Equity in the utilization of public health care services by regions in Spain: a multinivel analysis.

The aim of this paper is to analyse if there is horizontal equity in the utilisation of public health care services by región (comunidad autónoma) of residence in Spain. Data from the 2006 National Health Survey were considered to undertake a multilevel analysis, using a binary logistic function for each of the public health care services analysed (general practitioner –GP- visits, specialist visits and hospitalisations). Health care need and other socioeconomic and demographic characteristics were controlled at individual level. It can be concluded that, although there is no evidence of territorial inequity in hospitalisations, there is territorial inequity in the case of GP and also of specialist visits, which can not be explained by regional differences in the availability of resources at both health care levelsEquitiy, public health care utilization, multinivel analysis, region.

The effect of a change in co-payment on prescription drug demand in a National Health System: The case of 15 drug families by price elasticity of demand.

OBJECTIVES: To test the heterogeneity of the effect of a change in pharmaceutical cost-sharing by therapeutic groups in a Spanish region. METHODS: Data: random sample (provided by the Canary Islands Health Service) of 40,471 people covered by the Spanish National Health System (SNHS) in the Canary Islands. The database includes individualised monthly-dispensed medications (prescribed by the SNHS) from one year before (August 2011) to one year after (June 2013) the Royal Decree Law 16/2012 (RDL 16/2012). Sample: two intervention groups (low-income pensioners and middle-income working population) and one control group (low-income working population). Empirical model: quasi-experimental difference-in-differences design to study the change in consumption (measured in number of monthly Defined Daily Dose (DDDs) per individual) among 13 therapeutic groups. The policy break indicator (three-level categorical variable) tested the existence of stockpiling between the reform's announcement and its implementation. We ran 16 linear regression models (general, by therapeutic groups and by comorbidities) that considered whether the exclusion of some drugs from public provision impacted on consumption more than the co-payment increase. RESULTS: General: Reduction (-13.04) in consumption after the reform's implementation, which was fully compensated by a previous increase (16.60 i.e., stockpiling) among low-income pensioners. The middle-income working population maintained its trend of increasing consumption. Therapeutic groups: Reductions in consumption after the reform's implementation among low-income pensioners in 7 of the 13 groups, which were fully compensated for by a previous increase (i.e., stockpiling) in 4 groups and partially compensated for in the remaining 3. The analysis without the excluded medicines provided fewer negative coefficients. Comorbidities: Reduction in consumption that was only slightly compensated for by a previous increase (i.e., stockpiling). CONCLUSIONS: The negative impact of cost-sharing produced, among low-income pensioners, a risk of loss of adherence to treatments, which could deteriorate the health status of individuals, especially among pensioners within the most inelastic therapeutic groups (associated with chronic diseases) and patients with comorbidities (also, associated with chronic diseases). Notwithstanding the above, this risk was more related to the exclusion of some drugs from provision than to the cost-sharing increase

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

Background The objective of this paper is to analyse whether the recent recession has altered health care utilisation patterns of different income groups in Spain. Methods Based 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). Results The 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. Conclusions Specifically, 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

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

Introduction In 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. Material and Methods Micro-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. Results Initiation 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. Conclusions Law 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

Is more health always better? Exploring public preferences that violate monotonicity

Abásolo and Tsuchiya (2004a) report on an empirical study to elicit public preferences regarding the efficiency-equality trade-off in health, where the majority of respondents violated monotonicity. The procedure used has been subject to criticisms regarding potential biases in the results. The aim of this paper is to analyse whether violation of monotonicity remains when a revised questionnaire is used. We test: whether monotonicity is violated when we allow for inequality neutral preferences and also if we allow for preferences that would reject any option which gives no health gain to one group; whether those who violate monotonicity actually have non-monotonic or Rawlsian preferences; whether the titration sequence of the original questionnaire may have biased the results; whether monotonicity is violated when an alternative question is administered. Finally, we also test for symmetry of preferences. The results confirm the evidence of the previous study regarding violation of monotonicity.Health related social welfare functions, monotonicity, Rawlsian, equality-efficiency trade-off

La inversión pública en Sanidad

RESUMEN. En este trabajo se analizan las principales características de la inversión pública en sanidad en España. Aunque la inversión pública en España ha crecido de forma considerable en el período 1999-2005, se mantiene por debajo del nivel medio de la UE y de la OCDE. Además, aunque se han reducido en los últimos años, especialmente en el caso de la alta tecnología médica, se mantienen considerables desigualdades en la inversión pública per cápita por comunidades autónomas. La distribución territorial de la inversión pública no puede analizarse al margen de las economías de escala y de la inversión privada (concertada o a través de otras fórmulas de gestión sanitaria pública).ABSTRACT. In this study we examine the main features of public investment in health in Spain. Although public investment in Spain rose considerably in the period 1999-2005, it remains below the average EU and OECD level. n addition, although inequalities have been reduced in recent times, especially in the case of high medical technology, they continue to be considerable in per capita public investment by autonomous communities. Territorial distribution of public investment may not be analysed separately from economies of scale and private investment (either arranged or by way of other public health management formulas)