3.1. Inequities in need-adjusted doctor visits
Figure 1 shows income-related inequities in the probability of a doctor visit after adjusting for i di iduals eeds fo health a e. The i e uit i de is sig ifi a tl greater than zero in 14 out of 16 countries, indicating that for the same level of needs for health care, people with higher incomes are significantly more likely to visit a doctor than those with lower incomes. The magnitude of these inequities varies among countries, USA displaying the largest inequities followed by France, Poland, and Canada. In contrast, Slovak Republic, Spain and Switzerland show a lower degree of inequities.
At the other end of the spectrum, UK presents an inequity index which is not statistically different from zero, indicating that no inequities can be detected. This is also the case for Czech Republic although the small sample size in Czech Republic limits the ability to detect significant effects. The degree of inequity is the highest in USA, where the universal health primary coverage was not achieved. Beyond primary coverage, the role of private health insurance is of importance. USA, France, and Canada which present large inequities, are characterised by large share of private insurance expenditure (as shown in Table 2). Larger inequities are found in countries where the provision of care is predominantly private (USA, France, Poland, Canada, Estonia, and Belgium) although this is also true in Czech and Slovak Republics, Switzerland and Germany. Virtually no
21 Only in England, Scotland, and Wales.
delivery. Similar settings are in place in Spain and Germany22 where inequalities are small, but also, in Canada and Poland where inequities are larger, suggesting that other features may influence inequities in doctor visits.
Figure 1. Inequity index for the need-adjusted probability of a doctor visit and its 95% confidence intervals
3.2. Inequities in need-adjusted GP and specialist visits
Figure 2 presents income-elated i e uities i GP a d spe ialist isits afte adjusti g fo i di iduals needs for health care. Nine out of 16 countries display significant inequities in GP visits (Figure 2, Panel A). The largest inequities are observed in Canada, Poland, and New Zealand. Conversely, seven countries present no significant inequities, indicating that people with lower incomes are as likely as those with higher incomes to consult a GP. Germany and USA do not present data split by GP and specialist. The largest inequities in GP visits are found in New Zealand where the average cost-sharing for an outpatient primary care physician contact is about 30%, with a range of copayments depending on practice type and patient status. In contrast, smaller inequities are observed in countries providing free care at the point of delivery (Spain, Austria, and UK) or with a small copayment of about 1 euro per visit (Czech Republic and Hungary).
-0.10 -0.05 0.00 0.05 0.10 0.15 0.20 0.25
United Kingdom Czech Republic Slovak Republic Spain Switzerland Germany Finland Slovenia New Zealand Hungary Belgium Estonia Canada Poland France United States
Inequity index
95% confidence intervals
Panel A. GP Panel B. Specialists
The variation of inequities in specialist visits among countries (Figure 2 Panel B) is larger than that of inequities in GP visits, and the pattern is also clearer. In all countries -but two- the inequity index is significantly greater than zero, which means that for the same needs for health care, people with higher incomes visit specialists more often than those with lower incomes. In particular, France and Spain display the largest inequities. On the other hand, no inequities can be detected in UK (and in Czech Republic due to the small sample size) and low degrees of inequities are found in Slovak Republic, New Zealand23, and Slovenia. These three countries as well as UK are characterised by the fact that GPs act as gatekeepers and a referral is required to get access to specialist care. However, this is also true in Spain which has the second highest degree of inequities in specialist visits. Beyond that, the distinction between public and private sectors has its importance since inequities in specialist visits in Spain were found mainly in the private sector [21].
3.3. Inequalities in dentist visits
Figure 3 shows that all countries display significant income-related inequalities in dental visits. The extent of these inequalities varies greatly among countries. Canada and USA stand out with the strongest inequalities that are more than three times the degree of inequalities observed in Switzerland. The two countries with the strongest degrees of inequality are characterised by a large
23 In New Zealand, specialist visits in contrast with GP visits are exempted from copayments
-0.10
Czech Republic Spain Switzerland Austria Hungary United Kingdom Slovak Republic Ireland Finland France Slovenia Belgium Estonia Canada Poland New Zealand
Inequity index
United Kingdom Slovak Republic New Zealand Slovenia Czech Republic Finland Hungary Estonia Switzerland Canada Belgium Poland Spain France
Inequity index
Spain (99%), France (64%), and Poland (64%) where inequalities in dentist visits are large. However, Switzerland also presents a high share of private expenditure for dental care (93%) but has the lowest level of inequality. This suggests that other institutional factors play a role on inequalities in the use of dental care such as exemptions of copayments for certain groups of population.
Figure 3. Inequality index for the probability of a dental visit and its 95% confidence intervals
Note: (*) Visits in the past 24 months in France.
3.4. Inequalities in cancer screening
Figure 4 presents income-related inequalities in breast and cervical cancer screening (Panel A and B).
Inequalities in breast cancer screening in favour of the better-off are shown in 12 out of 16 countries. The largest inequalities are observed in Belgium, Estonia, France, and USA. In contrast, no inequalities can be detected in four countries (Czech Republic24, Slovak Republic, Slovenia, and UK).
Inequalities in cervical cancer screening are shown in all countries but two. The degree of these inequalities varies from below 0.10 in Ireland, Slovak Republic, Slovenia, and Switzerland to more than 0.20 in Belgium, Czech Republic, and France.
Inequality in cancer screening must be interpreted with regards to the level of cancer screening rates (displayed in Table 1). Breast cancer screening rates are high in Austria, France, New Zealand, Spain, and USA, with more than 75% of women aged 50-69 years having a mammogram in the past 2 years.
At the other end of the spectrum, in Estonia, only 36% of women had a mammogram in the past 2 years. Similarly, cervical cancer screening rates are high in USA, Austria, Spain, Slovenia, and Canada,
0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35
Switzerland Austria New Zealand Slovak Republic Ireland United Kingdom Slovenia Finland Czech Republic Estonia Hungary Spain France* Poland Belgium Canada United States
Inequality index
whereas this proportion is only 34% in Switzerland. The Wagstaff index used in this study already makes the adjustment for differences in the national average rate of screening, giving a higher weight to the countries with larger screening coverage. A country with a small degree of inequality and a wide screening coverage may count as much as a country with large inequalities and a small population coverage. This is the case for instance in Estonia and Belgium. Estonia has a large degree of inequality in breast cancer screening (crude CI=0.17) but a small proportion of screening uptake (36%). In comparison, Belgium has a smaller degree of inequality (crude CI=0.08) and a larger screening rate (74%). After adjustment for the level of screening rate, the Wagstaff inequality indexes are respectively 0.27 in Estonia and 0.30 in Belgium.
Figure 4. Inequality index for cancer screening and its 95% confidence intervals Panel A. Breast cancer Panel B. Cervical cancer
Note: (*) Visits in the past 12 months in Ireland.
The utilisation of cancer screening services may largely depend on the availability of national public screening programmes. For instance, recent findings in the European region highlight that inequalities are larger in countries without a population-based screening programme [8]. In our study, the degree on inequalities in cancer screening has been examined in the light of the existence of national screening programmes, however we do not find any clear association. Beyond the existence of screening programmes, the lack of association may be related to the time since programmes were rolled out. Another explanation relies on the fact that screening is often fully covered by insurance in most countries [22, 20]. This corroborates a recent study showing that the impact of the availability of national programmes on screening uptake is mediated to a minor extent by solving financial restriction, and to a large extent by preventing women from considering
Slovenia United Kingdom Slovak Republic Switzerland Austria Spain Hungary Poland Czech Republic Canada New Zealand Ireland* France Estonia Belgium United States
Inequality index
Slovak Republic Slovenia Ireland* Switzerland Estonia United Kingdom Hungary Austria Canada Poland Spain United States New Zealand Czech Republic France Belgium
Inequality index
individual characteristics. Ethnicity, younger age, higher education level, employment status, residential area, marital status, having health insurance, good health status, having an usual source of care and use of other preventative services, are all recognized as important additional predictors of participation in screening. For instance, in the United States, low-income women, women who are uninsured or receiving Medicaid (health insurance coverage for the poor, disabled or impoverished elderly), or women with lower educational levels report much lower use of mammography and pap smears [24]. Similarly, in European countries, significant inequalities related to education and socioeconomic status are found in the utilisation of early detection and preventive health care services [25, 26].