Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt

Background The Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees’ access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable. Methods A cross‐sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors. Results We found pro-rich inequality and horizontal inequity in the probability of refugees’ outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures. Conclusion Our results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

COVID-19 and Unmet Healthcare Needs of Older People: Did Inequity Arise in Europe?

Background: The disruption in healthcare provision due to the COVID-19 pandemic forced many non-urgent medical treatments and appointments to be postponed or denied, which is expected to have huge impact on non-acute health conditions, especially in vulnerable populations such as older people. Attention should be paid to equity issues related to unmet needs during the pandemic. Methods: We calculated concentration indices to identify income-related inequalities and horizontal inequity in unmet needs due to postponed and denied healthcare in people over 50 during COVID-19, using data from the Survey on Health, Ageing and Retirement in Europe (SHARE). Results: Very few countries show significant income-related inequalities in postponed, rescheduled or denied treatments and medical appointments, usually favouring the rich. Only Estonia, Italy and Romania show a significant horizontal inequity (HI) in postponed healthcare, which apparently favours the poor. Significant pro-rich inequity in denied healthcare is found in Italy, Poland and Greece. Conclusions: Although important income-related horizontal inequity in unmet needs of European older adults during the early waves of the COVID-19 pandemic is not evident for most countries, some of them have to carefully monitor barriers to healthcare access. Delays in diagnosis and treatments may ultimately translate into adverse health outcomes, reduced quality of life and, even, widen socio-economic health inequalities among older people.

Inequity in health care utilization for common childhood illnesses in India: measurement and decomposition analysis using the India demographic and health survey 2015–16

Background Though child mortality has dropped remarkably, it is considerably high in South Asia. Across the globe, 5.2 million children under 5 years of age died in 2019, and India accounts for a significant portion of these deaths. Common childhood illnesses are the leading cause of these deaths. Seeking care from formal providers can reduce these avoidable deaths. Inequity is a crucial blockage in optimum utilization of medical treatment for children. Hence, the present study analyzes the inequalities and horizontal inequities in utilizing the medical treatment for diarrhea, fever, acute respiratory infection (ARI), and any of these common childhood illnesses in India and across the Indian states. The study also attempts to locate significant contributors to these inequalities. Methods The study used 0 to 59 months children’s data sourced from the Demographic and Health Survey, India (2015–16). Concentration Index (CI) and Erreygers Corrected Concentration Index (EI) were used to measure the inequalities. The Horizontal Inequity Index (HII) was deployed to estimate inequity. The decomposition method introduced by Erreygers was applied to determine the significant contributors of inequalities. Results The EI in medical treatment-seeking for common childhood illnesses was 0.16, while the HII was 0.15. The highest inequality was perceived in the utilization of medical treatment for ARI (0.17). The primary contributing factors of these inequalities were continuum of maternal care (18.7%), media exposure (12%), affordability (9.3%), place of residence (9.1%), mother’s education (8.5%), and state groups (8.8%). The North-Eastern states showed the highest level of inequality across the Indian states. Conclusion The study reveals that the horizontal inequity in medical treatment utilization for children in India is pro-rich. The findings of the study suggest that attuning the efforts of existing maternal and child health programs into one seamless chain of care can bring the inequalities down and improve the utilization of child health care services. The spread of health education through different media sources, reaching out to rural and remote places with adequate health personnel, and easing out the financial hardship in accessing medical treatment could be the cornerstone in accelerating the utilization level amongst the impoverished children.

Redistributive Effects of Health Care Out-of-Pocket Payments in Cameroon

Background: The bulk of health care financing in Cameroon is derived from out-of-pocket payments. Given that poverty is pervasive with a third of the population living below the poverty line, health care financing from out-of-pocket payments is likely to have redistributive and equity effects. Out-of-pocket payments on health care limit the ability of households to afford non-healthcare goods and services.Method: The study uses data from the 2014 Cameroon Household Survey to estimate the Kwakwani index for analyzing tax progressivity and the model developed by Aronson, Johnson, and Lambert (1994) to measure the redistributive effect of out-of-pocket payments for health care. The estimated indexes measure the extent of the progressivity of health care payments and the reranking that results from the payments.Results: The results indicate that out-of-pocket payments for health care in Cameroon in 2014 represented a significant share of household prepayment income. The estimates also show that the redistributive effect is positive implying that health care payments are weakly progressive and will weakly enhance equity and post-payment reranking is low. Conclusion: The study concludes that out-of-pocket payments on health care in Cameroon are progressive (income redistributive effect = 0.00144). A positive redistributive effect suggests that out-of-pocket payments on health care exert an equalizing effect on the distribution of post-payment incomes. However, the existence of some horizontal inequity and re-ranking implying that people in the same income band are treated unequally depending on the burden of ill-health.

Trends in equity of inpatient health service utilization for the middle-aged and elderly in China: based on longitudinal data from 2011 to 2018

Background The aim of this study was to assess the trends in equity of receiving inpatient health service utilization (IHSU) in China over the period 2011–2018. Methods Longitudinal data obtained from China Health and Retirement Longitudinal Studies were used to determine trends in receiving IHSU. Concentration curves, concentration indices, and horizontal inequity indices were applied to evaluate the trends in equity of IHSU. Results This study showed that the annual rate of IHSU gradually increased from 7.99% in 2011 to 18.63% in 2018. Logistic regression shows that the rates of annual IHSU in 2018 were nearly 3 times (OR = 2.86, 95%CL: 2.57, 3.19) higher for rural respondents and 2.5 times (OR = 2.49, 95%CL: 1.99, 3.11) higher for urban respondents than the rates in 2011 after adjusting for other variables. Concentration curves both in urban and rural respondents lay above the line of equality from 2011 to 2018. The concentration index remained negative and increased significantly from − 0.0147 (95% CL: − 0.0506, 0.0211) to − 0.0676 (95% CL: − 0.0894, − 0.458), the adjusted concentration index kept the same tendency. The horizontal inequity index was positive in 2011 but became negative from 2013 to 2018, evidencing a pro-low-economic inequity trend. Conclusions We find that the inequity of IHSU for the middle-aged and elderly increased over the past 10 years, becoming more focused on the lower-economic population. Economic status, lifestyle factors were the main contributors to the pro-low-economic inequity. Health policies to allocate resources and services are needed to satisfy the needs of the middle-aged and elderly.

The benefits of an integrated social medical insurance for health services utilization in rural China: evidence from the China health and retirement longitudinal study

Background Improving health equity is a fundamental goal for establishing social health insurance. This article evaluated the benefits of the Integration of Social Medical Insurance (ISMI) policy for health services utilization in rural China. Methods Using the China Health and Retirement Longitudinal study (2011‒2018), we estimated the changes in rates and equity in health services utilization by a generalized linear mixed model, concentration curves, concentration indices, and a horizontal inequity index before and after the introduction of the ISMI policy. Results For the changes in rates, the generalized linear mixed model showed that the rate of inpatient health services utilization (IHSU) nearly doubled after the introduction of the ISMI policy (8.78 % vs. 16.58 %), while the rate of outpatient health services utilization (OHSU) decreased (20.25 % vs. 16.35 %) after the implementation of the policy. For the changes in inequity, the concentration index of OHSU decreased significantly from − 0.0636 (95 % CL: −0.0846, − 0.0430) before the policy to − 0.0457 (95 % CL: −0.0684, − 0.0229) after it. In addition, the horizontal inequity index decreased from − 0.0284 before the implementation of the policy to − 0.0171 after it, indicating that the inequity of OHSU was further reduced. The concentration index of IHSU increased significantly from − 0.0532 (95 % CL: −0.0868, − 0.0196) before the policy was implemented to − 0.1105 (95 % CL: −0.1333, − 0.0876) afterwards; the horizontal inequity index of IHSU increased from − 0.0066 before policy implementation to − 0.0595 afterwards, indicating that more low-income participants utilized inpatient services after the policy came into effect. Conclusions The ISMI policy had a positive effect on improving the rate of IHSU but not on the rate of OHSU. This is in line with this policy’s original intention of focusing on inpatient service rather than outpatients to achieve its principal goal of preventing catastrophic health expenditure. The ISMI policy had a positive effect on reducing the inequity in OHSU but a negative effect on the decrease in inequity in IHSU. Further research is needed to verify this change. This research on the effects of integration policy implementation may be useful to policy makers and has important policy implications for other developing countries facing similar challenges on the road to universal health coverage.

Income-related inequalities in informal care: Evidence from the Longitudinal Healthy Longevity Survey in China

Objectives This report seeks to examine income-related inequalities in informal care among older people with functional limitations in China. Methods Data are drawn from the 2005, 2008, 2011 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey. Erreygers Concentration Index, Concentration Index, and Horizontal Inequity Index are used to examine inequalities in informal care. Random effects model is then used to investigate the relationship between household income and informal care. Results There is no significant association between household income and the probability of receiving informal care. However, we observe a significantly positive association between household income and hours of informal care received, indicating that those with higher household income receive more hours of informal care compared to those with lower household income. The degree of this inequality increases as number of functional limitations increases. Discussion Lower household income is associated with lower intensity of informal care received, particularly for older people with more functional limitations. Policies are required to support low-income older people with more functional limitations.

In This Issue

This issue of the journal commences with an editorial that provides some discussion about the current approaches to Covid and the tensions that exists in that context..... Editorial SettingsCovid-19: A strife of interests for us all and what problem are we attempting to solve? Research Articles Gender Equity in Australian Health Leadership Research Articles Assessing Quality of Healthcare Delivery When Making Choices: National Survey on Health Consumers’ Decision Making Practices Research Articles The Case for a Reciprocal Health Care Agreement between Australia and South Korea Commentary COVID-19 and Working Within Health Care Systems: the future is flexible Review Articles Review of Public Private Partnership in the Health Care in Hong Kong Viewpoint Article Hong Kong’s Growing Need for Palliative Care Services and the Role of the Nursing Profession Commentary Vietnam’s Healthcare System Decentralization: how well does it respond to global health crises such as covid-19 pandemic? Research Articles Publicly Financed Health Insurance Schemes and Horizontal Inequity in Inpatient Service Use in India Research Articles Distress and Quality of Life among Type II Diabetic Patients: Role of physical activity Viewpoint Article Achievements and Challenges of Iran Health System after Islamic Revolution: Structural reforms at the second step Research Articles Strategic Analysis of Community Participation in Primary Health Care in Iran and Presentation of Promotion Strategies Using Internal and External Environment Assessment Techniques Research Articles Utilization of Healthcare Services & Healthcare Expenditure Patterns in the Rural Households of Nepal

Horizontal inequity in self-reported morbidity and untreated morbidity in India: Evidence from National Sample Survey Data

Background Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap.