

The results from the HI index indicate pro-poor inequities in the utilization of mental healthcare services in Turkey for both 2014 and 2016. For all individuals, the standardized HI indices were found to be - 0.3320 and - 0.3374 for 2014 and 2016, respectively. In 2014, the standardized HI indices were calculated to be - 0.3504 and - 0.3173 for males and females, respectively. In 2016, the HI indices were found to be - 0.3241 and - 0.3541 for females and males, respectively.

CONCLUSIONS

There is a great need for gender-focused policies to improve horizontal equity in mental healthcare services utilization.

Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China

BACKGROUND

Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness.

METHODS

A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices.

RESULTS

Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality.

CONCLUSIONS

The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.

Inequality in outpatient resource utilization among older adults during the 2007-2008 financial crisis: findings from Taiwan

BACKGROUND

Equity in medical resource utilization is a crucial concern in countries with national health insurance systems. From the perspective of an active aging framework, public health insurance is one of the pillars of economic security, as suggested by the World Bank, to achieve the goal of social security for older adults. This study thus sought to quantify income-related inequality in national health insurance systems, especially during the global economic crisis of 2007-2008.

METHODS

By employing the Taiwan National Health Interview Surveys (2005 and 2009) datasets, we analyzed the socioeconomic inequality of outpatient service utilization for older Taiwanese adults during the financial crisis of 2007-2008. We used corrected concentration indices (CCIs) to examine inequalities over time. Furthermore, we decomposed socioeconomic inequalities to reveal the contributions of determinant factors. The dependent variables related to whether participants had used outpatient services in the previous month, and the independent factors included individual's needs, enabling, predisposing, and environmental factors proposed by Andersen model.

RESULTS

The sample consisted of 2415 observations in 2005 and 2554 observations in 2009. The income-related health care inequality was minor from pro-rich to pro-poor across the study duration, although the difference was insignificant (women: from a concentration index [CI] of 0.0256 in 2005 to a CI of - 0.0098 in 2009; men: from a CI of 0.0379 in 2005 to a CI of 0.0310 in 2009). We used a probit model to analyze the effect of explanatory factors on outpatient resource utilization by men and women. After other factors were controlled for, we found that that the income variable had a positive and significant effect on outpatient service utilization in 2009 and the absolute contribution of income to inequality notably increased from 0.0480 in 2005 to 0.3247 in 2009 for older women.

CONCLUSIONS

In conclusion, Taiwan's National Health Insurance system guarantees the accessibility of health care services to older adults, but slight income-related inequality was maintained in the outpatient resource utilization of women during the 2007-2008 financial crisis. Close attention should be paid to the vulnerability of women during times of economic insecurity.

Early experience of universal health coverage in Turkey on access to health services for the poor: regression kink design analysis

BACKGROUND

In 2003, the Turkish government introduced a major health system reform, the Health Transformation Program (HTP), aimed at achieving Universal Health Coverage (UHC). HTP has helped to expand insurance coverage and health benefits for the uninsured population groups, which included low-income households and the unemployed, through the Green Card scheme, a non-contributory health insurance funded by the government. The Green Card scheme expansion began in 2005 and increased rapidly after 2008, following the introduction of a new comprehensive benefits package, to cover an additional 13 million people.

METHODS

We examine the impact of the Green Card scheme on the utilization of outpatient, inpatient, specialist, and diagnostics services using the Turkish Health Survey data (2010), using a kinked regression design. We take advantage of a sharp break in the availability of health insurance at a particular income level (minimum wage) to examine the impact of the Green Card scheme on health service utilization.

RESULTS

Our results show that having a Green Card increases the fraction of people using outpatient services by 68.30 percentage points, inpatient visit by 34.60 percentage points, and specialist visit by 74.10 percentage points.

CONCLUSIONS

Our findings suggest that a non-contributory health insurance program, such as the Green Card scheme in Turkey, could provide increased access to health care services by the poor and provide important lessons for countries which aim to introduce health programs targeting poor as part of a transition to UHC.

Socioeconomic inequities in health services' utilization following the Health Transformation Plan initiative in Iran

Health equity has become a progressively popular research topic in recent years. Therefore, this study was made to identify the contributions made by socioeconomic determinants in order to quantify their roles to healthcare utilization inequity and to show their status especially after the recent reform in Iran, i.e. Health Transformation Plan, which one of its main goals is providing access to healthcare for all people. This study is a cross-sectional study conducted on a national level in Iran in 2015. For the sampling frame, three-stage cluster sampling was used. A total of 22 470 households from the whole country were surveyed by questionnaires through face-to-face interviews. A total of 78 378 subjects responded to the survey, 18 984 subjects (24.2%) reported the need to outpatient healthcare services in the 2 weeks preceding the interview and 12 944 (68.2%) of them had utilized the outpatient services. In addition, 5928 participants (7.6% of total population) reported the need to inpatient healthcare in the 15-month interval prior to the interview. Of these, 5405 subjects (91.2%) had received the inpatient cares. Several factors such as age group, education, marital status and status of household economy play significant roles in seeking inpatient cares. In addition, age group and household economic status have significant impacts on the utilization of outpatient services. While there are several variables that have different effects in determining the need for both outpatient and inpatient services, most of them are not any more significant than what are on the receiving end of these services.

Disparities in dental healthcare utilization in China

OBJECTIVES

The goal of this study was to investigate inequality in dental service utilization in Chinese middle-aged and senior adults and changes in inequality over time and to determine the sources of inequality.

METHODS

The data included 17 648 individuals aged 45 years and older in 2013 and 15 450 individuals in 2015 who participated in the China Health and Retirement Longitudinal Study (CHARLS). The concentration index was used to quantify the degree of inequality. A decomposition method was employed to determine the sources of inequality, including need variables (demographic characteristics, self-reported health status, and presence of chronic diseases), living standard (measured by household consumption expenditure per capita), other non-need variables (education level, marital status, region of residence, urban-rural difference and type of health insurance plans).

RESULTS

The better-off not only had a higher likelihood of using dental care services than did the worse-off but also used them more often than the worse-off. The concentration index for probability of dental care utilization increased from 0.074 to 0.112 between 2013 and 2015, and the concentration index for total number of dental visits increased from 0.085 to 0.127. Living standard, education, health insurance plans and urban-rural disparities showed a pro-rich contribution to the inequality. The living standard contributed about 70% to the pro-rich inequality.

CONCLUSIONS

Dental care utilization in the Chinese middle-aged and older adults was concentrated in the better-off. Inequality in dental care utilization widened from 2013 to 2015. Achieving equity in dental care utilization remains a challenge for the healthcare system in China.

Assessment of Horizontal Inequity in Eye Care Utilization in the Iranian Middle-aged Population

PURPOSE

The present study was designed to determine the extent that horizontal inequity was realized regarding eye care utilization in a middle-aged population as well as factors affecting this equity.

METHODS

Data were obtained from a population-based study (Shahroud Eye Cohort Study) in 2009 that included 5190 participants from 40 to 64 years of age. Horizontal inequity was determined based on the following variables: (i) economic status, (ii) eye care service needs, (iii) non-need variables, and (iv) eye care utilization (visiting an ophthalmologist or optometrist). Decomposition analysis of the concentration index based on a nonlinear model and indirect standardization was used to ascertain the contribution of each factor in inequity of eye care utilization.

RESULTS

After adjusting for need variables, the results of our study demonstrated that horizontal inequity in eye care utilization in a middle-aged Iranian population remained positive and significant (horizontal inequity: 0.19; 95% confidence interval: 0.17-0.23) indicating that use of services was focused among participants with a better financial situation. Furthermore, decomposition analysis demonstrated that educational level and economic status had the greatest contribution (54.1% and 41.1%, respectively) in comparison to other variables.

CONCLUSION

This study demonstrated that horizontal inequity exists in eye care utilization among the middle-aged Iranian population.

Utilization of health-care services by young children: The aftermath of the Turkish Health Transformation Program

The Turkish Health Transformation Program, initiated in 2003, has identified achieving universal access to health care as 1 of its main tenets. To date, substantial progress has been made toward universal health coverage. Service utilization statistics display an upward trend. In this study, we use official and nationally representative microdata collected by the Turkish Health Research Surveys to examine young children's (ages 0-5) utilization of health services. Children in this age group deserve special attention because adverse health conditions in early childhood are known to have long-time consequences. Policy makers regularly monitor statistics such as infant mortality rate and under-5 mortality rate. We conduct logistic regression analyses to explain the probabilities of being taken to a health institution, to a dentist, and being included in the newborn screening program. We use a rich set of explanatory variables that represent the socioeconomic status (SES) of the child's household. Contrary to our expectations and to the goals of universal health coverage is SES indicators such as the insurance ownership of the parent matter for utilization. Decomposition analyses confirm these findings and reveal that the increase in utilization should have been higher than observed. Children from low SES households should be given special attention and that research efforts should focus on identifying the barriers that still hinder children's utilization of health-care services.

Self-rated health and endogenous selection into primary care

This study assesses the causal effects of primary care utilization on subjective health status in Turkey using individual-level data from the 2012 Health Research Survey. Employing recursive bivariate ordered models that take into account the possibility that selection into healthcare might be correlated with the respondent's self-reported health status, we find that selection into primary care is endogenously determined and that the utilization of primary care significantly improves self-rated health after controlling for sociodemographics, socioeconomic status, health behaviors and risk factors, and access to healthcare. We show that the causal association between healthcare utilization and health status is robust to the use of objective measures of health and specific types of care, suggesting that the use of a single-item question on self-rated health and binary measures of preventive care utilization is valid.

Socioeconomic inequalities of outpatient and inpatient service utilization in China: personal and regional perspectives

BACKGROUND

China's health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies.

METHODS

The China Health and Nutrition Survey (CHNS) 1991-2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals' age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991-2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy.

RESULTS

The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720-0.893), town (OR: 0.722, 95% CI: 0.648-0.804), rich (OR: 0.728, 95% CI: 0.656-0.807) and poor village (OR: 0.778, 95% CI: 0.698-0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472-0.785) and poor village (OR: 0.752, 95% CI: 0. 576-0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use.

CONCLUSION

Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access.

Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study

Background

Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need.

Methods

Hospital Discharge Register data on revascularisations among Finns aged 45–84 in 1995–2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII).

Results

The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = −12, C = −0.00; Women, SII = −30, C = −0.03), but differences favouring low-income groups emerged by 2010 (M: SII = −340, C = −0.08; W: SII = −195, C = −0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = −760 in 1995, SII = −681 in 2010; W: SII = −318 in 1995, SII = −211 in 2010), but relative differences increased significantly (M: C = −0.14 in 1995, C = −0.26 in 2010; W: C = −0.15 in 1995, C = −0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII.

Conclusions

Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.

Determinants of prevalence, awareness, treatment and control of high LDL-C in Turkey

Objective:

High blood cholesterol is one of the main modifiable risk factors for cardiovascular diseases (CVDs). The aim of the study is to determine the factors associated with the prevalence, awareness, treatment, and control of high “low-density lipoprotein-cholesterol” (LDL-C) among adults aged ≥20 years in Turkey.

Methods:

We used data from Chronic Diseases and Risk Factors Survey conducted in 2011–2012. The presence of high LDL-C, lipid-lowering treatment eligibility, and achievement of target LDL-C were defined according to the third Adult Treatment Panel guidelines on treatment of high cholesterol. Multivariate logistic regression analyses were performed to determine the associations between participant characteristics and high LDL-C prevalence, awareness, treatment, and control.

Results:

Framingham risk score categorization was performed for 13121 individuals aged ≥20 years. Approximately, 28% of the participants presented with high LDL-C. Among those with high LDL-C, 55.8% were aware of their situation; among those aware of high LDL-C, 46.9% were receiving lipid-lowering medication, and 50.6% of individuals who were receiving treatment achieved target LDL-C levels on the basis of their coronary heart disease (CHD) risk. Control of high LDL-C was negatively associated with the presence of diabetes mellitus (odds ratio: 0.36, 95% CI: 0.27–0.49, p<0.001).

Conclusion:

Despite the high awareness rates, there was a high proportion of adults who did not receive treatment or achieve recommended levels of LDL-C during treatment. The low treatment and control levels among individuals based on their CHD risk levels call for a better application of recommendations regarding personal preventive measures and treatments in Turkey.