Horizontal Inequity in Access to Healthcare Services and Educational Level in Spain

The aim of this study is to measure horizontal equity in the use of healthcare services in Spain, proposing two methodological innovations. First by defending it as equality of access for equal need, irrespective of educational level, unlike the prevailing methodological approach to horizontal equity which relates it to income. Second, by estimating it by means of the slope index of the inequality of characteristics, analagous to the inequity index proposed by Kakwani, Wagstaff and van Doorslaer (1997; HIWV) but presenting some methodological advantages, the greater robustness of the data available on educational level than of those on income, and the possibility of isolating the net effect of the educational level on the use of healthcare by controlling for other variables. The methodology is designed in three parts: (1) estimation of the relationship between the educational level and the use of healthcare services by means of a model of the likelihood of demand for healthcare services, commonly used in the literature; (2) estimation of the relationship between educational level and health by approximating a production function of individuals' health according to their personal characteristics and other factors conditioning health; and (3) estimation of the slope index of inequality as a measure of horizontal inequity, using educational level instead of income as the criterion for ranking individuals. The data base used was a sample of 55,598 observations from the Survey of disabilities, handicaps and state of health of 1999, carried out in Spain. No significant statistical association was found between educational level and use of healthcare services. On the other hand, the relationship between educational level and health, with the three proxy variables used (perception of health, days of limitation and number of chronic illnesses) shows a positive correlation, i.e. an increase in educational level is associated with a greater probability of enjoying better health. Horizontal inequity, measured by the proposed slope index of inequality, gives a range of statistically significant values between 13.91% and 9.40%, depending on cases, i.e. the significant inverse relationship between state of health and educational level is not reflected proportionally in healthcare use, implying that, with greater need, the access of individuals with a lower educational level to public healthcare services is the same as for the rest. These results suggest that the educational level may be a variable to consider when characterizing the healthcare needs of a population in a defined geographical area, at least from the normative characterization of horizontal equity proposedEducation and health; Healthcare needs; Horizontal Inequity; Logistic regression ; Ordinal regression; Regional funding

Horizontal inequity in access to healthcare services and educational level in Spain

The aim of this study is to measure horizontal equity in the use of healthcare services in Spain, proposing two methodological innovations. First by defending it as equality of access for equal need, irrespective of educational level, unlike the prevailing methodological approach to horizontal equity which relates it to income. Second, by estimating it by means of the slope index of the inequality of characteristics, analagous to the inequity index proposed by Kakwani, Wagstaff and van Doorslaer (1997; HIWV) but presenting some methodological advantages, the greater robustness of the data available on educational level than of those on income, and the possibility of isolating the net effect of the educational level on the use of healthcare by controlling for other variables. The methodology is designed in three parts: (1) estimation of the relationship between the educational level and the use of healthcare services by means of a model of the likelihood of demand for healthcare services, commonly used in the literature; (2) estimation of the relationship between educational level and health by approximating a production function of individuals' health according to their personal characteristics and other factors conditioning health; and (3) estimation of the slope index of inequality as a measure of horizontal inequity, using educational level instead of income as the criterion for ranking individuals. The data base used was a sample of 55,598 observations from the Survey of disabilities, handicaps and state of health of 1999, carried out in Spain. No significant statistical association was found between educational level and use of healthcare services. On the other hand, the relationship between educational level and health, with the three proxy variables used (perception of health, days of limitation and number of chronic illnesses) shows a positive correlation, i.e. an increase in educational level is associated with a greater probability of enjoying better health. Horizontal inequity, measured by the proposed slope index of inequality, gives a range of statistically significant values between 13.91% and 9.40%, depending on cases, i.e. the significant inverse relationship between state of health and educational level is not reflected proportionally in healthcare use, implying that, with greater need, the access of individuals with a lower educational level to public healthcare services is the same as for the rest. These results suggest that the educational level may be a variable to consider when characterizing the healthcare needs of a population in a defined geographical area, at least from the normative characterization of horizontal equity proposed

Andalusians´s economic vote: A dynamic approach via municipalities

Agradecemos a la Fundación Pública Andaluza Centro de Estudios Andaluces su financiación para esta línea de investigación (PRY 080/10).Aunque está muy extendido que muchos ciudadanos votan o no al partido en el gobierno en función de criterios económicos, lo cierto es que, en muchas ocasiones, los investigadores no encuentran una medida clara y amplia del denominado voto económico. Parte del problema puede estar en la metodología utilizada. Por este motivo, proponemos la utilización de datos agregados (a un nivel municipal) y de estimadores econométricos dinámicos que puedan recoger la influencia de la tendencia temporal, y no sólo de los datos económicos coyunturales, en la obtención de resultados electorales. Nuestros resultados constatan la existencia de voto económico en Andalucía en sus dos versiones, retrospectivo y prospectivo.Although it is widespread that many citizens vote or not for the party in government based on economic criteria, the truth is that, on many occasions, researchers do not find a clear and broad measure of the so-called economic vote. Part of the problem may be in the methodology used. For this reason, we propose the use of aggregate data (at a municipal level) and dynamic econometric estimators that can collect the influence of the temporal trend, and not only of the current economic data, in obtaining electoral results. Our results confirm the existence of economic voting in Andalusia in its two versions, retrospective and prospective.Junta de Andalucía PRY 080/1

Financing agreement for the spanish regions and regional inequality by tax collection (1986-2007)

La reforma del acuerdo de financiación de las CCAA españolas de 2009, en vigor desde enero de 2010, profundiza en la corresponsabilidad fiscal, ampliando la capacidad normativa de algunos impuestos y la participación en las cuotas territorializadas del Impuesto sobre la Renta de las Personas Físicas (IRPF), el Impuesto sobre el Valor añadido (IVA) y algunos Impuestos Especiales (IIEE). Según el mencionado acuerdo, el porcentaje descentralizado de la recaudación por IVA y por impuestos especiales se distribuye entre las Comunidades Autónomas (CCAA) en función de índices de consumo territorializado mientras que la recaudación por IRPF se distribuye en función de la cuota integra declarada por los sujetos pasivos residentes en cada Comunidad Autónoma (CA). Este artículo pretende mostrar evidencia sobre la traslación del ingreso tributario entre regiones en los tres tributos debida, en parte, a que el ingreso se realiza en la CA del domicilio fiscal del sujeto pasivo independientemente de donde se produzca el hecho imponible. Las conclusiones justifican la distribución del acuerdo por IVA e IIEE en función de criterios basados en el consumo territorializado, pero no así la distribución del tramo autonómico por IRPF que se distribuye en función del ingreso de los residentes.Since January, 2010, there's a new public financing agreement for the Spanish regions. This is based on the fiscal responsibility, expanding the regulatory capacity of some taxes and increasing the territorialized participation in the Income Tax (PIT), values added tax (VAT) and some special taxes (IISS). According to that agreement, the revenues decentralized of VAT and excise duties are distributed among the Autonomous Communities (CCAA) in terms of consumption rates, while the personal income tax revenue is distributed according to the amount declared by the persons living in each Autonomous Community (CA). This article treat on transfer of tax revenue between regions in the three taxes, due primarily that the tax pay is made in the CA of taxpayer's residence regardless of where the taxable event occurs. The findings justify the income distribution for IISS and VAT based on territorialized consumption, but not the regional distribution of personal income tax which is distributed according to revenue of residents

La distribución territorial de los recursos sanitarios: algunas propuestas

This paper summarises some of the territorial inequalities in the delivery of health care services, and consequently inequalities in population's health, for the Spanish Comunidades Autonomas. One of the causes for these differences comes from the criteria for allocating resources that has increasingly departed from the pure capitative system. In particular, the new health care financing model (2002) has changed the traditional definition of need, incorporating two new adjusting factors to the previous criterion: population older than 65 years old and insularity. An analysis of convergence in health status, proxied as life expectancy at birth and infant mortality rates, shows that health inequalities exist, and that these inequalities are increasing in recent years among Spanish provinces. On the other hand, since the area of residence of an individual has received little attention, this article explores to what extent the territory determines a different pattern of utilisation of the public health care services. The policy implication of these findings is that care should be taken in the selection of adjusting factors to allocate health care resources. This does not seem to be the case for Spain, where the introduction of a higher weight attached to the variable population older than 65 years old has had little justification in the current health care financing model.Este trabajo resume algunas de las desigualdades territoriales en la oferta de servicios sanitarios y, en consecuencia, de las desigualdades en salud, en el caso de las Comunidades Autónomas españolas. Una de las causas de estas diferencias procede de los criterios de asignación de recursos, que cada vez se han ido distanciando del criterio capitativo simple. En concreto, el nuevo modelo de financiación territorial de la sanidad (2002) ha alterado la definición tradicional de necesidad, incorporando dos variables de ajuste al anterior criterio: población mayor de 65 años e insularidad. Un análisis de la convergencia en salud, medida en términos de esperanza de vida al nacer y ratios de mortalidad infantil, demuestra que no sólo no existe convergencia en salud, sino que, durante los últimos años se están abriendo divergencias en salud entre las provincias españolas. Por otro lado, una variable de control poco analizada ha sido la zona geográfica de residencia, de forma que la cuestión que se plantea es analizar en qué medida la residencia determina un distinto uso de los servicios sanitarios públicos. La implicación fundamental, a un nivel de política sanitaria territorial, es la gran cautela que debería seguirse a la hora de realizar ajustes ad hoc en el criterio poblacional para la distribución de recursos sanitarios. Concretamente, en el caso español, se puede recordar la escasa justificación de la actual fórmula de definición de necesidad sanitaria, particularmente, la incorporación de la población mayor de 65 años con mayor valor de ponderación

La distribución territorial de los recursos sanitarios: Algunas propuestas

RESUMEN Este trabajo resume algunas de las desigualdades territoriales en la oferta de servicios sanitarios y, en consecuencia, de las desigualdades en salud, en el caso de las Comunidades Autónomas españolas. Una de las causas de estas diferencias procede de los criterios de asignación de recursos, que cada vez se han ido distanciando del criterio capitativo simple. En concreto, el nuevo modelo de financiación territorial de la sanidad (2002) ha alterado la definición tradicional de necesidad, incorporando dos variables de ajuste al anterior criterio: población mayor de 65 años e insularidad. Un análisis de la convergencia en salud, medida en términos de esperanza de vida al nacer y ratios de mortalidad infantil, demuestra que no sólo no existe convergencia en salud, sino que, durante los últimos años se están abriendo divergencias en salud entre las provincias españolas. Por otro lado, una variable de control poco analizada ha sido la zona geográfica de residencia, de forma que la cuestión que se plantea es analizar en qué medida la residencia determina un distinto uso de los servicios sanitarios públicos. La implicación fundamental, a un nivel de política sanitaria territorial, es la gran cautela que debería seguirse a la hora de realizar ajustes ad hoc en el criterio poblacional para la distribución de recursos sanitarios. Concretamente, en el caso español, se puede recordar la escasa justificación de la actual fórmula de definición de necesidad sanitaria, particularmente, la incorporación de la población mayor de 65 años con mayor valor de ponderación. ABSTRACT This paper summarises some of the territorial inequalities in the delivery of health care services, and consequently inequalities in population’s health, for the Spanish Comunidades Autonomas. One of the causes for these differences comes from the criteria for allocating resources that has increasingly departed from the pure capitative system. In particular, the new health care financing model (2002) has changed the traditional definition of need, incorporating two new adjusting factors to the previous criterion: population older than 65 years old and insularity. An analysis of convergence in health status, proxied as life expectancy at birth and infant mortality rates, shows that health inequalities exist, and that these inequalities are increasing in recent years among Spanish provinces. On the other hand, since the area of residence of an individual has received little attention, this article explores to what extent the territory determines a different pattern of utilisation of the public health care services. The policy implication of these findings is that care should be taken in the selection of adjusting factors to allocate health care resources. This does not seem to be the case for Spain, where the introduction of a higher weight attached to the variable population older than 65 years old has had little justification in the current health care financing model.Financiación autonómica, Salud pública, Oferta sanitaria, Convergencia, Necesidad sanitaria

Sombras y sombras en la aplicación de la ley de dependencia

El objetivo del presente trabajo es realizar un breve repaso a los aspectos más controvertidos de la Ley 39/2006, de Promoción de la Autonomía y Atención a las Personas en Situación de Dependencia, que han protagonizado en los últimos años fuertes debates entre el Estado y las comunidades autónomas. Los problemas de financiación surgidos tras una mala planificación inicial, el declive en las aportaciones de la Administración General del Estado en los últimos años, incluyendo la supresión del nivel acordado, y una baja recaudación del usuario mediante copago, han colmado de esfuerzo económico a las comunidades autónomas por mantener dicha política social, en un ambiente gobernado por la falta de transparencia del sistema. Por otro lado, las reformas normativas de mediados de 2012, con la finalidad de aliviar los presupuestos estatales y autonómicos, han supuesto un claro retroceso en el espíritu de la ley y una pérdida de bienestar de los dependientes y sus familias. Todas estas premisas han contribuido a un panorama muy heterogéneo de aplicación territorial de la norma, en el que se observan claras diferencias en las listas de espera, abuso de concesión de prestaciones económicas por parte de algunas regiones y disparidades en el número de solicitudes de acceso a las prestaciones y los servicios