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Background: Equity in the use of health care services is an issue which has increasingly been on the health policy agenda over recent years in both middle- and low-income countries. Aims: The purpose of this study was to investigate the degree and progress of equity in health care utilization in Turkey during 2008-2012. Methods: Wed use data from health surveys (2008, 2010, 2012) conducted by the Turkish Statistical Institute. The concentration index (CI) and the horizontal equity index (HI) were calculated as a measure of equity, and a Blinder-Oaxaca decomposition analysis was applied. Results: The general practitioner (GP), specialist and inpatient visits display a pro-poor orientation. Averages of the CI and HI indices for 2008-2012 were 0.74 and -0.17 for GP visits, 0.75 and -0.13 for specialist visits, 0.83 and -0.31 for inpatient visits. Conclusion: Our findings indicate that health care utilization in Turkey appears to have become equitable over the years; however, the sustainability of equity is an issue of concern.

Background Horizontal equity in access to public general practitioner (GP) services by socioeconomic group has been addressed econometrically by testing the statement “equal probability of using public GP services for equal health care needs, regardless of socioeconomic status”. Based on survey data, the conventional approach has been to estimate binomial econometric models in which when the respondent reports having visited a public GP, it counts as 1, otherwise it counts as 0. This is what we call a compartmentalised approach . Those respondents who did not visit a public GP but visited instead another doctor (specialist or private GP) would count as 0 (despite having used instead other modes of health care), thus conclusions of the compartmentalised approach might be biased. In such cases, a multinomial econometric model -that we called comprehensive approach - would be more appropriate to analyse horizontal equity in access to public GP services. The objective of this paper is to test for this potential bias by comparing a compartmentalised and a comprehensive approach, when analysing horizontal equity in access to public GP. Methods Using data from the 2016/17 Spanish National Health Survey, we estimate the probability of visiting a public GP as determined by socioeconomic status, health care need and demographic characteristics. We use binomial and multinomial logit and probit models in order to highlight the potential differences in the conclusions regarding socioeconomic inequities in access to public GP services. Socioeconomic status is proxied by education level, social class and employment situation. Results Our results show that conclusions are sensitive to the approach selected. Particularly, the horizontal inequity favouring individuals with lower education that resulted from the compartmentalised approach disappears under a comprehensive approach and only a social class effect remains. Conclusion An analysis of horizontal equity in access to a particular health care service (like public GP services) undertaken following a compartmentalised approach should be compared with a comprehensive approach in order to test that there is no bias as a consequence of considering as zeros the utilisation of other types of health care.

Horizontal equity is the principle that similarly situated persons should be treated similarly. While the principle is often invoked in tax policy debates, I demonstrate that the principle lacks a firm normative foundation. The paper presents a thought experiment to argue that neither an entitlement to pre-tax income, nor the presence of effort in generating pre-tax income, can provide the necessary foundation for such a principle. Then, I explore whether a concern for equal treatment and avoiding statistical discrimination can support horizontal equity even when there is no entitlement to pre-tax income. I show that tax discrimination can be objectionable, but because discrimination requires a relevant pre-tax benchmark, it follows that non-discrimination cannot support a general principle of horizontal equity without an entitlement to pre-tax income. In conclusion, despite the intuitive appeal of horizontal equity, I argue that its basis as a normative principle in tax policy is weak.

With the ageing population, equitable access to medical care has proven to be paramount for the effective and efficient management of all diseases. Healthcare access can be hindered by cost barriers for drugs or exams, long waiting lists or difficult access to the place where the needed healthcare service is provided. The aim of this paper is to investigate whether the probability of facing one of these barriers varies among individuals with different socio-economic status and care needs, controlling for geographical variability. Methods. The sample for this study included 9629 interviews with Italian individuals, aged 15 and over, from the second wave (2015) of the European Health Interview Survey, which was conducted in all EU Member States. To model barriers to healthcare, two-level variance components of logistic regression models with a nested structure given by the four Italian macro-areas were considered. Results. Of the barriers considered in this study, only two were found to be significantly associated with healthcare utilization. Specifically, they are long waiting lists for specialist service accessibility (adjOR = 1.20, 95% CI (1.07; 1.35)) and very expensive exams for dental visit accessibility (adjOR = 0.84, 95% CI (0.73; 0.96)). Another important result was the evidence of an increasing north–south gradient for all of the considered barriers. Conclusion. In Italy, healthcare access is generally guaranteed for all of the services, except for specialist and dental visits that face a waiting time and financial barriers. However, barriers to healthcare were differentiated by income and sex. The north–south gradient for healthcare utilization could be explained through the existing differences in organizational characteristics of the several regional healthcare services throughout Italy.

Background When today’s efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden’s long and ongoing journey towards universal health coverage and equal access to healthcare. Methods The focus is on macro-level policy. A document analysis is divided into three broad eras (1919–1955; 1955–1989; 1989–) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. Results Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system’s Achilles’ heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. Conclusions: brief summary and potential implications It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden’s welfare ‘exceptionalism’, or is a temporary decline remains to be assessed in the future.

The study aims to investigate both income-related health inequality and horizontal equity in urban and rural China. The 4th and 5th National Health Services Survey, and extended samples in Shaanxi Province surveyed in 2008 and 2013, were analysed. Health outcome was measured using the EQ-5D-3L utility, scored by the Chinese-specific tariff. The concentration index was calculated to measure the degree of income-related health inequality and was further decomposed to study the strength of different contributing factors to explain health inequality. The horizontal inequity was further measured based on the decomposition results. The final study sample consists of 15,505 respondents in 2008 and 48,808 respondents in 2013. Descriptive analysis shows that compared to 2008, respondents in both urban and rural China reported worse HRQoL in 2013. There was a pro-rich inequality of HRQoL in both urban and rural China. Controlling for demographic factors, the pro-rich inequity of HRQoL remains. Economic and educational statuses are found to be two key factors explaining the pro-rich inequity. The establishment of basic medical insurance has shown a mixed effect on reducing health inequality. Strategies to reduce the inequality of residents’economic and educational status, through further implementing the poverty reduction policies, should be prioritised by the local government.

Existing measures of health equity bear limitations due to the shortcomings of traditional economic methods (i.e., the spatial location information is overlooked). To fill the void, this study investigates the equity in health workforce distribution in China by incorporating spatial statistics (spatial autocorrelation analysis) and traditional economic methods (Theil index). The results reveal that the total health workforce in China experienced rapid growth from 2004 to 2014. Meanwhile, the Theil indexes for China and its three regions (Western, Central and Eastern China) decreased continually during this period. The spatial autocorrelation analysis shows that the overall agglomeration level (measured by Global Moran’s I) of doctors and nurses dropped rapidly before and after the New Medical Reform, with the value for nurses turning negative. Additionally, the spatial clustering analysis (measured by Local Moran’s I) shows that the low–low cluster areas of doctors and nurses gradually reduced, with the former disappearing from north to south and the latter from east to west. On the basis of these analyses, this study suggests that strategies to promote an equitable distribution of the health workforce should focus on certain geographical areas (low–low and low–high cluster areas).

Background Many countries agree with the horizontal equity that medical resources should be allocated according to medical needs, regardless of income. Although the short-term equity index calculated through cross-sectional data doesn't reflect the dynamics of individual income and medical use, it can be supplemented by the long-term equity index using panel data. Koreans tend to choose expensive but highly specialized services without considering their medical needs because they are free to choose service providers. This study aims to empirically examine how the patterns of outpatient medical use that are not based on medical needs differ in terms of short- and long-term equity for each type of medical institution. Methods Using Korea Health Panel Survey(2014-2018), the equity of outpatient medical use(number of visits, medical expenses) of 10,244 people was measured by type of medical institution (tertiary general hospital, general hospital, hospital, clinic, and dentist). Wagstaff&van Doorslaer(2000)’s tool and Jones & Lopez-Nicolas(2004)’s tool were used to calculate the short and long-term horizontal equity index(HI), and mobility index(MI) to compare short and long-term inequity. Results In tertiary general hospitals and dentists, there were short and long-term pro-rich inequalities(HI > 0, p < 0.05). As a result of comparison, long-term inequality was greater in the number of visits (MI < 0), while inequality was easing in the long-term in medical expenses(MI > 0) in tertiary general hospitals. In dentists, long-term inequality was less than short-term inequality in both the number of visits and medical expenses (MI > 0). Conclusions The short-term equity index is likely to underestimate or overestimate inequity in our society, so a long-term perspective is needed. Inequality patterns for each type of medical institution should be considered in healthcare reforms for fair distribution of medical resources. Key messages • Short-term equity index differs from the long-term equity index in outpatient medical use. • The pattern of short and long-term equity indices may differ by type of medical institutions.

The equitable allocation of healthcare resources reflects social equity. Previous studies of healthcare accessibility have overlooked the impact of inter-city patient mobility on local residents’ and local residents’ multi-mode travel choices, distorting accessibility calculation outcomes. Taking the area within Beijing’s Sixth Ring Road as an example, this study established a Multi-Mode Accessibility Model for Local Residents (MMALR) to tertiary hospitals, using the proportion of non-local patients to adjust hospital supply capacity and considering the various travel mode shares from residential communities to hospitals to calculate the number of potential patients. We compared the changes in geospatial accessibility under different travel modes and employed the Gini coefficient to evaluate the geospatial equity of accessibility for different regions when using different accessibility methods. The results indicate that the spatial distribution of healthcare accessibility via different methods is similar, and it gradually decreases along subway lines from the urban center to the periphery. We found that the equities in access to high-level healthcare for Dongcheng District, Xicheng District, the area between the Third and Fourth Ring Road, and the area between the Fourth and Fifth Ring Road, display different ranking results across different methods, revealing that an unreasonable analysis framework could mislead the placement decisions for new hospitals or the allocation of medical resources. These findings emphasize the impact of inter-city patient mobility and the diversity of travel mode choices on accessibility. Our model can assist stakeholders in more accurately evaluating the accessibility and equity of local residents in terms of tertiary hospitals, which is crucial for cities with abundant medical resources and superior conditions. Our analytical findings provide a scientific basis for the location decisions of tertiary hospitals.

Background The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed. Methods Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps –absolute (AIG), and relative (RIG)– were scenario outcomes. Results At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030. Conclusion The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.