Elsevier

Social Science & Medicine

Volume 64, Issue 1, January 2007, Pages 199-212
Social Science & Medicine

Horizontal equity in health care utilization evidence from three high-income Asian economies

https://doi.org/10.1016/j.socscimed.2006.08.033Get rights and content

Abstract

This paper compares the extent to which the principle of “equal treatment for equal need”(ETEN) is maintained in the health care delivery systems of Hong Kong, South Korea and Taiwan. Deviations in the degree to which health care is distributed according to need are measured by an index of horizontal inequity. Income-related inequality in utilization is split into four major sources: (i) direct effect of income; (ii) need indicators (self-assessed health status, activity limitation, and age and gender interaction terms); (iii) non-need variables (education, work status, private health insurance coverage, employer-provided medical benefits, Medicaid status (low-income medical assistance), geographic region and urban/rural residency and (iv) a residual term. Service types studied include western doctor, licensed traditional medicine practitioner (LTMP), dental and emergency room (ER) visits, as well as inpatient admissions. Violations of the ETEN principle are observed for physician and dental services in Hong Kong . There is pro-rich inequity in western doctor visits. Unusually, this inequity exists for general practitioner but not specialist care. In contrast, South Korea appears to have almost comprehensively maintained ETEN although the better-off have preferential access to higher levels of outpatient care. Taiwan shows intermediate results in that the rich are marginally more likely to use outpatient services, but quantities of western doctor and dental visits are evenly distributed while there is modest pro-rich bias in the number of LTMP episodes. ER visits and inpatient admissions in Taiwan are either proportional or slightly pro-poor. Future work should focus on the evaluation of policy interventions aimed at reducing the observed unequal distributions.

Introduction

Health systems are widely recognized as an important determinant of and means to improve population health; thus their performance matters (WHO, 2000). The distributional implication of the system is one dimension of performance that deserves particular attention because it is a major axis on which health systems are commonly judged. One of the core distributional concerns in most systems with egalitarian goals, mainly from the developed West so far, is to ensure that the horizontal equity standard is met, such that there is “equal treatment for equal need” or ETEN, notwithstanding the intense debate about its theoretical foundations and specifications previously (Culyer, Van Doorslaer, & Wagstaff, 1992; LeGrand, 1991; Mooney, Hall, Donaldson, & Gerard, 1991; Wagstaff, Van Doorslaer, & Paci, 1991). Consistency of health care delivery systems with this principle has been tested across a number of OECD countries (Van Doorslaer, Koolman & Jones, 2004; Van Doorslaer, Koolman, & Puffer, 2002; Van Doorslaer, Masseria, & Koolman, 2006). There is however little evidence against which to evaluate the equity performance of the health systems of the high-income economies in Asia.

Whereas most OECD countries, with the US as a notable exception, have had a long history of developing social protection systems which are rooted in the egalitarian tradition, the three Asian health systems under consideration, Hong Kong, South Korea and Taiwan, have developed over a much more compressed timeframe concomitant with their rapid economic advance. Comparison of the equity performance of these three health systems is interesting given substantial differences between them in the financing and organization of health care. Moreover, the pervasive use of non-western allopathic health care in this region calls for the inclusion of licensed traditional medicine practitioners (LTMPs) in any equity analysis.

Section snippets

Hong Kong

As a former British colony, the development of Hong Kong's health system closely followed that of the UK National Health Service. Annual total health expenditure was 5.5% of GDP in 2001/2 where public and private funding sources accounted for 56% and 44% of total spending, respectively. About 95% of public funding is derived from government general revenue with the rest recovered from fees and charges at the point-of-care. About 70% of private health financing is through out-of-pocket household

Data sources

Table 2 describes surveys of the three non-institutional populations on which the present set of analyses are based. All three surveys were carried out according to comparable methodologies adopted by the respective government census departments to ensure representativeness, based on stratified sampling designs with appropriate application of sampling weights. The surveys are selected on the basis of their suitability for this analysis and cross-comparability. In terms of content, they include

Income-related inequality and inequity (Table 3 and Fig. 1)

There is pro-poor inequality in the probability of visiting a western doctor in South Korea and Taiwan but pro-rich inequality in Hong Kong. The distributions of volume of doctor, i.e., both GP and SP, visits display a similar pattern. Controlling for variation in need shifts all probability and volume distributions of doctor visits in a pro-rich direction. The significantly positive HIs for doctor visits in Hong Kong indicate unequal treatment for given need that is to the advantage of the

Discussion

This paper provides the first analysis of income-related inequality and inequity of health care utilization in three high-income East Asian economies.

In general, the direct effect of income is to shift the distribution of health care in a pro-rich direction. . On the other hand, disparities in need factors are the major source of any pro-poor inequalities that arise in the utilization of health care. The contribution of non-need factors to income-related inequality in health care differs across

Acknowledgement

Preliminary findings from this paper were presented at an organized session “Horizontal equity in health care utilization—evidence from three high-income Asian economies (from the EQUITAP collaboration)” at the Fifth World Congress of the International Health Economics Association, Barcelona, 2005. The European Commission, INCO-DEV program (ICA4-CT-2001-10015), funds the EQUITAP project from which this paper derives. Analysis for Taiwan was funded by Taiwan Department of Health (DOH93-PL-1001)

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