Social inequalities in health care services utilisation after eight years of health care reforms: a cross-sectional study of Estonia, 1999
Introduction
Over the last years, attention for social inequalities in the utilisation of health care services has been increasing. In many regions of the world, studies have been carried out to assess inequalities in health care utilisation and to formulate implications for health sector reform. While most of the available empirical evidence on inequalities with respect to health care comes from developed regions in western Europe or northern America (Van Doorslaer et al., 2000; Paterson & Judge, 2002), evidence from developing countries is increasing. Little evidence is however yet available from post-Soviet countries (Balabanova & McKee, 2002). This lack of information is lamentable, as the profound health care reforms that have been carried out in central and eastern European countries during last decade may have important equity implications.
In Estonia, after regained independence in 1991, the first step in the health sector reform was the introduction of a social health insurance system. Because this system was based on the principle of solidarity, the delivery of health services was intended to be in agreement with the health needs of the population, independent of the patients’ financial situation. Therefore, all costs were covered by health insurance funds collected from earmarked payroll tax. The second wave of important reforms of the Estonian health sector occurred in first half of nineties with the substitution of a centralised and state-controlled health care planning and delivery system by a decentralised system (WHO, 2000). During these reforms, most of the financial barriers were removed for the 95% of the population that was enrolled in the health insurance scheme, which covered a wide range of services. In 1997, the third phase in the health sector reform took place with the aim to develop a system of public health services and general practitioners, who were to serve as partial gatekeepers to the health care system (Kiivet & Harro, 2002). Through remuneration system changes in 1998, the general practitioner based primary care was introduced, at a time that many practitioners were educated according to new curricula (Lember, 2002). By the year 2000, general practitioners served in primary health care centres all over Estonia, except in the capital area, where implementation of the new system had been slower. The fourth reform, which gradually has started from 2001, aimed to improve the quality of hospital services by centralising acute in-patient care and high-technology medicine as well as creating a modern and comprehensive system of long term and nursing care, lacking in Estonia until now (Kiivet & Harro, 2002).
In the late 1990s, health care provision was organised through primary care, specialist out-patient care, dental care, and in-patient care. Primary health care services were organised mostly through primary care doctors (who were private providers working under contracts with the insurance fund) but some of these services were still delivered by old-type polyclinics. All citizens of Estonia had the right to choose their personal primary care doctor or to be enrolled to polyclinics. In 1998, two thirds of population had chosen their personal family practitioner (Kalda, Põlluste, & Lember, 2003). Out-patient specialist care was organised mostly nearby hospitals outpatient departments, specialists’ own practices or in polyclinics where primary care doctors served as well. Access to specialist care was through referral by primary care doctors while some specialists were accessible directly (WHO, 2000). The availability of specialist services in rural areas was affected by a hospital sector reform that centralised acute care into big hospital centres. Of dental care, almost 70% was organised through private providers (Estonian Health Statistics, 1992–1999, 2000a). In-patient care was organised through extensive hospital capacity as 78 hospitals with a total capacity of 7.1 hospital beds per 1000 population (Estonian Health Statistics, 1992–1999, 2000a).
The direct financial burden to persons who used health care services consisted of out-of-pocket payments. In 1999 the share of out-of-pocket payments in the total health expenditure (6.5% share of GDP) amounted to 14%, compared to almost 20% in 2002 (Social Sector in Figures, 2003). The main share of out-of-pocket payments in 1999 were related to the purchase of medicines (48% of all household payments, mainly due to cost sharing in prescription drugs), utilisation of dental care (31%, due to only partial coverage by health insurance), and other out-patient services (6%, including primary care and also rehabilitation services) (National Health Accounts, 2000b). Relatively small cost sharing in primary care level settings were introduced since 1995, but large population groups such as retired persons, disabled persons, and children were exempted. All out-patient and in-patient specialist services were covered by health insurance including wide range of benefits (WHO, 2000). Thus, most of the cost sharing in Estonia was related to dental care and prescribed drugs.
Until present, the health sector reforms in Estonia have not been accompanied by comprehensive studies that evaluated how these reforms influenced the access to health care services in different population groups and regions. The reforms were initiated to improve the quality and efficiency of the health care system (WHO, 1996) and thus achieving equity was not a first priority. However, at present, equity in health and health care is becoming one important target of health care policies in Estonia. This growing concern was stimulated by a first overview produced in 2001 (Kunst, Leinsalu, Kasmel, & Habicht, 2002), which was followed by discussion on this issue among policy makers in Estonia.
The present study aimed to contribute to this discussion by providing a general overview of social inequalities in the utilisation of health care services in Estonia in 1999. The general objective of this paper is to describe social inequalities in the use of different types of health care, including hospitalisation and visits to general practitioners, specialists and dentists, respectively. The specific objectives are:
- (a)
to describe differences in health care services utilisation according to ethnicity, place of residence, income, education and employment status;
- (b)
to determine to what extent can these differences be attributed to differences in need, as measured by health indicators;
- (c)
to assess the extent to which the effect of one social variable (e.g. ethnicity) is independent of the effect of other social variables (e.g. income).
While the first objective is purely descriptive, the second and third objectives aim to contribute to explaining the differences that are observed. Possible explanations are discussed in more detail in the final section of this paper.
Section snippets
Data
Data were obtained from a nationally representative household interview survey, the NORBALT II survey, which was held during 1999. This survey was conducted by the Statistical Office of Estonia and supervised by the Norwegian FAFO Institute for Applied Social Sciences (Marksoo, Oja, Kutsar, & Einasto, 2000). The NORBALT survey gives detailed information about the respondents’ social-demographic characteristics, health status, and health care utilisation. The survey sample was 4728 respondents
Results
Table 1 presents information on social differences in the use of telephone consultations. The second column shows substantial differences, with more telephone consultations made by women, rural residents, ethnic Estonians and persons with high education. After adjustment for health indicators (third column) even larger differences are observed, especially in relation to educational level and income level, with a lower use by those in the lowest income quartile as compared to higher income
Discussion
This study revealed important variations in health care services utilisation according to each of the social dimensions studied. Residents of rural areas were more likely to visit a general practitioner or to use telephone consultation, but less often used outpatient specialist care or dentist care. Ethnic differences were generally smaller, with no consistently higher use by either Russians or ethnic Estonians. Gender differences with higher use by women were found for all services except
Acknowledgements
The baseline study about social inequalities in Estonia was carried out in 2001 and supported by grant from the Estonian Ministry of Social Affairs and the World Bank.
Work of JH is supported by the Estonian Science Foundation Grant #4552.
References (25)
- et al.
Socioeconomic inequity in health careA study of service utilization in Curacao
Social Science & Medicine
(1997) - et al.
Socio-economic status and the utilisation of physicians’ servicesResults from the Canadian National Population Health Survey
Social Science & Medicine
(2000) - et al.
Patient satisfaction with care is associated with personal choice of physician
Health Policy
(2003) - et al.
Evaluation of primary health care reform in Estonia
Social Science & Medicine
(2003) Social variation in self-related health in EstoniaA cross-sectional study
Social Science & Medicine
(2002)- et al.
Equity in the delivery of health care in Europe and the US
Journal of Health Economics
(2000) - et al.
Socio-economic differences in the utilisation of health services in a Dutch populationThe contribution of health status
Health Policy
(1996) - 2000 Population. (2001). Tallinn: Statistical Office of...
Revisiting the behavioural model and access to medical careDoes it matter?
Journal of Health and Social Behaviour
(1995)- et al.
Access to health care in a system transitionThe care of Bulgaria
International Journal of Health Planning and Management
(2002)