Impact of Health-Care Systems on Inequalities in Health Care Consumption

Abstract

Rational: In Europe it is well documented that significant inequalities exist in the use of health-care services. There is a large body of work showing that in many countries the probability of seeing a doctor (and the number of visits) are not identically distributed across socio-economic groups after correcting for differences in the need for care. There is also evidence that the degree of this inequality in access to care varies significantly from one country to other. Nevertheless, in previous work little attention is paid to the role of the health-care system in explaining these differences.

Objective: The objective of this paper is to provide new evidence on the impact of the health-care system (its organization and funding) on health-care consumption and social inequalities in health-care consumption. Methodology: The data for this study come from the European project Eurothine which collected and harmonized data from national health or multipurpose surveys in about 20 European countries. The cross-country harmonized data set provides individual level information on socio-economic status, self-reported health, health-related behavior and health-care utilization. We examine four types of medical-care utilization. In addition to the usual measures of visits to general practitioners and medical specialists, we include visits to dentists and a preventive measure, cholesterol screening in the past 12 months.

The health-care system level variables controlled for include: existence of a gatekeeping system; the ratio of public funding to total health expenditure, methods of paying ambulatory doctors (fee-for-service, capitation or salary). Some of these variables come from the OECD Health Database while for other health system characteristics, dummy variables are constructed by the authors in consultation with country experts.

Multilevel binominal models are used first to demonstrate and quantify the country-specific effect on the probability of health care utilization for each of the measures of utilization, controlling for the impact of individual-level characteristics. Second, we test the impact of differences in national health-care systems in explaining these country specific effects. Finally, a multilevel model is carried out to analyze the impact of health care systems on the influence of individual socio-economic characteristics on health care utilization.

Conclusion: This analysis sheds light on the contribution of health care systems to overall national differences in health care utilization as well as to cross-country differences in social inequalities in health care utilization.

Keywords: Health-care systems, consumption; socio-economic inequalities; multilevel modelling