Horizontal Equity in Health Care Utilization in Canada

Even under public and universal coverage of core services with no user charges, utilization of health care services may vary among individuals with similar need depending, for example, on where the person lives, the person's income, or education status. Therefore, horizontal equity in the utilization of health care services can be influenced by health policies beyond financing, such as decisions on concentration in the hospital sector, pricing and reimbursement of non core services (drugs, home care, dental care), or physician density. We build on the well established ECuity method of income-related equity measurement to assess and interpret the changes in horizontal equity in the 10 Canadian provinces from 1990 to 2004, a period of substantial health reform in Canada. This approach uses individual-level survey data to compute a series of income-based concentration indices of need-standardized utilization of physician visits, hospital stays and dental care services. Canada provides a unique opportunity to explore the link between health policies and horizontal equity in health care utilization because provinces within Canada operate their health care system under the umbrella of the national Canada Health Act. Moreover there is a higher level of cultural and professional homogeneity than in both the US and EU, which controls for important factors of horizontal equity beyond health policies. The years 1990-2004 also provide an opportunity to study the possible impact of changes in health care policy on equity in health care utilization since they were a time of substantial changes in provincial health care systems (governance of health care, hospital sector restructuring, funding of home care services and drugs, and physicians supply). These changes differ across provinces in their qualitative nature, amplitude and year of occurrence. The project integrates a qualitative assessment of key health policy events in each province since 1990 and the quantitative measurement of equity in health care utilization over this period. First, we conduct a qualitative assessment of the co-variations in health policies in the 10 provinces on one hand and our equity measures on the other hand. We use a systematic characterization of health policy changes in Canada and take advantage of the longitudinal nature of our dataset to estimate a fixed effect model (at the province level) of the impact of changes in policy on horizontal equity. This work adds to the literature on equity measurement in the following ways: systematically links equity to health policies over time and cross-sectionally; measures equity in home care utilization, a type of services which will become more important in the future albeit still outside the set of core services in Canada; measures equity in drug expenditures using a better descriptor of drug utilization than what is available in the European Household Panel Survey; we employ a fuller and richer set of need descriptors, allowing us testing the impact of enriching the need standardization on the value of the equity measure (the more one standardizes the lower observed inequity is); in addition to income-related inequity, we assess for inequity related to degree of rurality.