Equity of access to health care services:: Theory and evidence from the UK
Introduction
The concept of equity of access to health care is a central objective of many health care systems and has been an important buttress of the UK National Health Service since its inception in 1948. Yet the concept nevertheless remains somewhat elusive, and research evidence on the nature and magnitude of inequities, although extensive, proves patchy and difficult to interpret. As a result, it is often not straightforward to decide whether inequities in access pose a significant policy problem and if so, how they might best be tackled. Many governments have made commitments to tackle inequities in access but making this policy operational will be difficult without a clear picture of what is currently known about equity of access to health care services. The purpose of this paper is therefore to set out a theoretical framework for assessing studies relating to equity of access to health care. The framework is then used to assess recent research evidence on equity of access amongst socio-economic groups in UK. Although concentrating on the UK experience as an illustration, the paper uses a general analytic framework which is of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings (Whitehead, 1992).
An extensive theoretical literature on the various notions of equity relating to health and health care exists (Williams & Cookson, 2000). This paper focuses on equity in the form of equal access to health care for people in equal need. It is important to recognise that this is not necessarily the same thing as equality of treatment (for equal need) or equality of health outcome (Mooney, Hall, Donaldson & Gerard, 1991; Culyer, Doorslaer & Wagstaff, 1992; Mooney, Hall, Donaldson & Gerard, 1992). Equity of access is purely a supply side consideration, in the sense that equal services are made available to patients in equal need. In contrast, variations in treatment arise from the interaction between supply and demand which depend on the preferences, perceptions and prejudices of both patient and health care provider. Variations in health outcome depend on many factors in addition to the receipt of health care.
The concept of equity of access we address is therefore, at least in principle, an objective notion which is independent of ethical judgement. We do not consider here the issue of vertical equity (does access vary appropriately in accordance with variations in need?). The issue of vertical equity is less commonly addressed and gives rise to profound issues of ethical judgement, related for example, to the extent to which an element of efficiency should be sacrificed in pursuit of a vertical equity goal.
In practice, almost all empirical studies of equity of access, at least in the first instance, consider variations in treatment rather than variations in access and exhibit little or no consideration of any theoretical framework for the research. In many circumstances this compromises the usefulness of the results, and we believe that it is imperative that researchers in this area think harder about the theoretical underpinnings to their work. Section 2 therefore outlines a tentative framework which we found helpful for examining the results of empirical work.
We apply this framework in Section 3 to examine the extent to which the existing literature offers useful evidence relating to inequities of access experienced by different socio-economic groups in five health care sectors.
It is important to note that we are concerned only with systematic inequities suffered by identifiable groups of citizens, defined by social group. Other possible groupings of citizens (such as age, sex, ethnic group, geographical area) have been considered elsewhere (Goddard & Smith, 1998). Moreover, in addition to any systematic effects, substantial “random” inequity may also arise in any health care system because of factors such as variations in medical practice and historical accident. We do not consider inequities arising from such sources unless they systematically affect social groups differentially. Section 4 offers some conclusions arising from this study, and summarises the implications for policy and for future research in this area.
Section snippets
Towards a theoretical framework
The horizontal principle of equity addressed by this paper is the extent to which there exists equal access for equal need. This begs the questions: what is need? what is access? These questions lead us to consider concepts related to the quality of health care and the utilisation of health care. This section seeks to draw these concepts together into a unified theoretical framework. It draws on a literature which goes back to a small number of seminal contributions (Aday & Andersen, 1981;
A review of the empirical literature on the NHS
In this section we first summarise the research evidence on equity of access in relation to socio-economic group, bearing in mind the methodological issues described earlier. We then interpret the results in the light of the model, discussing the relevance of the parameters to the research findings.
Conclusions
Our survey revealed a wealth of recent research relating to equity of access amongst socio-economic groups. However, in the light of the theoretical framework set out in Section 2, it has also highlighted numerous methodological problems that inhibit the production of useable research evidence and has illustrated the difficulty of identifying the potential causes of inequity which may be amenable to policy initiatives. In particular, research focuses largely on variations in utilisation —
Acknowledgements
This work was in part funded by the UK Department of Health, through its research programme at the Centre for Health Economics. It also formed part of the Economic and Social Research Council health variations programme, project L128251050. Thanks are due to the journal's referees, whose comments proved immensely helpful when revising the paper and to Helen Parkinson for excellent secretarial assistance.
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