Three Pillars of Support for Orphan Drug Programs: Individual Valuations, Societal Valuations, and Anonymous Altruism.

OBJECTIVES: To identify and describe potential societal and individual sources of support for orphan drug programs. METHODS: The generalized risk-adjusted cost-effectiveness (GRACE) method shows that acute illness and disability severity increase individuals' willingness to pay (WTP) for health gains. We develop a social welfare function (SWF) that incorporates individuals' own values, combined with politically- or ethically determined weights. We introduce the concept of horizontal equity-that individuals in similar situations should be treated similarly-into the SWF. Finally, we introduce anonymous altruism into individuals' utility functions-the desire to help others, without knowing their identity. RESULTS: Combined with the empirical link between disease severity and rarity, GRACE demonstrates heightened WTP for health gains, leading rational individuals to support orphan drug programs, our first pillar of support. Adding horizontal equity to the SWF further increases societal support for orphan drug programs. Anonymous altruism, focusing most strongly on those in the most-dire circumstances, leads to altruistic support for those with severe disorders. Because innovators' economic incentives lead them to focus on larger markets, anonymous altruistic individuals to specifically support orphan drug programs. The presence of free-rider problems translates this into public program support. CONCLUSIONS: We identify supporting three pillars for orphan drug programs: (1) individuals' desire for treatments to treat rare disease that are often severe and life-threatening; (2) the concept of horizontal equity in our SWF: (3) anonymous altruism, the desire to people, even when unknown, in dire circumstances.

Horizontal and vertical equity and public subsidies for private health insurance in the U.S.

The United States offers two markedly different subsidy structures for private health insurance. When covered through employer-based plans, employees and their dependents benefit from the exclusion from taxable income of the premiums. Individuals without access to employer coverage may obtain subsidies for Marketplace coverage. This paper seeks to understand how the public subsidies embedded in the privately financed portion of the U.S. healthcare system impact the payments families are required to make under both ESI and Marketplace coverage, and the implications for finance equity. Using the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) and Marketplace premium data, we assess horizontal and vertical equity by calculating public subsidies for and expected family spending under each coverage source and using Lorenz curves and Gini and concentration coefficients. Our study pooled the 2018 and 2019 MEPS-HC to achieve a sample size of 10,593 observations. Our simulations showed a marked horizontal inequity for lower-income families with access to employer coverage who cannot obtain Marketplace subsidies. Relative to both the financing of employer coverage and earlier Marketplace tax credits, the more generous Marketplace premium subsidies, first made available in 2021 under the American Rescue Plan Act, substantially increased the vertical equity of Marketplace financing. While Marketplace subsidies have clearly improved equity within the United States, we conclude with a comparison to other OECD countries highlighting the persistence of inequities in the U.S. stemming from its noteworthy reliance on employer-based private health insurance.

Universal health coverage and equal access in Sweden: a century-long perspective on macro-level policy.

BACKGROUND: When today's efforts to achieve universal health coverage are mainly directed towards low-income settings, it is perhaps easy to forget that countries considered to have universal, comprehensive and high-performing health systems have also undergone this journey. In this article, the aim is to provide a century-long perspective to illustrate Sweden's long and ongoing journey towards universal health coverage and equal access to healthcare. METHODS: The focus is on macro-level policy. A document analysis is divided into three broad eras (1919-1955; 1955-1989; 1989-) and synthesises seven points in time when policies relevant to overarching goals and regulation of universal health coverage and equal access were proposed and/or implemented. The development is analysed and concluded in relation to two egalitarian goals in the context of health: equality of access and equal treatment for equal need. RESULTS: Over the past century, macro-level policy evolved from the concept of creating access for the neediest and those reliant on wages for their survival to a mandatory insurance with equal right to healthcare for all. However, universal health coverage was not achieved until 1955, and individuals had to rely on their personal financial resources to cover the cost at the time of care utilization until the 1970s. It was not until 1983 that legislation explicitly stated that access to healthcare should be equal for the entire population (horizontal equity), while a vertical equity-principle was not added until 1997. Subsequently, ideas of free choice and privatization have gained significance. For instance, they aim to increase service access, addressing the Swedish health system's Achilles' heel in this regard. However, the principle of equal access for all is now being challenged by the emergence of private health insurance, which offers quicker access to services. It can be concluded that there is no perpetual Swedish healthcare model and various dimensions of access have been the focus of policy discussion. The discussion on access barriers has shifted from financial to personal and organizational ones. Today, Sweden still ranks high in terms of affordability and equity in international comparisons: although not as well as a decade ago. Whether this marks the beginning of a new trend intertwined with a decline in Sweden's welfare 'exceptionalism', or is a temporary decline remains to be assessed in the future.

Inequality in Healthcare Utilization in Italy: How Important Are Barriers to Access?

With the ageing population, equitable access to medical care has proven to be paramount for the effective and efficient management of all diseases. Healthcare access can be hindered by cost barriers for drugs or exams, long waiting lists or difficult access to the place where the needed healthcare service is provided. The aim of this paper is to investigate whether the probability of facing one of these barriers varies among individuals with different socio-economic status and care needs, controlling for geographical variability. METHODS: The sample for this study included 9629 interviews with Italian individuals, aged 15 and over, from the second wave (2015) of the European Health Interview Survey, which was conducted in all EU Member States. To model barriers to healthcare, two-level variance components of logistic regression models with a nested structure given by the four Italian macro-areas were considered. RESULTS: Of the barriers considered in this study, only two were found to be significantly associated with healthcare utilization. Specifically, they are long waiting lists for specialist service accessibility (adjOR = 1.20, 95% CI (1.07; 1.35)) and very expensive exams for dental visit accessibility (adjOR = 0.84, 95% CI (0.73; 0.96)). Another important result was the evidence of an increasing north-south gradient for all of the considered barriers. CONCLUSION: In Italy, healthcare access is generally guaranteed for all of the services, except for specialist and dental visits that face a waiting time and financial barriers. However, barriers to healthcare were differentiated by income and sex. The north-south gradient for healthcare utilization could be explained through the existing differences in organizational characteristics of the several regional healthcare services throughout Italy.

Horizontal Inequity in the Utilization of Maternal and Reproductive Health Services: Evidence From the 2018 Nigeria Demographic and Health Survey.

Background: Maternal mortality and poor reproductive health outcomes remain major public health challenges in low-resource countries. The Sustainable Development Goals have proposed new targets to reduce global maternal mortality ratio to 70 per 100,000 live births and ensure universal access to sexual and reproductive healthcare services by 2030. Inequity in the utilization of maternal and reproductive health services leads to poor reproductive health outcomes and maternal mortality. Despite reduction in global maternal mortality over the decades, the level of maternal mortality remains unacceptably high in Nigeria with limited attention given by governments to addressing health inequities. This study aimed to examine horizontal inequity in the utilization of maternal and reproductive health services in Nigeria. Methods: Secondary data from the 2018 Nigeria Demographic and Health Survey were utilized to examine horizontal inequity in the utilization of maternal and reproductive health services such as postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning. Equity was measured using equity gaps, equity ratios, concentration curves, and concentration indices. All analyses were performed using ADePT 6.0 and STATA version 14.2 software. Results: The overall coverage level of postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning was 20.81, 2.97, 10.23, and 84.22%, respectively. There is inequity in the utilization of postnatal care, delivery by cesarean section, and modern contraceptive favoring the rich, educated, and urban populations. Met need for family planning was found to be almost perfectly equitable. Conclusion: There is inequity in the utilization of maternal and reproductive health services in Nigeria. Inequity in the utilization of maternal and reproductive health services is driven by socioeconomic status, education, and location. Therefore, governments and policymakers should give due attention to addressing inequities in the utilization of maternal and reproductive health services by economically empowering women, improving their level of education, and designing rural health interventions. Addressing inequities in the utilization of maternal and reproductive health services would also be important toward achieving the Sustainable Development Goal targets 3.1 and 3.7.

Socio-economic inequalities in arts engagement and depression among older adults in the United Kingdom: evidence from the English Longitudinal Study of Ageing.

OBJECTIVES: Arts engagement has been positively linked with mental health and well-being; however, socio-economic inequalities may be prevalent in access to and uptake of arts engagement reflecting on inequalities in mental health. This study estimated socio-economic inequality and horizontal inequity (unfair inequality) in arts engagement and depression symptoms of older adults in England. Trends in inequality and inequity were measured over a period of ten years. STUDY DESIGN: This is a repeated cross-sectional study. METHODS: In this analysis, we used data from six waves (waves 2 to 7) of the nationally representative English Longitudinal Study of Ageing. We estimated socio-economic inequality using concentration curves that plot the distribution of arts engagement and depression symptoms against the distribution of wealth. A concentration index was used to measure the magnitude of the inequality. Unfair inequality was then calculated for need-standardised arts engagement using a horizontal inequity index (HII). RESULTS: The study sample included adults aged 50 years and older from waves 2 (2004/2005, n = 6620) to 7 (2014/2015, n = 3329). Engagement with cinema, galleries and theatre was pro-rich unequal, i.e. concentrated among the wealthier, but inequality in depression was pro-poor unequal, i.e. concentrated more among the less wealthy. While pro-rich inequality in arts engagement decreased from wave 2 (conc. index: 0·291, 95% confidence interval 0·27 to 0·31) to wave 7 (conc. index: 0·275, 95% confidence interval 0·24 to 0·30), pro-poor inequality in depression increased from wave 2 (conc. index: -0·164, 95% confidence interval -0·18 to -0·14) to wave 7 (conc. index: -0·189, 95% confidence interval -0·21 to -0·16). Depression-standardised arts engagement showed horizontal inequity that increased from wave 2 (HII: 0·455, 95% confidence interval 0·42 to 0·48) to wave 7 (HII: 0·464, 95% confidence interval 0·42 to 0·50). CONCLUSIONS: Our findings suggest that while socio-economic inequality in arts engagement might appear to have reduced over time, once arts engagement is standardised for need, inequality has actually worsened over time and can be interpreted as inequitable (unfair). Relying on need-unstandardised estimates of inequality might thus provide a false sense of achievement to policy makers and lead to improper social prescribing interventions being emplaced.

Eligibility or use? Disentangling the sources of horizontal inequity in home care receipt in the Netherlands.

We study horizontal inequity in home care use in the Netherlands, where a social insurance scheme aims to allocate long-term care according to care needs. Whether the system reaches its goal depends not only on whether eligible individuals have equal access to care but also on whether entitlements for care reflect needs, irrespective of socioeconomic status and other characteristics. We assess and decompose total inequity into inequity in (i) entitlements for home care and (ii) the conversion of these entitlements into actual use. This distinction is original and important, because inequity calls for different policy responses depending on the stage at which it arises. Linking survey and administrative data on the 65 and older, we find higher income elderly to receive less home care than poorer elderly with similar needs. Although lower income elderly tend to make greater use of their entitlements, need-standardized entitlements are similar across income, education, and wealth levels. However, both use and entitlements vary by origin and place of residence. The Dutch need assessment seems effective at restricting socioeconomic inequity in home care use but may not fully prevent inequity along other dimensions. Low financial barriers and universal eligibility rules may help achieve equity in access but are not sufficient conditions.

Equity in utilization of health care services in Turkey: an index based analysis.

BACKGROUND: Equity in the use of health care services is an issue which has increasingly been on the health policy agenda over recent years in both middle- and low-income countries. AIMS: The purpose of this study was to investigate the degree and progress of equity in health care utilization in Turkey during 2008-2012. METHODS: Wed use data from health surveys (2008, 2010, 2012) conducted by the Turkish Statistical Institute. The concentration index (CI) and the horizontal equity index (HI) were calculated as a measure of equity, and a Blinder-Oaxaca decomposition analysis was applied. RESULTS: The general practitioner (GP), specialist and inpatient visits display a pro-poor orientation. Averages of the CI and HI indices for 2008-2012 were 0.74 and -0.17 for GP visits, 0.75 and -0.13 for specialist visits, 0.83 and -0.31 for inpatient visits. CONCLUSION: Our findings indicate that health care utilization in Turkey appears to have become equitable over the years; however, the sustainability of equity is an issue of concern.

Equal long-term care for equal needs with universal and comprehensive coverage? An assessment using Dutch administrative data.

The Netherlands is one of the few countries that offer generous universal public coverage of long-term care (LTC). Does this ensure that the Dutch elderly with similar care needs receive similar LTC, irrespective of their income? In contrast with previous studies of inequity in care use that relied on a statistically derived variable of needs, our paper exploits a readily available, administrative measure of LTC needs stemming from the eligibility assessment organized by the Dutch LTC assessment agency. Using exhaustive administrative register data on 616,934 individuals aged 60 and older eligible for public LTC, we find a substantial pro-poor concentration of LTC use that is only partially explained by poorer individuals' greater needs. Among those eligible for institutional care, higher-income individuals are more likely to use-less costly-home care. This pattern may be explained by differences in preferences, but also by their higher copayments for nursing homes and by greater feasibility of home-based LTC arrangements for richer elderly. At face value, our findings suggest that the Dutch LTC insurance "overshoots" its target to ensure that LTC is accessible to poorer elderly. Yet, the implications depend on the origins of the difference and one's normative stance.

The National Health Service (NHS) in 'crisis': the role played by a shift from horizontal to vertical principles of equity.

Explanations of the state of 'crisis' in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be 'failing' and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.

Trends in horizontal inequity in access to public health care services by immigrant condition in Spain (2006-2017).

BACKGROUND: The objective of this research is to analyse trends in horizontal inequity in access to public health services by immigration condition in Spain throughout the period 2006-2017. We focus on "economic immigrants" because they are potentially the most vulnerable group amongst immigrants. METHODS: Based on the National Health Surveys of 2006-07 (N = 29,478), 2011-12 (N = 20,884) and 2016-17 (N = 22,903), hierarchical logistic regressions with random effects in Spain's autonomous communities are estimated to explain the probability of using publicly-financed health care services by immigrant condition, controlling by health care need and other socioeconomic and demographic variables. RESULTS: Our results indicate that there are several horizontal inequities, though they changed throughout the decade studied. Regarding primary care services, the period starts (2006-07) with no global evidence of horizontal inequity in access (although the analysis by continent shows inequity that is detrimental to Eastern Europeans and Asians), giving way to inequity favouring economic immigrants (particularly Latin Americans and Africans) in 2011-12 and 2016-17. An opposite trend happens with specialist care, as the period starts (2006-07) with evidence of inequity that is detrimental to economic immigrants (particularly those from North of Africa) but this inequity disappears with the economic crisis and after it (with the only exception of Eastern Europeans in 2011-12, whose probability to visit a specialist is lower than for natives). Regarding emergency care, our evidence indicates horizontal inequity in access that favours economic immigrants (particularly Latin Americans and North Africans) that remains throughout the period. In general, there is no inequity in hospitalisations, with the exception of 2011-12, where inequity in favour of economic immigrants (particularly those from Latin America) takes place. CONCLUSIONS: The results obtained here may serve, firstly, to prevent alarm about negative discrimination of economic immigrants in their access to public health services, even after the implementation of the Royal Decree RD Law 16/2012. Conversely, our results suggest that the horizontal inequity in access to specialist care that was found to be detrimental to economic immigrants in 2006-07, disappeared in global terms in 2011-12 and also by continent of origin in 2016-17.

Horizontal equity in access to public GP services by socioeconomic group: potential bias due to a compartmentalised approach.

BACKGROUND: Horizontal equity in access to public general practitioner (GP) services by socioeconomic group has been addressed econometrically by testing the statement "equal probability of using public GP services for equal health care needs, regardless of socioeconomic status". Based on survey data, the conventional approach has been to estimate binomial econometric models in which when the respondent reports having visited a public GP, it counts as 1, otherwise it counts as 0. This is what we call a compartmentalised approach. Those respondents who did not visit a public GP but visited instead another doctor (specialist or private GP) would count as 0 (despite having used instead other modes of health care), thus conclusions of the compartmentalised approach might be biased. In such cases, a multinomial econometric model -that we called comprehensive approach- would be more appropriate to analyse horizontal equity in access to public GP services. The objective of this paper is to test for this potential bias by comparing a compartmentalised and a comprehensive approach, when analysing horizontal equity in access to public GP. METHODS: Using data from the 2016/17 Spanish National Health Survey, we estimate the probability of visiting a public GP as determined by socioeconomic status, health care need and demographic characteristics. We use binomial and multinomial logit and probit models in order to highlight the potential differences in the conclusions regarding socioeconomic inequities in access to public GP services. Socioeconomic status is proxied by education level, social class and employment situation. RESULTS: Our results show that conclusions are sensitive to the approach selected. Particularly, the horizontal inequity favouring individuals with lower education that resulted from the compartmentalised approach disappears under a comprehensive approach and only a social class effect remains. CONCLUSION: An analysis of horizontal equity in access to a particular health care service (like public GP services) undertaken following a compartmentalised approach should be compared with a comprehensive approach in order to test that there is no bias as a consequence of considering as zeros the utilisation of other types of health care.

Incorporating Spatial Statistics into Examining Equity in Health Workforce Distribution: An Empirical Analysis in the Chinese Context.

Existing measures of health equity bear limitations due to the shortcomings of traditional economic methods (i.e., the spatial location information is overlooked). To fill the void, this study investigates the equity in health workforce distribution in China by incorporating spatial statistics (spatial autocorrelation analysis) and traditional economic methods (Theil index). The results reveal that the total health workforce in China experienced rapid growth from 2004 to 2014. Meanwhile, the Theil indexes for China and its three regions (Western, Central and Eastern China) decreased continually during this period. The spatial autocorrelation analysis shows that the overall agglomeration level (measured by Global Moran’s I) of doctors and nurses dropped rapidly before and after the New Medical Reform, with the value for nurses turning negative. Additionally, the spatial clustering analysis (measured by Local Moran’s I) shows that the low⁻low cluster areas of doctors and nurses gradually reduced, with the former disappearing from north to south and the latter from east to west. On the basis of these analyses, this study suggests that strategies to promote an equitable distribution of the health workforce should focus on certain geographical areas (low⁻low and low⁻high cluster areas).

Is healthcare really equal for all? Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians.

BACKGROUND: There is a lack of focused research on the older population in Ghana and about issues pertaining to their access to healthcare services. Furthermore, information is lacking regarding the fairness in the access to these services. This study aimed to ascertain whether horizontal and vertical equity requirements were being met in the healthcare utilisation among older adults aged 50 years and above. METHODS: This study was based on a secondary cross-sectional data from the World Health Organization's Study on global AGEing (SAGE) and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Bivariate and multivariable analyses were carried out to analyse the association between outpatient/inpatient utilisation and (1) socioeconomic status (SES), controlling for need variables (horizontal equity) and (2) need variables, controlling for SES (vertical equity). Odds ratios with 95% confidence intervals were calculated to analyse the association between relevant variables. RESULTS: Horizontal and vertical inequities were found in the utilisation of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. CONCLUSION: Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The study reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access. It provides the basis for further research in bridging the healthcare access inequity gap among older adults in Ghana.

Does free choice of hospital conflict with equity of access to highly specialized hospitals? A case study from the Danish health care system.

Equity of access to health care is a central objective of European health care systems. In this study, we examined whether free choice of hospital, which has been introduced in many systems to strengthen user rights and improve hospital competition, conflicts with equity of access to highly specialized hospitals. We chose to carry out a study on 134,049 women who had uncomplicated pregnancies from 2005 to 2014 in Denmark because of their homogeneity in terms of need, the availability of behavioral data, and their expected engagement in choice of hospital. Multivariate logistic regression was used to link the dependent variable of bypassing the nearest non-highly specialized public hospital in order to "up-specialize", with independent variables related to socioeconomic status, risk attitude, and choice premises, using administrative registries. Overall, 16,426 (12%) women were observed to bypass the nearest hospital to up-specialize. Notably, high education level was significantly associated with up-specialization, with an odds ratio of 1.50 (95% CI: 1.40-1.60, p < 0.001) compared to low education group. This confirms our hypothesis that there is a socioeconomic gradient in terms of exercising the right to a free choice of hospital, and so the results indicate that the policy exacerbates inequity of access to health care.

Educational inequalities in hospital care for mortally ill patients in Norway.

AIMS: Health care should be allocated fairly, irrespective of patients' social standing. Previous research suggests that highly educated patients are prioritized in Norwegian hospitals. This study examines this contentious issue by a design which addresses two methodological challenges. Control for differences in medical needs is approximated by analysing patients who died from same causes of death. Area fixed effects are used for avoiding that observed educational inequalities are contaminated by geographical differences. METHODS: Men and women who died 2009-2011 at age 55-94 were examined ( N=103,000) with register data from Statistics Norway and the Norwegian Patient Registry. Educational differences in quantity of hospital-based medical care during the 12-24 months before death were analysed, separate for main causes of death. Multivariate negative binomial regression models were estimated, with fixed effects for residential areas. RESULTS: High-educated patients who died from cancers had significantly more outpatient consultations at somatic hospitals than low-educated patients during an average observation period of 18 months prior to death. Similar, but weaker, educational inequalities appeared for outpatient visits for patients whose deaths were due to other causes. Also, educational inequalities in number of hospital admissions were marked for those who died from cancers, but insignificant for patients who died from other causes. CONCLUSIONS: Even when medical needs are similar for mortally ill patients, those with high education tend to receive more medical services in Norwegian somatic hospitals than patients with low education. The roles played by physicians and patients in generating these patterns should be explored further.

Inequity in healthcare use among older people after 2008: The case of southern European countries.

Despite the sizeable cuts in public healthcare spending, which were part of the austerity measures recently undertaken in Southern European countries, little attention has been devoted to monitoring its distributional consequences in terms of healthcare use. This study aims at measuring socioeconomic inequities in primary and secondary healthcare use experienced some time after the crisis onset in Italy, Spain and Portugal. The analysis, based on data drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE), focuses on older people, who generally face significantly higher healthcare needs, and whose health appeared to have worsened in the aftermath of the crisis. The Horizontal Inequity indexes reveal remarkable socioeconomic inequities in older people's access to secondary healthcare in all three countries. In Portugal, the one country facing most severe healthcare budget cuts and where user charges apply also to GP visits, even access to primary care exhibits a significant pro-rich concentration. If reducing inequities in older people's access to healthcare remains a policy objective, austerity measures maybe pulling the Olive belt countries further away from achieving it.

Changes in health care inequity in Brazil between 2008 and 2013.

BACKGROUND: Brazil has made progress towards a more equitable distribution of health care, but gains may be threatened by economic instability resulting from the 2008 global financial crisis. This study measured predictors of health care utilization and changes in horizontal inequity between 2008 and 2013. METHOD: Data were from two nationally representative surveys that measured a variety of sociodemographic, health behaviors and health care indicators. We used Poisson regression models to estimate adjusted prevalence ratios and the Horizontal Equity Index (HEI) standardized by health needs to measure inequity in the utilization of doctor and dentist visits, hospitalizations and reporting of a usual source of care (USC) for those 18 and older. To estimate the HEI, we ranked the population from the poorest to the richest using a wealth index. We also decomposed the HEI into its different components and assessed changes from 2008 to 2013. RESULTS: The population proportion with doctor and dentist visits in the past year and a USC increased between 2008 and 2013, while hospitalizations declined. In 2013, pro-rich inequity in doctor visits increased significantly while the distribution of hospitalizations shifted from pro-rich in 2008 to neutral in 2013. Dentist visits were highly pro-rich and USC was slightly pro-rich; the distribution of dentist visits and USC did not change over time. Health need was a strong predictor of health care utilization regardless of the type of coverage (public or private). Education, wealth, and private health plans were associated with the pro-rich orientation of doctor and dentist visits. Private health plans contributed to the pro-rich orientation of all outcomes, while the Family Health Strategy contributed to the pro-poor orientation of all outcomes. CONCLUSION: The results of this study support the claim that Brazil's population continued to see absolute gains in access to care despite recent economic crises. However, gains in equity have slowed and may even decline if investments are not maintained as the country enters deeper financial and political crises.

An exploratory study on equity in funding allocation for essential medicines and health supplies in Uganda's public sector.

BACKGROUND: To ascertain equity in financing for essential medicines and health supplies (EMHS) in Uganda, this paper explores the relationships among government funding allocations for EMHS, patient load, and medicines availability across facilities at different levels of care. METHODS: We collected data on EMHS allocations and availability of selected vital medicines from 43 purposively sampled hospitals and the highest level health centers (HC IV), 44 randomly selected lower-level health facilities (HC II, III), and from over 400 facility health information system records and National Medical Stores records. The data were analyzed to determine allocations per patient within and across levels of care and the effects of allocations on product availability. RESULTS: EMHS funding allocations per patient varied widely within facilities at the same level, and allocations per patient between levels overlapped considerably. For example, HC IV allocations per patient ranged from US$0.25 to US$2.14 (1:9 ratio of lowest to highest allocation), and over 75 % of HC IV facilities had the same or lower average allocation per patient than HC III facilities. Overall, 43 % of all the facilities had optimal stock levels, 27 % were understocked, and 30 % were overstocked. Using simulations, we reduced the ratio between the highest and lowest allocations per patient within a level of care to less than two and eliminated the overlap in allocation per patient between levels. CONCLUSIONS: Inequity in EMHS allocation is demonstrated by the wide range of funding allocations per patient and the corresponding disparities in medicines availability. We show that using patient load to calculate EMHS allocations has the potential to improve equity significantly. However, more research in this area is urgently needed. TRIAL REGISTRATION: The article does not report any results of human participants. It is implemented in collaboration with the Uganda's Ministry of Health, Pharmacy Division.

Can a poverty-reducing and progressive tax and transfer system hurt the poor?

To analyze anti-poverty policies in tandem with the taxes used to pay for them, comparisons of poverty before and after taxes and transfers are often used. We show that these comparisons, as well as measures of horizontal equity and progressivity, can fail to capture an important aspect: that a substantial proportion of the poor are made poorer (or non-poor made poor) by the tax and transfer system. We illustrate with data from seventeen developing countries: in fifteen, the fiscal system is poverty-reducing and progressive, but in ten of these at least one-quarter of the poor pay more in taxes than they receive in transfers. We call this fiscal impoverishment, and axiomatically derive a measure of its extent. An analogous measure of fiscal gains of the poor is also derived, and we show that changes in the poverty gap can be decomposed into our axiomatic measures of fiscal impoverishment and gains.