Equitable access to health care may alleviate health inequalities

Access to good quality health services is an important health determinant. Over the years, improved access to health care services for the lower socio-economic groups helped reduce inequities in health, notably differences in mortality (Dahlgren & Whitehead, 2006). Health systems are still widely recognized as an important means to improve population health and improving health systems can play a role in tackling health inequalities (WHO, 2000c; Mackenbach, 2005). Socio-economic differences in health services access across may exacerbate existing health inequalities. Thus, understanding the extent of inequalities in access is essential in understanding the broader goal of health equity (Allin et al., 2005).

Principles of universal and equitable access widely acknowledged

Equitable distribution of health care is a principle subscribed to in many EU countries, as are universal rights to health care access. This is reflected in the Charter of Fundamental Rights of the European Union: article 35 states that “Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices” (Official Journal of the European Communities, 2000).

The EU Council endorsed universality, access to good quality care, equity, and solidarity as common values and principles underpinning the health systems in the EU Member States. It also confirmed that health systems should aim to reduce the gap in health inequalities (CEU, 2006).

EU Member States have identified the need to ensure equal access for all as a priority. At EU-level, work on safeguarding equity of access to good-quality care is predominantly channeled via the Open Method of Coordination (OMC) on social protection and social inclusion. Accessible healthcare is included in the common objectives of in this process.

Defining equity of access not clear-cut

There is no one clear-cut definition of equitable access to health services (Allin et al., 2007). Most commonly, it is described as equal access to treatment for those in equal medical need, irrespective of other characteristics, such as income. This principle is also known as ‘horizontal equity’ of health care delivery (Wagstaff & Van Doorslaer, 2000). In contrast, the concept of ‘vertical equity’ refers to the extent to which individuals on unequal incomes are treated unequally to achieve equity (‘fairness’) in health care finance (Tamsma & Berman, 2004). WHO defines accessibility as ‘a measure of the proportion of the population that reaches appropriate health services’ (WHO, 1998b).

Potential of universal access may be hindered by access barriers

Even where universal access to health services is formally in place, individuals can face a range of barriers hindering the actual utilisation of that service. If persisting inequities in access are to be addressed it is necessary to look beyond the assumption of universal coverage (Busse et al., 2006).

Barriers to access may stem from factors within the health system itself (i.e. at the supply side) or be due to patient-related (demand side) aspects. Supply-side barriers may be due to:

• gaps in population coverage of health insurance;
• scope of the public health benefit package (‘health basket’);
• financial factors such as cost-sharing;
• geographical factors such as distance;
• organisational factors, including waiting lists and opening hours;
• lack/appropriateness of information

Inequality of access at the demand side is related to the characteristics of the potential service users, such as income, age, gender, cultural background, health literacy, or health beliefs.

Some access hurdles have relatively more impact on disadvantaged groups than others (Tamsma & Berman, 2004). Examples of these are costs and distance, as well as demand-side factors such as communication skills and health beliefs (Dixon et al., 2003). This points towards the relevance of targeted measures when aiming to tackle inequalities in access.

Measuring inequity of access often indirect

Access as such can rarely be observed and measured. Instead, a range of indicators can be used to measure its dimensions, and the various barriers to access. Service utilisation is most commonly used as a proxy measure for access (Allin, 2006), as are indicators of access hurdles such a user charges or waiting times.

Typically, lower socio-economic status is associated with poorer health status. In order to measure inequity, inequality in utilization of health care must therefore be standardized for differences in need (O’Donnell et al., 2007). More qualitative aspects of access that may help understand inequalities tend to receive less attention. Need for services is often measured by levels of –self-reported- ill-health (Allin et al., 2007).

This approach is also reflected in the way access is measured within EU-related frameworks. While the ECHI shortlist does not include one specific indicator for equity of access, it does include indicators of access barriers:

• Population coverage by public insurance
• Waiting times elective surgeries

Indicators of service utilisation are also included, albeit not specified for differences by socio-economic status as regards uptake:

• Vaccination coverage children
• Breast cancer screening
• Cervical cancer screening
• GP utilisation

Within the EU’s social protection and social inclusion process, the following common indicators are especially relevant:

• Unmet need for medical care
• Unmet need for dental care
• Population coverage by public insurance
• Infant mortality
• Life expectancy
• Self-perceived health

Socio-economic inequalities in access exist across Europe

Evidence based on the 2003 European Quality of Life Survey suggests income-related inequalities in access existed in all current EU Member States as regards distance, delay, waiting and cost factors. Differences are most pronounced as regards the proportion of people who indicated that their most recent visit to the doctor was made very difficult by cost factors (Anderson, 2004).

The overall picture emerging from research is that richer, better educated people find their way to medical specialists and dentist more easily and more frequent, while people in the lower income brackets tend to use more emergency services. The access to GP services seems fairly equally distributed across income. However, once people go to see their GP the poor are more likely to consult them more often. In contrast, the level of pro-rich inequality as regards access to medical specialist increases with the total number of specialist visits. Education appears to be a more important cause of inequality in specialist care than in other health care services (Van Doorslaer et al., 2004; Allin et al., 2005).

Financial hurdles of relatively great importance

EU-SILC data from 2005 indicate a social gradient for total self-reported unmet need exists across the EU. The organisation of health systems are somewhat reflected in the absolute and relative importance of the various access hurdles. Compared to organisational –waiting- and geographical – distance and availability of transport- hurdles, costs appear to be the most important hurdle in the vast majority of Member States. See Self reported unmet need for medical examination by income quintile in 2005 in EU-25 Norway and Iceland.

Nevertheless, out-of-pocket payments have consistently increased across EU countries. This is due to the exclusion of certain types of care from the public benefits package, and to rises in co-payments. See Private expenditure on medical service. To compensate more vulnerable groups for the effects, Member States have introduced exemptions, pre-payments and expenditure ceilings (CEU, 2007).

Extent and characteristics of financial hurdles are shaped by national health system characteristics and vary from country to country. Health services may be funded through taxation, social health insurance, private health insurance and/or private costs sharing. The latter includes direct user charges, or ‘out-of-pocket payments’. Evidence suggests that private health insurance and especially costs sharing most negatively impact equity of access (Mossialos & Dixon, 2002; Tamsma & Berman, 2004).