Dolores Jiménez-Rubio

Inequalities in the use of health services between immigrants and the native population in Spain: what is driving the differences?

In Spain, a growing body of literature has drawn attention to analysing the differences in health and health resource utilisation of immigrants relative to the autochthonous population. The results of these studies generally find substantial variations in health-related patterns between both population groups. In this study, we use the Oaxaca-Blinder decomposition technique to explore to what extent disparities in the probability of using medical care use can be attributed to differences in the determinants of use due to, e.g. a different demographic structure of the immigrant collective, rather than to a different effect of health care use determinants by nationality, holding all other factors equal. Our findings show that unexplained factors associated to immigrant status determine to a great extent disparities in the probability of using hospital, specialist and emergency services of immigrants relative to Spaniards, while individual characteristics, in particular self-reported health and chronic conditions, are much more important in explaining the differences in the probability of using general practitioner services between immigrants and Spaniards.

The impact of fiscal decentralization on infant mortality rates: evidence from OECD countries.

This study re-examines the hypothesis that shifts towards more decentralization would be accompanied by improvements in population health on a panel of 20 OECD countries over a thirty year period (1970-2001). Decentralization is proxied using a conventional indicator of revenue decentralization and a new measure of fiscal decentralization that reflects better than previous measures the existence of autonomy in the decision-making authority of lower tiers of government, a crucial issue in the decentralization process. The results show a considerable and positive effect of fiscal decentralization on infant mortality only if a substantial degree of autonomy in the sources of revenue is devolved to local governments. The proportion of health care expenditure on GDP and, in particular, education, were found to have a larger contribution to the reduction of infant mortality in the sample of OECD countries analysed over the period of study.

Income inequalities in unhealthy life styles in England and Spain.

Health inequalities in developed societies are persistent. Arguably, the rising inequalities in unhealthy lifestyles might underpin these inequality patterns, yet supportive empirical evidence is scarce. We examine the patterns of inequality in unhealthy lifestyles in England and Spain, two countries that exhibit rising obesity levels with a high prevalence of smoking and alcohol use. This study is unique in that it draws from health survey data spanning over a period in which major contextual and policy changes have taken place. We document persistent income-related inequalities in obesity and smoking; both unhealthy lifestyles appear to be disproportionately concentrated among the relatively poor in recent decades. In contrast, alcohol use appears to be concentrated among richer individuals in both periods and countries examined.

Inequity in long-term care use and unmet need: Two sides of the same coin

We investigate the determinants of several LTC services and unmet need using data from a representative sample of the non-institutionalised disabled population in Spain in 2008. We measure the level of horizontal inequity and compare results using self-reported versus a more objective indicator of unmet needs. Evidence suggests that after controlling for a wide set of need variables, there is not an equitable distribution of use and unmet need of LTC services in Spain; formal services are concentrated among the better-off, while intensive informal care is concentrated among the worst-off. The distribution of unmet needs for LTC services depends on the service considered and on whether we focus on subjective or objective measures. In 2008, only individuals with the highest dependency level had universal coverage. Our results show that inequities in most LTC services and unmet needs among this group either remain or even increase for formal services.

Social determinants of health: an economic perspective

The World Health Organization has recently received the findings of its Commission on the Social Determinants of Health. The Commissions report offers a remarkable summary of the evidence, and makes a passionate case for government action to address the social determinants of health, especially as they relate to health inequity. This paper summarizes the ways in which economic analysis could strengthen policy under three headings: examining the causal impact of the determinants of health and of associated policies; prioritizing actions; and determining the role of government in influencing behaviour.

Explaining the demand for pharmaceuticals in Spain: are there differences in drug consumption between foreigners and the Spanish population?

OBJECTIVE The aim of this study is to examine the factors driving the demand for drugs in Spain, focusing on the existence of disparities in pharmaceutical consumption between the Spanish and the foreign population. METHODS Our analysis is based on a multilevel multinomial probit model that compares three consumption options (no consumption, prescribed consumption and self-medicated consumption) on the five most consumed drugs in Spain. Data is taken from the adult sample of the 2006 Spanish National Health Survey, including 29,478 individuals over 15 years old. RESULTS Overall, the findings show a lower consumption of medicines by some immigrants categories relative to Spaniards. In addition, the results indicate that the consumption of medicines is mainly related to variables associated to the specific cost sharing structure in Spain, such as health limitations and retirement status. Other variables found to explain the demand for drugs were: private health insurance, age, sex, alcohol and cigarette consumption and drug class. CONCLUSION Further understanding of the reasons for the observed differences in drug consumption on the basis of country of birth would allow the health system to design more effective health policies aimed at ensuring equality of access to health resources to all population groups.

Explaining divorce rate determinants: new evidence from Spain

ABSTRACT This article examines the main determinants of divorce rates in Spain for the period 1995 to 2010. According to the results, the so-called Express Divorce Law (passed in 2005) seems to be positively associated with divorce rates in the short term. Income level and growth, female employment rate, and the proportion of foreign population are also positively related to divorce rates. However, as expected, the percentage of conservative vote seems to have a negative impact.

Fiscal Decentralization of Health Services

This chapter presents the main economic arguments for and against devolution in the allocation of public expenses and revenues to subnational governments. It then explores the implications that follow from fiscal decentralization to the health sector in particular. The most common indicators of fiscal decentralization used in the research literature are discussed, together with their benefits and limitations. The chapter concludes by providing a summary of the current empirical evidence on the relationship between different measures of fiscal decentralization and various health outcome indicators.

Decentralization of health care systems and health outcomes: Evidence from a natural experiment

While many countries worldwide are shifting responsibilities for their health systems to local levels of government, there is to date insufficient evidence about the potential impact of these policy reforms. We estimate the impact of decentralization of the health services on infant and neonatal mortality using a natural experiment: the devolution of health care decision making powers to Spanish regions. The devolution was implemented gradually and asymmetrically over a twenty-year period (1981-2002). The order in which the regions were decentralized was driven by political factors and hence can be considered exogenous to health outcomes. In addition, we exploit the dynamic effect of decentralization of health services and allow for heterogeneous effects by the two main types of decentralization implemented across regions: full decentralization (political and fiscal powers) versus political decentralization only. Our difference in differences results based on a panel dataset for the 50 Spanish provinces over the period 1980 to 2010 show that the lasting benefit of decentralization accrues only to regions which enjoy almost full fiscal and political powers and which are also among the richest regions.