Inequalities in health care in Spain : the case of Catalonia
Equity is a major policy objective in the Spanish health care system, both at national and regional levels. Partly in consequence, there have been many studies of inequalities in health and health care in Spain. However, given the decentralisation process of health care such research efforts should better be addressed at the appropriate level of policy-making, which in the case of Spain are largely the regions enjoying full competencies such as Catalonia. The objectives of this research were to study the extent to which the health system in Catalonia delivered services according to need criteria and, further, to find patterns of inequality in the utilisation of health care services by types of care. The 1994 Catalan Health Survey (15,000 interviews) has been used to assess whether the goal of equal treatment for equal need has been achieved, taking equal treatment as equal expenditure, and equal need as equal ill-health and self-reported morbidity. Concentration curves, Le Grand and Collins and Klein indices of inequality have been used together with logistic regressions models of the determinants of utilisation. The results suggest that, to a large extent Catalonia has achieved equity in the provision of health care overall. Despite this, different patterns of utilisation of services according to primary care, outpatient care and inpatient care have emerged. Utilisation of primary care is marked, by infants and old age groups, by women, and low income groups and education levels. Out-patient care utilisation is dominated by intermediate age groups, particularly among women, and high income groups and education levels. Finally, inpatient care, representing almost half of the health care budget, has not shown income nor education as significant variables, pointing to medical need as the variable that could best explain utilisation. In all three patterns described it is need, in terms of acute sickness, limiting chronic illness and self-perceived health status. which stand out as significant predictors of utilisation. Among many other issues, this research has disclosed at a regional level of analysis that overall equitable systems may co-exist with inequalities in more specific services and types of care. Policy implications derived from this study aim at better targeting the causes of inequality and to foster the need of continuing research along these and other lines, both better to understand the dimensions of inequalities and to monitor the effectiveness of policy responses.