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Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]

Background: Worldwide, Cervical Cancer (CC) is the fourth most common type of cancer and cause of death in women. It is a significant public health problem, especially in low and middle-income/Gross Domestic Product (GDP) countries. In the past decade, several studies of CC have been published, that identify the main modifiable and non-modifiable CC risk factors for Mexican women. However, there are no studies that attempt to explain the residual spatial variation in CC incidence In Mexico, i.e. spatial variation that cannot be ascribed to known, spatially varying risk factors. Methods: This paper uses a spatial statistical methodology that takes into account spatial variation in socioeconomic factors and accessibility to health services, whilst allowing for residual, unexplained spatial variation in risk. To describe residual spatial variations in CC risk, we used generalised linear mixed models (GLMM) with both spatially structured and unstructured random effects, using a Bayesian approach to inference. Results: The highest risk is concentrated in the southeast, where the Matlapa and Aquismón municipalities register excessive risk, with posterior probabilities greater than 0.8. The lack of coverage of Cervical Cancer-Screening Programme (CCSP) (RR 1.17, 95 % CI 1.12-1.22), Marginalisation Index (RR 1.05, 95 % CI 1.03-1.08), and lack of accessibility to health services (RR 1.01, 95 % CI 1.00-1.03) were significant covariates. Conclusions: There are substantial differences between municipalities, with high-risk areas mainly in low-resource areas lacking accessibility to health services for CC. Our results clearly indicate the presence of spatial patterns, and the relevance of the spatial analysis for public health intervention. Ignoring the spatial variability means to continue a public policy that does not tackle deficiencies in its national CCSP and to keep disadvantaging and disempowering Mexican women in regard to their health care. [ABSTRACT FROM AUTHOR]

Background: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil. Method: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators. Results: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital. Conclusion: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed. [ABSTRACT FROM AUTHOR]

Introduction: In countries such as Bangladesh many women may only seek skilled care at birth when complications become evident. This often results in higher neonatal mortality for women who give birth in institutions than for those that give birth at home. However, we hypothesise that this apparent excess mortality is concentrated among less advantaged women. The aim of this paper is to examine the association between place of birth and neonatal mortality in Bangladesh, and how this varies by socio-economic status. Methodology: The study is based on pooled data from four Bangladesh Demographic and Household Surveys, and uses descriptive analysis and binomial multivariate logistic regression. It uses regression models stratified for place of delivery to examine the impact of socio-economic status and place of residence on neonatal mortality. Results: Poor women from rural areas and those with no education who gave birth in institutions had much worse outcomes than those who gave birth at home. There is no difference for more wealthy women. There is a much stronger socio-economic gradient in neonatal mortality for women who gave birth in institutions than those who delivered at home. Conclusion: In Bangladesh babies from lower socio-economic groups and particularly those in rural areas have very poor outcomes if born in a facility. This suggests poorer, rural and less educated women are failing to obtain the timely access to quality maternal health care services needed to improve newborn outcomes. [ABSTRACT FROM AUTHOR]

Background: Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods: We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results: The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions: Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS. [ABSTRACT FROM AUTHOR]

Introduction Globally, health facility delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. However, access to facility-based delivery care remains low in many less developed countries. This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Methods Data come from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Results Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Conclusion Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area. [ABSTRACT FROM AUTHOR]

Oral health is an important component of people's general health status. Many studies have shown that socioeconomic status is an important determinant of access to health services. In the present study, we explored the inequality and socioeconomic factors associated with people's non-use of dental care across Europe. Methods We obtained data from the European Union Statistics on Income and Living Conditions survey conducted by Eurostat in 2007. These cross-sectional data were collected from people aged 16 years and older in 24 European countries, except those living in long-term care facilities. The variable of interest was the prevalence of non-use of dental care while needed. We used the direct method of standardisation by age and sex to eliminate confounders in the data. Socioeconomic inequalities in the non-use of dental care were measured through differences in prevalence, the relative concentration index (RCI), and the relative index of inequality (RII). We compared the results among countries and conducted standard and multilevel logistic regression analyses to examine the socioeconomic factors associated with the non-use of dental care while needed. Results The results revealed significant socio-economic inequalities in the non-use of dental care across Europe, the magnitudes of which depended on the measure of inequality used. For example, inequalities in the prevalence of non-use among education levels according to the RCI ranged from 0.005 (in the United Kingdom) to -0.271 (Denmark) for men and from -0.009 (Poland) to 0.176 (Spain) for women, whereas the RII results ranged from 1.21 (Poland) to 11.50 (Slovakia) for men and from 1.62 (Poland) to 4.70 (Belgium) for women. Furthermore, the level-2 variance (random effects) was significantly different from zero, indicating the presence of heterogeneity in the probability of the non-use of needed dental care at the country level. Conclusion Overall, our study revealed considerable socioeconomic inequalities in the non-use of dental care at both the individual (intra-country) and collective (inter-country) levels. Therefore, to be most effective, policies to reduce this social inequality across Europe should address both levels. [ABSTRACT FROM AUTHOR]

Background In Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients' perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients' perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience. Methods Twenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery. Results Thematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants' accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon's office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others. Conclusion Patients' perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible. [ABSTRACT FROM AUTHOR]

Introduction: Despite greater need, rural inhabitants and individuals of low socioeconomic status (SES) are less likely to undertake cardiac rehabilitation (CR). This study examined barriers to enrollment and participation in CR among these under-represented groups. Method: Cardiac inpatients from 11 hospitals across Ontario were approached to participate in a larger study. Rurality was assessed by asking participants whether they lived within a 30-minute drive-time from the nearest hospital, with those >30 minutes considered “rural.” Participants completed a sociodemographic survey, which included the MacArthur Scale of Subjective Social Status. One year later, they were mailed a survey which assessed CR utilization and included the Cardiac Rehabilitation Barriers Scale. In this cross-sectional study, CR utilization and barriers were compared by rurality and SES. Results: Of the 1809 (80.4%) retained, there were 215 (11.9%) rural participants, and the mean subjective SES was 6.37 ± 1.76. The mean CRBS score was 2.03 ± 0.73. Rural inhabitants reported attending significantly fewer CR sessions (p < .05), and greater CR barriers overall compared to urban inhabitants (p < .01). Patients of lower subjective SES were significantly less likely to be referred, enroll, and participate in CR, and reported significantly greater barriers to CR compared to their high SES counterparts (p < .01). Prominent barriers for both groups included distance, cost, and transportation problems. These relationships sustained adjustment, and a significant relationship between having undergone coronary artery bypass graft surgery and lower barriers was also identified. Conclusions: The results confirm that rural inhabitants and patients of low SES experience greater barriers to CR utilization when compared to their urban, high SES counterparts. It is time to implement known strategies to overcome these barriers, to achieve equitable and greater use of CR. [ABSTRACT FROM AUTHOR]

Introduction: Skilled birth attendance (SBA) and measles immunization reflect two aspects of a health system. In Kenya, their national coverage gaps are substantial but could be largely improved if the total population had the same coverage as the wealthiest quintile. A decomposition analysis allows identifying the factors that influence these wealth-related inequalities in order to develop appropriate policy responses. The main objective of the study was to decompose wealth-related inequalities in SBA and measles immunization into their contributing factors. Methods: Data from the Kenyan Demographic and Health Survey 2008/09 were used. The study investigated the effects of socio-economic determinants on [1] coverage and [2] wealth-related inequalities of SBA utilization and measles immunization. Techniques used were multivariate logistic regression and decomposition of the concentration index (C). Results: SBA utilization and measles immunization coverage differed according to household wealth, parent's education, skilled antenatal care visits, birth order and father's occupation. SBA utilization further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent's education (28%), antenatal care (9%), and province (6%). The overall C for measles immunization was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent's education (28%). Rural residence (-19%) reduced this inequality. Conclusion: Both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups. [ABSTRACT FROM AUTHOR]

Introduction: One issue that continues to attract the attention of public health researchers is the possible relationship in high-income countries between income, income inequality and infant mortality (IM). The aim of this study was to assess the associations between IM and major socio-economic determinants in Italy. Methods: Associations between infant mortality rates in the 20 Italian regions (2006--2008) and the Gini index of income inequality, mean household income, percentage of women with at least 8 years of education, and percentage of unemployed aged 15--64 years were assessed using Pearson correlation coefficients. Univariate linear regression and multiple stepwise linear regression analyses were performed to determine the magnitude and direction of the effect of the four socio-economic variables on IM. Results: The Gini index and the total unemployment rate showed a positive strong correlation with IM (r = 0.70; p < 0.001 and r = 0.84; p < 0.001 respectively), mean household income showed a strong negative correlation (r = ?0.78; p < 0.001), while female educational attainment presented a weak negative correlation (r = ?0.45; p < 0.05). Using a multiple stepwise linear regression model, only unemployment rate was independently associated with IM (b = 0.15, p < 0.001). Conclusions: In Italy, a high-income country where health care is universally available, variations in IM were strongly associated with relative and absolute income and unemployment rate. These results suggest that in Italy IM is not only related to income distribution, as demonstrated for other developed countries, but also to economic factors such as absolute income and unemployment. In order to reduce IM and the existing inequalities, the challenge for Italian decision makers is to promote economic growth and enhance employment levels. [ABSTRACT FROM AUTHOR]

Introduction: Family (i.e., unpaid) caregiving has long been thought of as a 'woman's issue', which ultimately results not only in gendered, but also financial and health inequities. Because of this, gender-based analyses have been prioritized in caregiving research. However, trends in current feminist scholarship demonstrate that gender intersects with other axes of difference, such as culture, socio-economic status, and geography to create diverse experiences. In this analysis we examine how formal front-line palliative care providers understand the role of such diversities in shaping Canadian family caregivers' experiences of end-of-life care. In doing so we consider the implications of these findings for a social benefit program aimed at supporting family caregivers, namely the Compassionate Care Benefit (CCB). Methods: This analysis contributes to a utilization-focused evaluation of Canada's CCB, a social program that provides job security and limited income assistance to Canadian family caregivers who take a temporary leave from employment to provide care for a dying family member at end-of-life. Fifty semi-structured phone interviews with front-line palliative care providers from across Canada were conducted and thematic diversity analysis of the transcripts ensued. Results: Findings reveal that experiences of caregiving are not homogenous and access to services and supports are not universal across Canada. Five axes of difference were commonly raised by front-line palliative care providers when discussing important differences in family caregivers' experiences: culture, gender, geography, lifecourse stage, and material resources. Our findings reveal inequities with regard to accessing needed caregiver services and resources, including the CCB, based on these axes of difference. Conclusions: We contend that without considering diversity, patterns in vulnerability and inequity are overlooked, and thus continually reinforced in health policy. Based on our findings, we demonstrate that re-framing categorizations of caregivers can expose specific vulnerabilities and inequities while identifying implications for the CCB program as it is currently administered. From a policy perspective, this analysis demonstrates why diversity needs to be acknowledged in policy circles, including in relation to the CCB, and seeks to counteract single dimensional approaches for understanding caregiver needs at end-of-life. Such findings illustrate how diversity analysis can dramatically enhance evaluative health policy research. [ABSTRACT FROM AUTHOR]

Background: In this study we investigated the distribution of self-reported health care utilisation by education and household income in a county population in Norway, in a universal public health care system based on ideals of equal access for all according to need, and not according to wealth. Methods: The study included 24,147 women and 20,608 men aged 20 years and above in the third Nord-Trøndelag Health Survey (HUNT 3) of 2006--2008. Income-related horizontal inequity was estimated through concentration indexes, and inequity by both education and income was estimated as risk ratios through conventional regression. Results: We found no overall pro-rich or pro-educated socioeconomic gradient in needs-adjusted utilisation of general practitioner or inpatient care. However, we found overall pro-rich and pro-educated inequity in utilisation of both private medical specialists and hospital outpatient care. For these services there were large differences in levels of inequity between younger and older men and women. Conclusion: In contrast with recent studies from Norway, we found pro-rich and pro-educated social inequalities in utilisation of hospital outpatient services and not only private medical specialists. Utilisation of general practitioner and inpatient services, which have low access threshold or are free of charge, we found to be equitable. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to explore possible differences in health care seeking behaviour among a rural and urban African population. Design: A cross sectional design was followed using the infrastructure of the PURE-SA study. Four rural and urban Setswana communities which represented different strata of urbanisation in the North West Province, South Africa, were selected. Structured interviews were held with 206 participants. Data on general demographic and socio-economic characteristics, health status, beliefs about health and (access to) health care was collected. Results: The results clearly illustrated differences in socio-economic characteristics, health status, beliefs about health, and health care utilisation. In general, inhabitants of urban communities rated their health significantly better than rural participants. Although most urban and rural participants consider their access to health care as sufficient, they still experienced difficulties in receiving the requested care. The difference in employment rate between urban and rural communities in this study indicated that participants of urban communities were more likely to be employed. Consequently, participants from rural communities had a significantly lower available weekly budget, not only for health care itself, but also for transport to the health care facility. Urban participants were more than 5 times more likely to prefer a medical doctor in private practice (OR:5.29, 95% CI 2.83-988). Conclusion: Recommendations are formulated for infrastructure investments in rural communities, quality of health care and its perception, improvement of household socio-economical status and further research on the consequences of delay in health care seeking behaviour. [ABSTRACT FROM AUTHOR]

Background: Catastrophic health expenditure (CHE) is well established as an indicator of financial protection on which there is extensive literature. However, most works analyse mainly low to middle income countries and do not address the different distributional dimensions of CHE. We argue that, besides incidence, the latter are crucial to better grasp the scope and nature of financial protection problems. Our objectives are therefore to analyse the evolution of CHE in a high income country, considering both its incidence and distribution. Methods: Data are taken from the last three waves of the Portuguese Household Budget Survey conducted in 2005/2006, 2010/2011 and 2015/2016. To identify CHE, the approach adopted is capacity to pay/normative food spending, at the 40% threshold. To analyse distribution, concentration curves and indices (CI) are used and adjusted odds ratios are calculated. Results: The incidence of CHE was 2.57, 1.79 and 0.46%, in 2005, 2010 and 2015, respectively. CHE became highly concentrated among the poorest (the respective CI evolved from − 0.390 in 2005 to − 0.758 in 2015) and among families with elderly people (the absolute CI evolved from 0.520 in 2005 to 0.740 in 2015). Absolute CI in geographical context also increased over time (0.354 in 2015, 0.019 in 2005). Medicines represented by far the largest share of catastrophic payments, although, in this case concentration decreased (the median share of medicines diminished from 93 to 43% over the period analysed). Contrarily, the weight of expenses incurred with consultation fees has been growing (even for General Practitioners, despite the NHS coverage of primary care). Conclusions: The incidence of CHE and inequality in its distribution might progress in the same direction or not, but most importantly policy makers should pay attention to the distributional dimensions of CHE as these might provide useful insight to target households at risk. Greater concentration of CHE can actually be regarded as an opportunity for policy making, because interventions to tackle CHE become more confined. Monitoring the distribution of payments across services can also contribute to early detection of emerging (and even, unexpected) drivers of catastrophic payments. [ABSTRACT FROM AUTHOR]