Horizontal Equity in Health Care Utilization in South Korea

Abstract

Background In South Korea, given high out-of-pocket payments and steep competition among health care providers, there has been growing concerns on access to health care, financial risk protection, and inefficient health care delivery. To tackle these problems, a series of health policies intended to reduce high out-of-pocket payments have been implemented since the late 2000s. Therefore, research on addressing the impact of those health policies needs to be carried out.

Objective The purpose of this paper is to measure and explain income-related horizontal inequity in the delivery of health care in South Korea after the late 2000s, employing the concentration indices and the horizontal inequity index proposed by Wagstaff and van Doorsaler(the HIwv index) based on a one-and two-part model.

Methods This study was conducted using data from the 2010 Korean National Health and Nutrition Examination Survey(KNHANES). We ranked individuals by the logarithm of monthly income per equivalent adult. Health care utilization consists of outpatient care, inpatient care, and medical expenditure

the level and type of health care were distinguished into health centers, clinics, hospitals, general hospitals, dental care, and licensed traditional medical practitioners. For need variables, age, gender, self-assessed health, the number of chronic diseases, and activity limitation due to any health problems were used. We included non-need variables such as education, economic activity, region, medicaid status, and private insurance. To assess income-related inequality and horizontal inequity in health care use, the concentration indices and the HIwv indices were obtained.

Results The results provide some evidence of the equitable distribution of overall health care utilization with pro-poor tendencies and of modest pro-rich inequity in the positive medical expenditures, which is consistent with the Korean literature. With regard to the decomposition analysis, although need factors are important, non-need variables, particularly income, education, private insurance, and occupation status, are more important and substantially contribute to pro-rich inequality in health care. For outpatient care, the disadvantaged in South Korea are less likely to have access to primary care, showing a more pro-rich tendency aggravated over time

there is a pro-poor pattern in the use of secondary care, indicating that access to such care for the poor is improved. Once access to care is made, they tend to be treated equally according to their needs. But for secondary care, a more pro-rich pattern than that of access to care seems to appear. In addition, there is evidence of a socio-economic gradient in health care utilization. That is, the better-off tend to use sophisticated services in a hospital more frequently

the worse-off tend to have a visit to a health center more often, to which education effects contribute. For inpatient care, access to care is pro-poor, while pro-rich tendencies appear in the number of inpatient stays for the use of clinics and general hospitals. Furthermore, the worse-off are more likely to have expenditure on health care because of their higher need. But small pro-rich inequity in the positive medical expenditure due to the contributions of income and education indicates the better-off may be able to enjoy more expensive and good quality of services in the health system.

Conclusions We find the degree of horizontal inequity in health care in South Korea is fairly equitable, and policies for reducing out-of-pocket payments since the late 2000s have worked in some ways by improving access to secondary care for the disadvantaged. But the poor still have some barriers to access to primary care and to continuing to receive medical care. Therefore, there needs to be relevant policies to tackle these problems.