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Background Healthcare inequities pose a substantial challenge to achieving universal health coverage, particularly in low- and middle-income countries (LMICs). The Chinese government implemented Hierarchical Medical System (HMS) to optimize resource allocation and improve healthcare access. This study aimed to evaluate the impact of HMS on healthcare utilization and the inequities. Methods This study utilized longitudinal data from the China Family Panel Studies (CFPS) conducted in 2012, 2014, 2016, and 2018, which included a final sample of 105,335 individuals. A multiple-period difference-in-differences method was employed to explore the impact on outpatient and inpatient utilization across socioeconomic dimensions. The concentration Index and the horizontal inequity index (HI) were used to assess inequities in healthcare utilization. Additionally, a decomposition analysis was performed to identify the contributors to inequalities. Results HMS demonstrated significant negative impacts on both outpatient and inpatient utilization (OR = 0.825, SE = 0.058; OR = 0.869, SE = 0.071, respectively), with a short-term decline in outpatient services and a lasting reduction in inpatient services. The heterogeneity tests revealed a pronounced impact in central and rural areas. The results indicated pro-poor inequities in outpatient utilization and pro-rich inequities in inpatient utilization. HMS reduced inequalities and inequities in healthcare utilization, particularly for outpatient services. HI in inpatient services increased in the initial year but decreased after 2 years of HMS. The decomposition analyses identified the primary contributors as economic level and health status. While the economic level exacerbated inequalities, health insurance and higher educational attainment mitigated inequalities in healthcare utilization. Conclusion HMS had an unintended impact on decreasing healthcare utilization in China. HMS improved equity in outpatient utilization, it faced challenges in enhancing equity in inpatient utilization. Policymakers should prioritize strengthening primary care infrastructure in central and rural areas, ensuring affordable healthcare models, reinforcing educational attainment, and expanding health insurance coverage to promote equity in healthcare utilization. These findings provide crucial insights for guiding equitable healthcare reform in LMICs and advancing progress toward the Sustainable Development Goals.

By utilizing the China Health and Nutrition Survey (CHNS) data, this paper examines the extent of deviations in terms of horizontal equity in the field of China’s health and medical community, i.e., that those in equal demand ought to be treated equally, and computes the contribution of income in health inequality and utilization inequality of health care. The main conclusions are: There is pro-rich inequality in health and utilization of health care; income contribution to inequality of health care utilization accounts for 0.13–0.2; insurance also enlarges the inequality of health care utilization; health inequality in rural area is larger than that of in urban area; and both rural and urban health inequality are increasing. From 1991 to 2006, income changes in urban districts and rural area account for 7.08% and 13.38% respectively of raising inequality of rural and urban health.

Background The National Development Plan (NDP) strives that South Africa, by 2030, in pursuit of Universal Health Coverage (UHC) achieve a significant shift in the equity of health services provision. This paper provides a diagnosis of the extent of socio-economic inequalities in health and healthcare using an integrated conceptual framework. Method The 2012 South African National Health and Nutrition Examination Survey (SANHANES-1), a nationally representative study, collected data on a variety of questions related to health and healthcare. A range of concentration indices were calculated for health and healthcare outcomes that fit the various dimensions on the pathway of access. A decomposition analysis was employed to determine how downstream need and access barriers contribute to upstream inequality in healthcare utilisation. Results In terms of healthcare need, good and ill health are concentrated among the socio-economically advantaged and disadvantaged, respectively. The relatively wealthy perceived a greater desire for care than the relatively poor. However, postponement of care seeking and unmet need is concentrated among the socio-economically disadvantaged, as are difficulties with the affordability of healthcare. The socio-economic divide in the utilisation of public and private healthcare services remains stark. Those who are economically disadvantaged are less satisfied with healthcare services. Affordability and ability to pay are the main drivers of inequalities in healthcare utilisation. Conclusion In the South African health system, the socio-economically disadvantaged are discriminated against across the continuum of access. NHI offers a means to enhance ability to pay and to address affordability, while disparities between actual and perceived need warrants investment in health literacy outreach programmes.

Background Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention. Methods A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings. Results The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn. Conclusions The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations. Trial registration The review protocol was registered on PROSPERO ( CRD42014015162 ).

Background The high fragmentation and decentralization in the provision of health care services that characterizes Argentina’s health system, as well as the economic and social inequalities, challenge the achievement of the Universal Health Coverage (UHC). The objective of this study is to measure socioeconomic-related inequality and horizontal inequity in the use of health care services in Argentina as well as identify the factors that contribute to these disparities. Methods The 2013 National Risk Factor Survey, developed by the Ministry of Health of Argentina, was used to measure socioeconomic-related inequality and inequity in the use of health care services through concentration curves, the Erreygers concentration index, and the index of horizontal inequity. Econometric micro-decomposition was applied to estimate the contribution of each determining factor to inequality in the use of health care services. Results The Erreygers concentration index for the use of health care services was 0.1223, evidencing pro-rich inequalities. By adding variables of health care needs, the horizontal inequity index was 0.1296. Non-need factors such as education and health coverage with social security increase pro-rich inequality. Conclusions The Argentine health system shows pro-rich inequality in the use of health care services. It is necessary to design strategies to improve articulation between the three coverage subsectors and national, provincial, and municipal governments to keep the commitment of “not leaving anyone behind.” The results showed here could provide lessons for countries with similar contexts and challenges in public health.

Background Racial concordance between patients and clinician has been linked to improved satisfaction and patient outcomes. Objectives (1) To examine the likelihood of clinician-patient racial concordance in non-Hispanic White, non-Hispanic Black, Asian, and Hispanic patients and (2) to evaluate the impact of patient-clinician race concordance on healthcare use and expenditures within each racial ethnic group. Methods We analyzed data from the 2010–2016 Medical Expenditure Panel Survey (MEPS). We used bivariate and multivariate models to assess the association between patient-clinician race concordance and emergency department (ED) use, hospitalizations, and total healthcare expenses, controlling for patient socio-demographic factors, insurance coverage, health status, and survey year fixed effects. Results Of the 50,626 adults in the analysis sample, 32,350 had racial concordance with their clinician. Among Asian and Hispanic patients, low income, less education, and non-private insurance were associated with an increased likelihood of patient-clinician racial concordance. Emergency department use was lower among Whites and Hispanics with concordant clinicians compared to those without a discordant clinician (15.6% vs. 17.3%, p  = 0.02 and 12.9% vs. 16.2%, p  = 0.01 respectively). Total healthcare expenditures were lower among Black, Asian, and Hispanic patients with race-concordant clinicians than those with discordant clinicians (14%, 34%, and 20%, p  < 0.001 respectively). Conclusions These results add to the body of evidence supporting the hypothesis that racial concordance contributes to a more effective therapeutic relationship and improved healthcare. These results emphasize the need for medical education surrounding cultural humility and the importance of diversifying the healthcare workforce.

Background Ensuring equitable access to medical care with financial risk protection has been at the center of achieving universal health coverage. In this paper, we assess the levels and trends of inequalities in medical care utilization and household catastrophic health spending (HCHS) at the national and sub-national levels in Rwanda. Methods Using the Rwanda Integrated Living Conditions Surveys of 2005, 2010, 2014, and 2016, we applied multivariable logit models to generate the levels and trends of adjusted inequalities in medical care utilization and HCHS across the four survey years by four socio-demographic dimensions: poverty, gender, education, and residence. We measured the national- and district-level inequalities in both absolute and relative terms. Results At the national level, after controlling for other factors, we found significant inequalities in medical care utilization by poverty and education and -in HCHS by poverty in all four years. From 2005 to 2016, inequalities in medical care utilization by the four dimensions did not change significantly, while the inequality in HCHS by poverty was reduced significantly. At the district level, inequalities in both medical care utilization and HCHS were larger than zero in all four years and decreased over time. Conclusions Poverty and poor education were significant contributors to inequalities in medical care utilization and HCHS in Rwanda. Policies or interventions targeting poor households or households headed by persons receiving no education are needed in order to effectively reduce inequalities in medical care utilization and HCHS.

Global progress toward achieving universal health coverage (UHC) by 2030 remains insufficient, as significant regional disparities in access to healthcare persist. In Kazakhstan, the uneven distribution of healthcare resources continues despite reforms aimed at improving equity. This retrospective study analyzed inequalities in the distribution of medical infrastructure, healthcare personnel, and service utilization across 14 regions and 2 cities of republican significance from 2002 to 2023. Data were obtained from national statistical reports on healthcare and population income. The analysis included the following indicators: the number of primary care facilities, hospital beds, healthcare personnel, outpatient visits, and hospitalizations per population. Inequality was assessed using the Gini coefficient and the concentration index, and spatiotemporal trends were visualized through cluster analysis in ArcGIS PRO. Results revealed that southern and western regions exhibit lower availability of hospital beds and healthcare personnel, with moderate levels of inequality particularly evident in outpatient care. Despite Kazakhstan’s commitment to UHC, these disparities underscore the need for further measures to ensure equitable access to healthcare services.

Background With the rise of the aging population, it is particularly important for health services to be used fairly and reasonably in the elderly. This study aimed to assess the present inequality and horizontal inequity for health service use among the elderly in China and to identify the main determinants associated with the disparity. Methods This cross-sectional study was based on the sample of the survey of the China Health and Retirement Longitudinal Study (CHARLS) for 2015. The elderly was defined as individuals aged 60 and above, with a total of 7836 participants. We used the concentration index (CI) and the horizontal inequity (HI) to measure the inequity of the utilization of health services. The method of concentration index decomposition was utilized to measure the contribution of various influential factors to the overall unfairness. Results The CI for the probability and the frequency of outpatient use were 0.1102 and 0.1015, respectively, and the corresponding values of inpatient use were 0.2777 and 0.2980, respectively. The household consumption expenditure disparity was the greatest inequality factor favoring the better-off. The Urban Employee Basic Medical Insurance made a pro-wealth contribution to inequality in frequency of health services utilization (17.58% for outpatient and 13.40% for inpatient). The contributions of New Rural Cooperative Medical Scheme on reducing unfairness in inpatient use were limited (− 2.23% for probability of inpatient use and − 5.89% for frequency of inpatient use). Conclusions There was a strong pro-rich inequality in both the probability and the frequency of use for health services among the elderly in China. The medical insurance was not enough to address this inequity, and different medical insurance schemes had different effects on the unfairness of health service utilization.

Background This study aimed to assess the trend in income-related inequalities in oral health services utilization by the Brazilian population from 1998 to 2013. This period represents a timeline that includes different stages of implementation of the National Oral Health Policy. Methods The design was based on repeated cross-sectional surveys using secondary data from household-based studies carried out in Brazil in 1998, 2003, 2008, and 2013. The dependent variable was “having access to a dentist appointment at least once in a lifetime (yes/no).” Monthly household per capita income, based on Brazil’s minimum wage, was included as the main independent variable. To measure the inequalities in oral health access related to economic position, the following complex indexes based on regression were used: (a) the slope index of inequality (SII) and (b) the relative index of inequality (RII). Results There was a reduction in the percentage of individuals who never had a dentist appointment for all age groups and income classifications. In general, there was a reduction trend in absolute inequality for all age groups ( p  < 0.001). The relative inequality and reduction trend were different between the age groups studied. Conclusions The National Oral Health Policy was very important for expanding free of charge, public access to dental appointment. However, despite policy implementation, there continues to be high levels of inequality in access to dental consultation. Assessing which strategies are necessary to overcome this challenge is discussed.