Inequalities in access to medical care by income in developed countries

Abstract

Background: Most of the member countries of the Organization for Economic Cooperation and Development (OECD) aim to ensure equitable access to health care. This is often interpreted as requiring that care be available on the basis of need and not willingness or ability to pay. We sought to examine equity in physician utilization in 21 OECD countries for the year 2000.

Methods: Using data from national surveys or from the European Community Household Panel, we extracted the number of visits to a general practitioner or medical specialist over the previous 12 months. Visits were standardized for need differences using age, sex and reported health levels as proxies. We measured inequity in doctor utilization by income using concentration indices of the need-standardized use.

Results: We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland.

Interpretation: Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.

Fig. 1: Sample of a concentration curve of medical care use. Distribution of use is equal among income levels if the concentration curve coincides with the diagonal; a curve that lies above the diagonal indicates that use is more concentrated among the poor.

Fig. 2: Proportion of adult population consulting any doctor, general practitioner (GP) or specialist in 19 OECD countries within the previous 12 months. Countries are ranked by the proportion of the population visiting any doctor. UK and German results reflect data obtained in the 1996 ECHP; all other data were obtained in 2000.

Fig. 3: Annual adult population mean numbers of consultations with any doctor, general practitioner (GP) and specialist in 18 OECD countries in 2000. Countries are ranked by mean number of doctor visits. UK and German results reflect data obtained in the 1996 ECHP.

Fig. 4: Horizontal inequity (HI) indices for the annual probability of visiting a doctor in 21 OECD countries. Countries are ranked by HI for doctor visits. German general practitioner (GP) and specialist indices reflect data obtained in the 1996 ECHP.

Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits to a doctor in 19 OECD countries. Countries are ranked by HI index for doctor visits. German general practitioner (GP) and specialist indices reflect data obtained in the 1996 ECHP.