L'universalismo incompiuto.Disuguaglianze socioeconomiche e inquità nell'accesso ai servizi sanitari in Italia

Equity has long been considered an important goal in the health sector. Yet, inequalities between different social groups persist. In particular, lower-status socioeconomic groups tend to suffer higher rates of mortality and morbidity than do higher-status socioeconomic groups. Also, disadvantaged groups often use health care services less, despite generally having higher levels of need. Scholars often argue that these inequalities reflect mainly differences in constraints, rather than differences in preferences, so that they should be considered as inequities, i.e., as an instance of social injustice. The purpose of this dissertation is to investigate whether, and to what extent, patterns of access to health care services deviate from the ideal of horizontal equity – i.e., equal access for equal need – in a country with a universal and egalitarian health care system: Italy. The Italian National Health Service (Servizio Sanitario Nazionale – Ssn) was established in 1978 through a major reform largely inspired by the British Nhs, with the declared goal of providing uniform and comprehensive care to all Italian citizens. The reform rested on the egalitarian principle that health care should be financed according to ability to pay – through general taxation – but distributed according to need, thereby setting out equity objectives in terms of both financial contribution and access to care. There is evidence, however, that these goals have not been fully achieved yet. The present work aims at analyzing this issue and bridging some of the method- ological and substantive gaps in existing research. Using large-scale survey data collected in three different years (1994, 2000, and 2005) and multilevel regression modeling, we investigate whether and how the probability of accessing a compre- hensive set of health care services varies among individuals with equal need but different socioeconomic status (Ses). Along with the standard indicators of health care utilization (GP visits, specialist visits, and inpatient hospital care), we consider two other variables generally neglected in previous research: propensity to take basic medical tests and use of diagnostic services. Moreover, in addition to the usual estimation of global horizontal inequity, we carry out a stratified analysis aimed at providing distinct estimates of inequity for each level of need, as proxied by health status. Overall, the results of this study confirm a well-established finding in the inter- national literature on health care: even countries with a universal and egalitarian public health care system, like Italy, exhibit a certain degree of Ses-related hori- zontal inequity in health services utilization. Specifically, we found a significant amount of pro-rich inequity in the utilization of specialist care, diagnostic services, and basic medical tests. Use of primary care was found inequitable, too, but in favor of the less well-off. Finally, we found that hospitalization is essentially equitable. The stratified analysis of inequity by level of health status uncovers a noteworthy pattern of heterogeneity in the phenomenon of interest: the degree of inequity in health services utilization tends to decrease as health status decreases – and, therefore, as the need for health care increases. Although this trend is neither regular nor strictly monotonic, our tests show that it is not a mere artifact of sampling error. Thus, there are good reasons to assume that as the need for health care increases, its utilization approaches equity. Finally, our analyses show no substantial difference in inequity of access to health care across regions and time. The articulation of the Italian Ssn into twenty different – and relatively autonomous – Regional Health Services was expected to generate some regional variation in inequity of health care utilization. Likewise, the reforms the Ssn underwent during the period 1994-2005 were plausible sources of variation over time. However, no systematic evidence of regional or longitudinal heterogeneity was revealed by our analyses, suggesting that socioeconomic inequity of access to health care is a stable, well-structured phenomenon.