The aim of this article is to analyze the role of the health care system in reducing socioeconomic inequalities in health in countries with good access to health services, using the Dutch example. In the past, health care has contributed substantially to reducing a number of health problems in the population, particularly health problems leading to mortality. Data on trends in mortality from selected conditions by socioeconomic group show that both higher and lower socioeconomic groups have profited from these mortality reductions, probably because of largely equal access to essential health care services, and that absolute inequalities in mortality from these conditions have declined notably. The current situation is still one of largely equal financial access to health care services, with relatively small differences between socioeconomic groups in health care utilization, after adjustment for differences in prevalence of health problems. There is no evidence that inequalities in health care utilization contribute to a widening of socioeconomic inequalities in health. Financing of the health care system, however, is slightly regressive, and out-of-pocket payments contribute to the poor financial situation of the chronically ill. For the future, three possible contributions of the health care system to reducing socioeconomic inequalities in health are described: preservation of equal access to high-quality health care; development of specific care packages for lower socioeconomic groups; promotion and support of intersectoral activities.
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References
1.
MaCkenbachJ. P.Ongezonde verschillen: Over sociale stratifiatie en gezondheid in Nederland. Van Gorcum, Assen, 1994.
2.
StronksK.van de MheenH., and MaCkenbachJ. P.Sociaal-economische gezondheidsverschillen. In Volksgezondheid Toekomst Verkenning 1997, deel II: Gezondheidsverschillen, ed. MaCkenbachJ. P. and VerkleijH., pp. 153–180. Elsevier/De Tijdstroom, Maarssen, 1997.
3.
MaCkenbachJ. P.Socioeconomic inequalities in health in developed countries: The facts and the options. In Oxford Textbook of Public HealthEd. 4, ed. DetelsR.Oxford University Press, Oxford, 2000.
4.
van der MeerJ. B. W.Equal Care, Equal Cure? Socioeconomic Differences in the Use of Health Services and the Course of Health Problems. Dissertation, Erasmus University Rotterdam, Rotterdam, 1998.
5.
BenzevalM.JudgeK., and WhiteheadM.The role of the NHS. In Tackling Inequalities in Health: An Agenda for Action, ed. BenzevalM.JudgeK., and WhiteheadM., pp. 95–121. King's Fund, London, 1995.
6.
AchesonD.Independent Inquiry into Inequalities in Health Report. Acheson Committee, London, 1998.
7.
McKeownT.The Role of Medicine: Dream, Mirage, or Nemesis?Nuffield, London, 1976.
8.
MaCkenbachJ. P., Post-1950 mortality trends and medical care: Gains in life expectancy due to declines in mortality from conditions amenable to medical intervention in the Netherlands. Soc. Sci. Med.27: 889–894, 1988.
9.
BunkerJ. P.FrazierH. S., and MostellerF., Improving health: Measuring effects of medical care. Milbank Q.74: 225–258, 1994.
10.
MaCkenbachJ. P., The contribution of medical care to mortality decline: McKeown revisited. J. Clin. Epidemiol.49: 1207–1213, 1996.
11.
PamukE. R., Social class and inequality in mortality from 1921 to 1972 in England and Wales. Popul. Stud.39: 17–31, 1985.
12.
DreverF., and BuntingJ.Patterns and trends in male mortality. In Health Inequalities, Series DS No. 15, ed. DreverF. and WhiteheadM., pp. 95–107. Stationery Office, London, 1997.
13.
MaCkenbachJ. P.StronksK., and KunstA. E., The contribution of medical care to inequalities in health: Differences between socio-economic groups in decline of mortality from conditions amenable to medical intervention. Soc. Sci. Med.29: 369–376, 1989.
14.
MaCkenbachJ. P., and KunstA. E., Measuring the magnitude of socio-economic inequalities in health: An overview of available measures illustrated with two examples from Europe. Soc. Sci. Med.44: 757–771, 1997.
15.
van de MheenH.ReijneveldS. A., and MaCkenbachJ. P., Socio-economic inequalities in perinatal and infant mortality from 1854 till 1990 in Amsterdam, the Netherlands. Eur. J. Public Health6: 166–174, 1996.
16.
EricsonA., Secular trends in the effects of socioeconomic factors on birth weight and infant survival in Sweden. Scand J. Soc. Med.21: 10–16, 1993.
17.
PostD., and van der WalG.Structuur, financiering en functioneren van de gezondheidszorg. In Volksgezondheid en Gezondheidszorg, ed. van der MaasP. J. and MaCkenbachJ. P.. Elsevier gezondheidszorg, Maarssen, 1999.
18.
van AgtH. M. E.StronksK., and MaCkenbachJ. P.De financiële situatie van chronisch zieken. Instituut Maatschappelijke Gezondheidszorg, Erasmus University Rotterdam, Rotterdam, 1996.
19.
FoetsM.Armoede en gezondheidszorgbeleid. In Armoede en verzorgingsstaat, ed. EngbersenG.VroomanJ. C. and SnelE., pp. 127–141. Amsterdam University Press, Amsterdam, 1999.
20.
StarmansB., and PaulusA., Eigen betalingen voor medische zorg. Tijdschr. Soc. Gezondheidsz.77: 386–396, 1999.
21.
van VlietR. J. C. A.van DoorslaerE. K. A., and van der BurgH. G., Effecten van eigen betalingen op ziektekosten in Nederland. Tijdschr. Soc. Gezondheidsz.77: 397–405, 1999.
22.
Newhouse, J. P., and the Insurance Experiment Group.Free for All? Lessons from the RAND Health Insurance Experiment. Harvard University Press, Cambridge, 1993.
23.
SwinkelsH., and MaessenJ., Het gebruik van tandheelkundige voorzieningen naar sociaal-economische status tussen 1981 en 1995. Maandber. Gezondheid.4: 10–18, 1996.
24.
DelnoijD. M. J., Effecten van eigen bijdragen in het ziekenfonds in Nederland. Tijdschr. Soc. Gezondheidsz.77: 401–412, 1999.
25.
van DoorslaerE., The redistributive effect of health care finance in twelve OECD countries. J. Health Econ. 18: 291–313, 1999.
26.
WagstaffA.van DoorslaerE., and PaciP., Equity in the finance and delivery of health care: Some tentative cross-country comparisons. Oxford Rev. Econ. Policy.5: 89–112, 1989.
27.
WagstaffA., Equity in the finance of health care: Some international comparisons. J. Health Econ. 11: 361–387, 1992.
28.
Centraal Bureau voor de Statistiek/Ministerie van Volksgezondheid, Welzijn en Sport.Vademecum gezondheidsstatistiek Nederland 1999. Centraal Bureau voor de Statistiek, Voorburg/Heerlen, 1999.
29.
Centraal Bureau voor de Statistiek.Netherlands Health Interview Survey 1981–1995. SDU Publishers, Den Haag, 1996.
30.
van der MeerJ. B. W., and MaCkenbachJ. P., Low education, high GP consultation rates: The effect of psychosocial factors. J. Psychosom. Med.44: 587–597, 1998.
31.
BongersI. M. B., Socio-economic differences in general practitioner and outpatient specialist care in the Netherlands: A matter of health insurance?Soc. Sci. Med.44: 1161–1168, 1997.
32.
van der WulpC. G., and de KoningH. J., Het consultatiebureau voor zuigelingen en peuters. Opkomst, waardering en verwijzingen. Maandber. Gezondheid.11: 4–7, 1994.
33.
KempkensL., De griepvaccinatie van risicogroepen in Nederland. Maandber. Gezondheid.1: 4–9, 1996.
34.
van LeidenH. A.van Gessel-DabekaussenA. A. M. W., and de KoningH. J., Mammografie en het bevolkingsonderzoek naar borstkanker 1991–1996. Maandber. Gezondheid.12: 5–12, 1997.
35.
Ben-ShlomoY., and ChaturvediN., Assessing equity in access to health care provision in the UK: Does where you live affect your chances of getting a coronary artery bypass graft? J. Epidemiol. Community Health49: 200–204, 1995.
36.
JacobsonB.Tackling inequalities in health and healthcare—The role of the NHS. In Inequalities in Health, ed. GordonD., pp. 100–117. Policy Press, Bristol, 1999.
37.
PayneN., and SaulC., Variations in use of cardiology services in a health authority: Comparison of coronary artery revascularisation rates with prevalence of angina and coronary mortality. BMJ314: 257–261, 1997.
38.
KeskimäkiI., Socioeconomic and gender inequities in access to coronary artery bypass grafting in Finland. Eur. J. Public Health7: 392–397, 1997.
39.
KeskimäkiI.SalintoM., and AroS., Socioeconomic equity in Finnish hospital care in relation to need. Soc. Sci. Med.41: 425–431, 1995.
40.
van der MeerJ. B. W.MaCkenbachJ. P., Course of health status among chronically ill persons: Differentials according to level of education. J. Clin. Epidemiol.51: 171–179, 1998.
41.
SchrijversC. T. M., Socioeconomic variation in cancer survival in the Southeastern Netherlands, 1980–1989. Cancer75: 2946–2953, 1995.
42.
Wetenschappelijke Raad voor het Regeringsbeleid.Volksgezondheidszorg. Sdu uitgevers, Den Haag, 1997.
43.
van der VeldenJ.General Practice at Work: Its Contribution to Epidemiology and Health Policy. Dissertation, Erasmus University Rotterdam, Rotterdam, 1999.
44.
WorrallA.ReaJ. N., and Ben-ShlomoY., Counting the cost of social disadvantage in primary care: Retrospective analysis of patient data. BMJ314: 38–42, 1997.
45.
JudgeK., and MaysN., Allocating resources for health and social care in England. BMJ308: 1363–1366, 1994.
46.
Inspectie voor de Volksgezondheid/Staatstoezicht op de Volksgezondheid.Staat van de gezondheidszorg. Ministerie van Volksgezondheid, Welzijn en Sport, Rijswijk, 1997.
47.
MajeedF. A., Equity in the NHS: Monitoring and promoting equity in primary and secondary care. BMJ308: 1426–1429, 1994.
48.
ArblasterL.Review of the Research on the Effectiveness of Health Service Interventions to Reduce Variations in Health. Centre for Reviews and Dissemination, York, 1995.
49.
MaCkenbachJ. P., Determinants of levels and changes in physical functioning in chronically ill persons: Results from the GLOBE-study. J. Epidemiol. Community Health55: 631–638, 2001.
50.
BenzevalM., and DonaldM.The role of the NHS in tackling inequalities in health. In Inequalities in Health, ed. GordonD., pp. 87–99. Policy Press, Bristol, 1999.
51.
PoppingR., and PescharJ.Next patient: A feasibility study into registration of occupational and educational titles in hospitals. In Sociaal-economische Gezondheidsverschillen onderzocht, deel VII, ed. MaCkenbachJ. P.. Ministerie WVC, Rijswijk, 1994.
