Ignacio Abásolo

Equity in utilization of and access to public-sector GPs in Spain

A framework is outlined for testing empirically whether utilization of and access to public-sector GPs in Spain in 1993 was consistent with the twin criteria of horizontal and vertical equity, where these are defined with respect to need. Vertical (horizontal) inequities in access are assessed by including interactions between determinants of access and need (non-need) variables in a utilization equation. Findings are consistent with the principle of vertical equity in the utilization of GP services, but are not consistent with horizontal equity. Travel time for individuals who did not visit their GP are imputed but it is not a significant determinant of utilization or access. However, caution is expressed when interpreting these findings, as they may be contaminated by biases arising from unit non-response, measurement error and simultaneity. The paper concludes with a set of recommendations for future studies.

Equity in specialist waiting times by socioeconomic groups: evidence from Spain

In countries with publicly financed health care systems, waiting time—rather than price—is the rationing mechanism for access to health care services. The normative statement underlying such a rationing device is that patients should wait according to need and irrespective of socioeconomic status or other non-need characteristics. The aim of this paper is to test empirically that waiting times for publicly funded specialist care do not depend on patients’ socioeconomic status. Waiting times for specialist care can vary according to the type of medical specialty, type of consultation (review or diagnosis) and the region where patients’ reside. In order to take into account such variability, we use Bayesian random parameter models to explain waiting times for specialist care in terms of need and non-need variables. We find that individuals with lower education and income levels wait significantly more time than their counterparts.

Understanding preference for egalitarian policies in health: are age and sex determinants?

This article presents an empirical assessment of the relevance of different factors when understanding preferences for outcome-egalitarian policies in health, in particular respondent age and sex. A representative sample of the Spanish population was interviewed (n = 1209). After being informed that those from the higher social class have longer life expectancy at birth than those from the lower social class, respondents were required to choose between two programmes: to increase life expectancy of the two groups by the same amount (the ‘distribution neutral’ programme); and to target the lowest social class group, thereby reducing current health inequalities (the ‘targeting’ or ‘egalitarian’ programme). Two variants, one with and the other without visual aid, are used. Majority (69%) of respondents support targeting. An effect of age was observed, where younger and older individuals are less likely to target the egalitarian policy than those in middle age. However, individuals sex was not associated with targeting behaviour. In addition, right-wingers or/and individuals living in a high per capita income region are less likely to target. On the other hand, neither individuals education nor household income has a significant impact on targeting. Finally, regarding the two variants, results suggest that the visual aid is associated with less targeting.

Health inequalities by socioeconomic characteristics in Spain: the economic crisis effect

BackgroundAn economic crisis can widen health inequalities between individuals. The aim of this paper is to explore differences in the effect of socioeconomic characteristics on Spaniards’ self-assessed health status, depending on the Spanish economic situation.MethodsData from the 2006–2007 and 2011–2012 National Health Surveys were used and binary logit and probit models were estimated to approximate the effects of socioeconomic characteristics on the likelihood to report good health.ResultsThe difference between high and low education levels leads to differences in the likelihood to report good health of 16.00–16.25 and 18.15–18.22 percentage points in 2006–07 and 2011–12, respectively. In these two periods, the difference between employees and unemployed is 5.24–5.40 and 4.60–4.90 percentage points, respectively. Additionally, the difference between people who live in households with better socioeconomic conditions and those who are in worse situation reaches 5.37–5.46 and 3.63–3.74 percentage points for the same periods, respectively.ConclusionsThe magnitude of the contribution of socioeconomic characteristics to health inequalities changes with the economic cycle; but this effect is different depending on the socioeconomic characteristics indicator that is being measured. In recessive periods, health inequalities due to education level increase, but those linked to individual professional status and household living conditions are attenuated. When the joint effects of individuals’ characteristics are considered, the economic crisis brings about a slight increase in the inequalities in the probability of reporting good health between the two extreme profiles of individuals. The design of public policies aimed at preventing any worsening of health inequalities during recession periods should take into account these differential effects of socioeconomic characteristics indicators on health inequalities.

Egalitarianism and altruism in health: some evidence of their relationship.

BackgroundEgalitarianism and altruism are two ways in which people may have attitudes that go beyond the narrowly defined selfish preferences. The theoretical constructs of egalitarianism and altruism are different from each other, yet there may be connections between the two. This paper explores the empirical relationship between egalitarianism and altruism, in the context of health.MethodsWe define altruism as individual behaviour that aims to benefit another individual in need; and egalitarianism as a characteristic of a social welfare function, or a meta-level preference. Furthermore, we specify a model that explains the propensity of an individual to be egalitarian in terms of altruism and other background characteristics. Individuals who prefer a hypothetical policy that reduces socioeconomic inequalities in health outcomes over another that does not are regarded ‘egalitarian’ in the health domain. On the other hand, ‘altruism’ in the health context is captured by whether or not the same respondents are (or have been) regular blood donors, provided they are medically able to donate. Probit models are specified to estimate the relationship between egalitarianism and altruism, thus defined. A representative sample of the Spanish population was interviewed for the purpose (n = 417 valid cases).ResultsOverall, 75% of respondents are found to be egalitarians, whilst 35% are found to be altruists. We find that, once controlled for background characteristics, there is a statistically significant empirical relationship between egalitarianism and altruism in the health context. On average, the probability of an altruist individual supporting egalitarianism is 10% higher than for a non-altruist person. Regarding the other control variables, those living in high per capita income regions have a lower propensity and those who are politically left wing have a higher propensity to be an egalitarian. We do not find evidence of a relationship between egalitarianism and age, socioeconomic status or religious practices.ConclusionAltruist individuals have a higher probability to be egalitarians than would be expected from their observed background characteristics.

Utilización y tiempos de espera: dos vertientes inseparables del análisis de la equidad en el acceso al sistema sanitario público

El objetivo de esta investigacion consiste en analizar si existe equidad en el acceso a los servicios sanitarios publicos por niveles socioeconomicos. Se analiza conjuntamente la probabilidad de utilizar los servicios sanitarios y los tiempos de espera hasta ser atendidos, corrigiendose asi el sesgo de seleccion que se derivaria de su estudio separado, tal y como se evidencia en esta investigacion. Se propone una aproximacion bayesiana y se hace uso de la informacion a nivel individual sobre la utilizacion sanitaria, tiempos de espera, nivel socioeconomico, necesidad sanitaria y otras variables sociodemograficas contenidas en la En-cuesta nacional de salud (2006). Los resultados muestran que hay inequidad en el acceso a los servicios especializados y hospitalarios (tanto en utilizacion como en tiempos de espera) que perjudica a los niveles socioeconomicos inferiores. En los servicios de medicina general, si bien la utilizacion beneficia relativa-mente mas a los grupos de menor nivel socioeconomico, los tiempos de espera perjudican a los de menor nivel educativo.

Real waiting times for surgery: proposal for an improved system for their management

OBJECTIVES In Spain, official information on waiting times for surgery is based on the interval between the indication for surgery and its performance. We aimed to estimate total waiting times for surgical procedures, including outpatient visits and diagnostic tests prior to surgery. In addition, we propose an alternative system to manage total waiting times that reduces variability and maximum waiting times without increasing the use of health care resources. This system is illustrated by three surgical procedures: cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair. METHODS Using data from two Autonomous Communities, we adjusted, through simulation, a theoretical distribution of the total waiting time assuming independence of the waiting times of each stage of the clinical procedure. We show an alternative system in which the waiting time for the second consultation is established according to the time previously waited for the first consultation. RESULTS Average total waiting times for cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair were 331, 355 and 137 days, respectively (official data are 83, 68 and 73 days, respectively). Using different negative correlations between waiting times for subsequent consultations would reduce maximum waiting times by between 2% and 15% and substantially reduce heterogeneity among patients, without generating higher resource use. CONCLUSION Total waiting times are between two and five times higher than those officially published. The relationship between the waiting times at each stage of the medical procedure may be used to decrease variability and maximum waiting times.

The effect of policies regulating tobacco consumption on smoking initiation and cessation in Spain: is it equal across socioeconomic groups?

BackgroundIn Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels.MethodsMicro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals’ tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on “time to event analysis”. Cox’s proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults.ResultsInitiation rates among young people went from 25% (95% confidence interval (CI), 23–27) to 19% (95% CI, 17–21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11–13) to 20% (95% CI, 19–21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p = 0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law’s implementation.ConclusionLaw 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes.

Financial crisis and income-related inequalities in the universal provision of a public service: the case of healthcare in Spain

BackgroundThe objective of this paper is to analyse whether the recent recession has altered health care utilisation patterns of different income groups in Spain.MethodsBased on information concerning individuals ‘income and health care use, along with health need indicators and demographic characteristics (provided by the Spanish National Health Surveys from 2006/07 and 2011/12), econometric models are estimated in two parts (mixed logistic regressions and truncated negative binominal regressions) for each of the public health services studied (family doctor appointments, appointments with specialists, hospitalisations, emergencies and prescription drug use).ResultsThe results show that the principle of universal access to public health provision does not in fact prevent a financial crisis from affecting certain income groups more than others in their utilisation of public health services.ConclusionsSpecifically, in relative terms the recession has been more detrimental to low-income groups in the cases of specialist appointments and hospitalisations, whereas it has worked to their advantage in the cases of emergency services and family doctor appointments.