Comparing aversions to outcome inequality and social risk in health and income: An empirical analysis using hypothetical scenarios with losses.

Evaluation of future social welfare may not only depend on the aggregate of individual prospects, but also on how the prospects are distributed across individuals. The latter in turn would depend on how people perceive inequality and risk at the collective level (or "social risk"). This paper examines distributional preferences regarding inequality in outcomes and social risk for health and income in the context of losses. Specifically, four kinds of aversions are compared, (a) outcome-inequality aversion in health, (b) outcome-inequality aversion in income, (c) social-risk aversion in health, (d) and social-risk aversion in income. Face-to-face interviews of a representative general public sample in Spain are undertaken using hypothetical scenarios involving losses in health or income across otherwise equal groups. Aversion parameters are compared assuming social welfare functions with constant relative or constant absolute aversion. We find that in both domains, outcome-inequality aversion and social-risk aversion are not the same; and that neither aversion is the same across the two domains. Outcome-inequality aversion in income is the strongest, followed by social-risk aversion in income and social-risk aversion in health, and outcome-inequality aversion in health coming last, where most of these are statistically significantly different from each other.

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.

Correction to: Financial crisis and income-related inequalities in the universal provision of a public service: the case of healthcare in Spain.

Following publication of the original article [1], the autor reported 5 references should be indicated in Spanish. The correct references can be found below.

Financial crisis and income-related inequalities in the universal provision of a public service: the case of healthcare in Spain.

BACKGROUND: The objective of this paper is to analyse whether the recent recession has altered health care utilisation patterns of different income groups in Spain. METHODS: Based on information concerning individuals 'income and health care use, along with health need indicators and demographic characteristics (provided by the Spanish National Health Surveys from 2006/07 and 2011/12), econometric models are estimated in two parts (mixed logistic regressions and truncated negative binominal regressions) for each of the public health services studied (family doctor appointments, appointments with specialists, hospitalisations, emergencies and prescription drug use). RESULTS: The results show that the principle of universal access to public health provision does not in fact prevent a financial crisis from affecting certain income groups more than others in their utilisation of public health services. CONCLUSIONS: Specifically, in relative terms the recession has been more detrimental to low-income groups in the cases of specialist appointments and hospitalisations, whereas it has worked to their advantage in the cases of emergency services and family doctor appointments.

Health inequalities by socioeconomic characteristics in Spain: the economic crisis effect.

BACKGROUND: An economic crisis can widen health inequalities between individuals. The aim of this paper is to explore differences in the effect of socioeconomic characteristics on Spaniards' self-assessed health status, depending on the Spanish economic situation. METHODS: Data from the 2006-2007 and 2011-2012 National Health Surveys were used and binary logit and probit models were estimated to approximate the effects of socioeconomic characteristics on the likelihood to report good health. RESULTS: The difference between high and low education levels leads to differences in the likelihood to report good health of 16.00-16.25 and 18.15-18.22 percentage points in 2006-07 and 2011-12, respectively. In these two periods, the difference between employees and unemployed is 5.24-5.40 and 4.60-4.90 percentage points, respectively. Additionally, the difference between people who live in households with better socioeconomic conditions and those who are in worse situation reaches 5.37-5.46 and 3.63-3.74 percentage points for the same periods, respectively. CONCLUSIONS: The magnitude of the contribution of socioeconomic characteristics to health inequalities changes with the economic cycle; but this effect is different depending on the socioeconomic characteristics indicator that is being measured. In recessive periods, health inequalities due to education level increase, but those linked to individual professional status and household living conditions are attenuated. When the joint effects of individuals' characteristics are considered, the economic crisis brings about a slight increase in the inequalities in the probability of reporting good health between the two extreme profiles of individuals. The design of public policies aimed at preventing any worsening of health inequalities during recession periods should take into account these differential effects of socioeconomic characteristics indicators on health inequalities.

Time trends in socio-economic inequalities in the lack of access to dental services among children in Spain 1987-2011.

INTRODUCTION: Adult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children's dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987-2011. METHODS: Pooled data from eight editions of the Spanish National Health Survey for the years 1987-2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children's household. RESULTS: The mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80). CONCLUSION: There has been a reduction in children's lack of access to dentists in Spain over the period 1987-2011. However, this reduction has not corrected the socioeconomic inequalities in children's access to dentists in Spain.

Egalitarianism and altruism in health: some evidence of their relationship.

BACKGROUND: Egalitarianism and altruism are two ways in which people may have attitudes that go beyond the narrowly defined selfish preferences. The theoretical constructs of egalitarianism and altruism are different from each other, yet there may be connections between the two. This paper explores the empirical relationship between egalitarianism and altruism, in the context of health. METHODS: We define altruism as individual behaviour that aims to benefit another individual in need; and egalitarianism as a characteristic of a social welfare function, or a meta-level preference. Furthermore, we specify a model that explains the propensity of an individual to be egalitarian in terms of altruism and other background characteristics. Individuals who prefer a hypothetical policy that reduces socioeconomic inequalities in health outcomes over another that does not are regarded 'egalitarian' in the health domain. On the other hand, 'altruism' in the health context is captured by whether or not the same respondents are (or have been) regular blood donors, provided they are medically able to donate. Probit models are specified to estimate the relationship between egalitarianism and altruism, thus defined. A representative sample of the Spanish population was interviewed for the purpose (n = 417 valid cases). RESULTS: Overall, 75% of respondents are found to be egalitarians, whilst 35% are found to be altruists. We find that, once controlled for background characteristics, there is a statistically significant empirical relationship between egalitarianism and altruism in the health context. On average, the probability of an altruist individual supporting egalitarianism is 10% higher than for a non-altruist person. Regarding the other control variables, those living in high per capita income regions have a lower propensity and those who are politically left wing have a higher propensity to be an egalitarian. We do not find evidence of a relationship between egalitarianism and age, socioeconomic status or religious practices. CONCLUSION: Altruist individuals have a higher probability to be egalitarians than would be expected from their observed background characteristics.

The effect of policies regulating tobacco consumption on smoking initiation and cessation in Spain: is it equal across socioeconomic groups?

BACKGROUND: In Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels. METHODS: Micro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals' tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on "time to event analysis". Cox's proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults. RESULTS: Initiation rates among young people went from 25% (95% confidence interval (CI), 23-27) to 19% (95% CI, 17-21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11-13) to 20% (95% CI, 19-21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p = 0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law's implementation. CONCLUSION: Law 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes.

Exploring social welfare functions and violation of monotonicity: an example from inequalities in health.

The social welfare function (SWF) has been used within the economics literature, to study trade-offs between equality and efficiency. These SWFs are characterised by properties determined by traditional welfare economics. One of these properties, the monotonicity principle is explored in this paper. In the context of health there may be occasions when the monotonicity principle is violated as there may be circumstances where distributional issues dominate efficiency concerns. When this is the case, conventional SWFs are not flexible enough to represent such social preferences. Therefore, we propose a SWF with an alternative specification, which is general enough to accommodate preferences that are not necessarily monotonic. A survey of the Spanish general public was undertaken to estimate preferences regarding equality in health, relative to efficiency in health. The results (with 973 usable responses) give strong support to the existence of public preferences which violate the monotonicity principle, and thus to the usefulness of the alternative specification proposed here.

Blood donation as a public good: an empirical investigation of the free rider problem.

A voluntary blood donation system can be seen as a public good. People can take advantage without contributing and have a free ride. We empirically analyse the extent of free riding and its determinants. Interviews of the general public in Spain (n = 1,211) were used to ask whether respondents were (or have been) regular blood donors and, if not, the reason. Free riders are defined as those who are medically capable to donate blood but do not. In addition, we distinguish four different types of free riding depending on the reason given for not donating. Binomial and multinomial logit models estimate the effect of individual characteristics on the propensity to free ride and the likelihood of the free rider types. Amongst those who are able to donate, there is a 67 % probability of being a free rider. The most likely free rider is female, single, with low/no education and abstained from voting in a recent national election. Gender, age, religious practice, political participation and regional income explain the type of free rider.

Equity in specialist waiting times by socioeconomic groups: evidence from Spain.

In countries with publicly financed health care systems, waiting time--rather than price--is the rationing mechanism for access to health care services. The normative statement underlying such a rationing device is that patients should wait according to need and irrespective of socioeconomic status or other non-need characteristics. The aim of this paper is to test empirically that waiting times for publicly funded specialist care do not depend on patients' socioeconomic status. Waiting times for specialist care can vary according to the type of medical specialty, type of consultation (review or diagnosis) and the region where patients' reside. In order to take into account such variability, we use Bayesian random parameter models to explain waiting times for specialist care in terms of need and non-need variables. We find that individuals with lower education and income levels wait significantly more time than their counterparts.

Real waiting times for surgery. Proposal for an improved system for their management.

OBJECTIVES: In Spain, official information on waiting times for surgery is based on the interval between the indication for surgery and its performance. We aimed to estimate total waiting times for surgical procedures, including outpatient visits and diagnostic tests prior to surgery. In addition, we propose an alternative system to manage total waiting times that reduces variability and maximum waiting times without increasing the use of health care resources. This system is illustrated by three surgical procedures: cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair. METHODS: Using data from two Autonomous Communities, we adjusted, through simulation, a theoretical distribution of the total waiting time assuming independence of the waiting times of each stage of the clinical procedure. We show an alternative system in which the waiting time for the second consultation is established according to the time previously waited for the first consultation. RESULTS: Average total waiting times for cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair were 331, 355 and 137 days, respectively (official data are 83, 68 and 73 days, respectively). Using different negative correlations between waiting times for subsequent consultations would reduce maximum waiting times by between 2% and 15% and substantially reduce heterogeneity among patients, without generating higher resource use. CONCLUSION: Total waiting times are between two and five times higher than those officially published. The relationship between the waiting times at each stage of the medical procedure may be used to decrease variability and maximum waiting times.

Real waiting times for surgery. Proposal for an improved system for their management / Los tiempos de espera reales en cirugía. Propuesta de un sistema mejorado para su gestión

Objectives In Spain, official information on waiting times for surgery is based on the interval between the indication for surgery and its performance. We aimed to estimate total waiting times for surgical procedures, including outpatient visits and diagnostic tests prior to surgery. In addition, we propose an alternative system to manage total waiting times that reduces variability and maximum waiting times without increasing the use of health care resources. This system is illustrated by three surgical procedures: cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair. Methods Using data from two Autonomous Communities, we adjusted, through simulation, a theoretical distribution of the total waiting time assuming independence of the waiting times of each stage of the clinical procedure. We show an alternative system in which the waiting time for the second consultation is established according to the time previously waited for the first consultation. Results Average total waiting times for cholecystectomy, carpal tunnel release and inguinal/femoral hernia repair were 331, 355 and 137 days, respectively (official data are 83, 68 and 73 days, respectively). Using different negative correlations between waiting times for subsequent consultations would reduce maximum waiting times by between 2% and 15% and substantially reduce heterogeneity among patients, without generating higher resource use. Conclusion Total waiting times are between two and five times higher than those officially published. The relationship between the waiting times at each stage of the medical procedure may be used to decrease variability and maximum waiting times (AU)

Objetivos En España, la información oficial sobre tiempos de espera para cirugía está basada en el tiempo desde que se indica la cirugía hasta que se realiza. Nuestro objetivo es estimar el tiempo de espera total considerando también la visita al especialista y las pruebas diagnósticas previas a la cirugía, y proponer un sistema alternativo para gestionar tiempos de espera totales que reduce la variabilidad y los tiempos máximos sin incrementar los de recursos. Se ilustra para tres procedimientos quirúrgicos: colecistectomía, reparación quirúrgica del túnel carpiano y de la hernia inguinal/femoral. Métodos Con datos de dos Comunidades Autónomas, se ajusta mediante simulación, una distribución teórica del tiempo de espera total, asumiendo independencia de los tiempos de cada etapa del proceso asistencial. Se muestra un sistema alternativo donde el tiempo de espera para la segunda consulta se establece condicionado al esperado previamente en la primera consulta. Resultados Los tiempos de espera totales medios para la colecistectomía, túnel carpiano y hernia inguinal/femoral son 331, 355 y 137 días, siendo los oficiales 83, 68 y 73, respectivamente. Utilizando diferentes correlaciones negativas entre los tiempos de espera de consultas sucesivas se reducirían tanto los tiempos de espera máximos (entre el 2% y el 15%) como la heterogeneidad entre pacientes, sin mayor uso de recursos. Conclusión Los tiempos totales de espera son entre dos y cinco veces mayores que los publicados oficialmente. La relación entre tiempos de espera en cada etapa del procedimiento puede utilizarse para reducir la variabilidad y los tiempos máximos de espera (AU)