Eddy van DoorslaerEddy van Doorslaer Erasmus University RotterdamErasmus University Rotterdam

Equity in Health Care Finance and Delivery Equity in Health Care Finance and Delivery

in Europe: the ECuity Projectin Europe: the ECuity Project

European Health Forum, Gastein, 26 September 2002, AustriaEuropean Health Forum, Gastein, 26 September 2002, Austria

IntroductionIntroduction

What is the ECuity Project?What is the ECuity Project? What are its ambitions?What are its ambitions? What sort of results has it achieved?What sort of results has it achieved? What impact has it had on:What impact has it had on:

• EU member state policiesEU member state policies• EC PolicyEC Policy• monitoring of health system performance by OECD, WHO, monitoring of health system performance by OECD, WHO,

World BankWorld Bank

The ECuity Project ...The ECuity Project ...

is a (series of) EU-funded research projectsis a (series of) EU-funded research projects aimed at international comparison of equity in the aimed at international comparison of equity in the

finance and delivery of health carefinance and delivery of health care includes most EU and 2 non-EU countries (US and includes most EU and 2 non-EU countries (US and

Switzerland)Switzerland) involves 13 teams of health economists, working involves 13 teams of health economists, working

along “concerted action” principlesalong “concerted action” principles new phase to be started in 2002, aimed at new phase to be started in 2002, aimed at

establishing causal links, using ECHP panel dataestablishing causal links, using ECHP panel data Website: www.eur.nl/ecuity/Website: www.eur.nl/ecuity/

Objectives of the projectObjectives of the project

Develop methods to Develop methods to measuremeasure inequality and inequality and inequity: concentration indices -- examplesinequity: concentration indices -- examples

Develop methods to Develop methods to explainexplain inequality and inequity: inequality and inequity: decomposition into sources – examplesdecomposition into sources – examples

Improve Improve understandingunderstanding of between-country and of between-country and within-country differenceswithin-country differences

Derive policy implications based on Derive policy implications based on evidenceevidence

What is equity? What is equity?

European health care equity goals mostly egalitarian, European health care equity goals mostly egalitarian, but requiring equality of what? Health care utilization? but requiring equality of what? Health care utilization? Health? Access? Health care payments?Health? Access? Health care payments?

ECuity Project looks at equity in:ECuity Project looks at equity in:• finance: do those with higher ability to pay, contribute more?finance: do those with higher ability to pay, contribute more?• delivery: do those in equal need get treated equally, delivery: do those in equal need get treated equally,

irrespective of income?irrespective of income?• health: what contributes to lower income-related inequality?health: what contributes to lower income-related inequality?

Equity in health care utilisation: are Equity in health care utilisation: are those in equal need treated equally? those in equal need treated equally?

Can be assessed by comparing the Can be assessed by comparing the actualactual distribution distribution of health care use in relation to the of health care use in relation to the expectedexpected distribution on the basis of need characteristicsdistribution on the basis of need characteristics

Does not require equality of utilisationDoes not require equality of utilisation Equitable if use and need distributions coincideEquitable if use and need distributions coincide Degree of inequity can be measured by an index of Degree of inequity can be measured by an index of

(horizontal) inequity, which is negative if pro-poor (horizontal) inequity, which is negative if pro-poor and positive if pro-rich and positive if pro-rich

Data taken from Eurostat’s European Community Data taken from Eurostat’s European Community Household Panel, wave 3 (1996)Household Panel, wave 3 (1996)

European Community Household European Community Household PanelPanel

Major source of comparable micro data on health Major source of comparable micro data on health and health care use in EUand health care use in EU

5 waves available: 1994, 1995, 1996, 1997, 19985 waves available: 1994, 1995, 1996, 1997, 1998 12 EU member countries (+ Austria in 95 and 12 EU member countries (+ Austria in 95 and

Finland in 96)Finland in 96) total sample size: +130 000 adults (> 16 years), total sample size: +130 000 adults (> 16 years),

ranging from n=2000 (Luxembourg) to n=17 000 ranging from n=2000 (Luxembourg) to n=17 000 (Italy).(Italy).

Income measured as disposable income per Income measured as disposable income per equivalent adult (modified OECD scale) equivalent adult (modified OECD scale)

GP utilisation tends to be higher among the GP utilisation tends to be higher among the lower income groups ...lower income groups ...

0

1

2

3

4

5

6

7

1 2 3 4 5

I ncome quintiles

# G

P v

isit

s/year

B EU-12 NL

After standardisation for need differences, After standardisation for need differences, inequality in GP utilisation is much lowerinequality in GP utilisation is much lower

0

1

2

3

4

5

6

1 2 3 4 5

Income quintiles

standard

ised #

GP v

isit

s/year

B EU-12 NL

Examples: need-standardized Examples: need-standardized distribution of doctor visitsdistribution of doctor visits

First level bulletsFirst level bullets• Second level bulletsSecond level bullets

– Third level bulletsThird level bullets

0

1

2

3

4

5

6

7

1 2 3 4 5Income quintiles

mean

# o

f d

octo

r vis

its/a

du

lt/y

ear

EU-12

Can

USA

Inequity indices for distribution of Inequity indices for distribution of specialist care utilisation in 13 EU specialist care utilisation in 13 EU countries, 1995countries, 1995

Specialist visits

0

0.05

0.1

0.15

0.2

0.25

0.3

NL BE DK DE AT LU ES UK IT GR IE PT

HIwv

Pro-rich

Income-related inequity in health Income-related inequity in health care usecare use

Little evidence of inequitable distribution of GP Little evidence of inequitable distribution of GP services (some even pro-poor)services (some even pro-poor)

But strong evidence of pro-rich inequity in access to:But strong evidence of pro-rich inequity in access to:• Specialist services (all countries)Specialist services (all countries)• Hospital services (most countries)Hospital services (most countries)• Dental services (all countries)Dental services (all countries)

And more so in countries offering private options And more so in countries offering private options alongside public system (UK, Portugal, Spain, Ireland) alongside public system (UK, Portugal, Spain, Ireland)

And in countries with wide regional disparities in And in countries with wide regional disparities in availability of facilities (Italy, Spain, Greece)availability of facilities (Italy, Spain, Greece)

Health inequality by incomeHealth inequality by income

Concern about equity in health care stems from Concern about equity in health care stems from concern about inequalities in healthconcern about inequalities in health

Degree of inequality can be measured using Degree of inequality can be measured using concentration index of (self-reported) healthconcentration index of (self-reported) health

In all countries, good health is more prevalent among In all countries, good health is more prevalent among higher income groupshigher income groups

But Portugal and UK more unequal than Netherlands, But Portugal and UK more unequal than Netherlands, Belgium, GermanyBelgium, Germany

Health inequality closely associated with income Health inequality closely associated with income inequality but more influenced by health policy than inequality but more influenced by health policy than by income redistributionby income redistribution

Indices of inequality in (self-reported) Indices of inequality in (self-reported) healthhealthby income level for 13 EU countries, 1995by income level for 13 EU countries, 1995

-0.12

-0.1

-0.08

-0.06

-0.04

-0.02

0

NL IT DE AT BE IE ES FR DK LU UK PT GR

Correlation between income inequality Correlation between income inequality and health inequalityand health inequality

ATBE

DE

DK

ES

FR

GR

IE

IT

LU

NL

PTUK

-0.06

-0.04

-0.02

0.2 0.3 0.4

Gini coeff

I* hui

Low inequality

High inequality

Impact of the project on:Impact of the project on:

1.1. Research methods?Research methods?• Concentration indices have become one of the major health Concentration indices have become one of the major health

inequality measures, like the Gini index for incomeinequality measures, like the Gini index for income• Decomposition methods prove tremendously useful in Decomposition methods prove tremendously useful in

identifying sources of inequityidentifying sources of inequity

2.2. Health system performance indicators?Health system performance indicators?• OECD’s Health project on Equity in accessOECD’s Health project on Equity in access• WHO’s framework for health system performanceWHO’s framework for health system performance• World Bank’s Health and Poverty Network country sheetsWorld Bank’s Health and Poverty Network country sheets

Impact of the project on:Impact of the project on:

1.1. EU policies?EU policies?• Included in indicators for social exclusion (cf Atkinson report)Included in indicators for social exclusion (cf Atkinson report)• Recommended for National Action Plans on Social InclusionRecommended for National Action Plans on Social Inclusion• Health Monitoring?Health Monitoring?

2.2. EU member state policies?EU member state policies?• Input through participants) in numerous health system reform Input through participants) in numerous health system reform

plan preparations; e.g. in Netherlands, France, (CMU), Ireland , plan preparations; e.g. in Netherlands, France, (CMU), Ireland , ItalyItaly

3.3. Non-EU countries’ policies?Non-EU countries’ policies?• E.g. Canada’s Royal Commission on the Future of the Canadian E.g. Canada’s Royal Commission on the Future of the Canadian

Health Care System, Swiss health reforms, Health Care System, Swiss health reforms,

Main achievement?Main achievement?

Contributed to understanding that: Contributed to understanding that: In health and health care, not only the level but In health and health care, not only the level but

also the distribution mattersalso the distribution matters That degree of inequality can be measured and That degree of inequality can be measured and

compared at system levelcompared at system level That different policy choices lead to different That different policy choices lead to different

distributional outcomesdistributional outcomes