Inequality and inequity in healthcare utilization in urban Nepal: a cross-sectional observational study

Abstract

Inequality in access to quality healthcare is a major health policy challenge in many low- and middle-income countries. This study aimed to identify the major sources of inequity in healthcare utilization using a population-based household survey from urban Nepal. A cross-sectional survey was conducted covering 9177 individuals residing in 1997 households in five municipalities of Kathmandu valley between 2011 and 2012. The concentration index was calculated and a decomposition method was used to measure inequality in healthcare utilization, along with a horizontal inequity index (HI) to estimate socioeconomic inequalities in healthcare utilization. Results showed a significant pro-rich distribution of general healthcare utilization in all service providers (Concentration Index: 0.062, P < 0.001; HI: 0.029, P < 0.05) and private service providers (Concentration Index: 0.070, P < 0.001; HI: 0.030, P < 0.05). The pro-rich distribution of probability in general healthcare utilization was attributable to inequalities in the level of household economic status (percentage contribution: 67.8%) and in the self-reported prevalence of non-communicable diseases such as hypertension (36.7%) and diabetes (14.4%). Despite the provision of free services by public healthcare providers, our analysis found no evidence of the poor making more use of public health services (Concentration Index: 0.041, P = 0.094). Interventions to reduce the household economic burden of major illnesses, coupled with improvement in the management of public health facilities, warrant further attention by policy-makers.

Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa

“…Need therefore matters much more in the Nepal setting than in the South African setting, but proxies of socioeconomic status more or less equally. Similar to our study, the unexplained residual is substantially larger for private than public healthcare [41].…”

“…Alternatively, a negative contribution (x % < 0), all things being equal, would increase socio-economic inequality [20,38,39]. The unexplained part of the contribution of factors to inequality, the residual, can take on negative values, with an explained percentage in excess of 100%, which, by interpretation, suggests that measured inequality is completely explained by the model's explanatory variables [40], as has been the case in other decomposition studies [40][41][42][43][44]. To determine whether actual and perceived need and access barriers are sector-specific, the decomposition analysis was stratified by private/public healthcare utilisation as characterised by the two-tiered South African health system.…”

“…One such study in Mongolia found private hospital outpatient visits and inpatient admissions were concentrated among those economically better-off while the worse-off used public secondary outpatient care [55]. Saito et al [41] instead made an overall comparison between sectors in Nepal and found significant pro-rich inequality in private healthcare use but found no conclusive evidence for inequality in public healthcare use.…”

“…Only one other study has conducted a sector-specific decomposition analysis of inequalities in healthcare use, this in Nepal [41]. The authors, using a much smaller set of explanatory variables, which apart from need excludes upstream proxies of other pathways on the access continuum, detect some differences in the factors contributing to inequality in public as opposed to private healthcare use.…”

Inequality Assessment of Oral Health Workforce’s Distribution in Iran’s National Oral Health Promotion Program

“…(13,14) Although there have been many disparities in the dispersion of human resources in countries and among regions and cities. (15,16) Though previous researches in Iran assessed the association between social determinants with the oral health status of the population (9,(17)(18)(19) and the use of dental services, (20,21) little attention was actually paid to the distribution of oral health human resources such as dental therapists, oral hygienists and dentists, especially in NOHP programs. In order to cover this knowledge gap, this study assessed the availability of oral health team in public sector of Iran using different inequity indices to assess oral and dental human resource disparity within school-based Iran's NOHP Program.…”