Equality of Access in Health Care

Sammanfattning: Equality of access may be defined and operationalised in several ways. Paper I, 'Equality of access. Definitions and policy implications', proposes a theoretical outline of possible definitions of equal access, of the policy measures needed to attain equality and of their consequences. The health economic literature proposes two main definitions of equal access. Equal access prevails either when individuals face equal costs of a consultation, or when they have an opportunity to consume the same amount of health care. Paper II, 'Health care utilisation and individual consumption possibilities', analyses the distribution of needs-standardised health care utilisation in relation to individuals' economic circumstances. We find that the degree of measured inequity in Sweden is greater if individuals' consumption possibilities are measured in traditional terms as annual income than as the level of consumption approximated by the size of the dwelling. In an alternative approach we also explore the effect of treating children as one choice of consumption which generates utility, rather than conventionally as costs, and we adjust income and the level of consumption only to the number of adults in the household. Using this approach, the measured degree of inequity is greater. Papers III and IV contain studies on Swedish in-patient care. We propose that in the case of in-patient care, if the actual treatment of a patient depends only on supply side factors such as the current practice in the hospital, the conditions for fulfilling equality of access to hospital resources coincides with those for equal treatment or utilisation. Paper III, 'Variations in the treatment of patients with acute myocardial infarction', finds that higher income increases the risk of death in hospital and decreases resource use and length of stay for patients who die. One explanation is then that income may affect the process before admittance to hospital. Paper IV, 'Are there socio-economic differences in the treatment of emergency or elective patients in the Swedish public health care system?', analyses five well-specified and fairly common diagnoses. We take several different socio-economic variables into account in the analysis such as income, education, unemployment, civil status and the number of children the household. We find that income, education and civil status affect treatment for certain diagnoses, which may be interpreted as indications of socio-economic inequality of treatment in hospital or access to hospital care. In both paper III and IV we find that resource use and length of stay varies considerably between hospitals which may be troublesome not only from an efficiency but also from an equity perspective. Paper V, 'On the exploration of variations in the cost of access to medical care', explores empirically the total cost of access defined as an individual's sum of financial and time costs incurred by a consultation. The time cost is based on an estimation of the individual value of time and the time requirement for a consultation. We also present measures for illustrating the variations in the individually calculated total cost of access among people with different characteristics, e.g. health, income, employment status and region of living.