Health Investment Management and Healthcare Quality in the Public System: A Gender Perspective
Abstract
1. Introduction
Literature Background and Hypotheses
2. Materials and Methodology
2.1. Sample and Data Collection
2.2. Measurement Variables
2.3. Data Analysis
3. Results
3.1. Measurement Model
3.1.1. Composite Mode A
3.1.2. Composite Mode B
3.2. Structural Model
3.3. Multi-Group Analysis (MGA)
4. Discussion
5. Conclusions
Author Contributions
Funding
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Composite | Indicators | Description |
---|---|---|
Patient satisfaction (mode A) | PS1 | Degree of satisfaction with functioning of public health system |
PS2 | Degree of satisfaction with knowledge of history and monitoring of health problems by family doctors and pediatricians | |
PS3 | Degree of satisfaction with information received at specialists’ offices about health problems | |
Expenses (mode B) | EX1 | Public health expenditure managed by autonomous community per protected inhabitant |
EX2 | Percentage of spending on specialized care services | |
EX3 | Percentage of spending on primary care | |
EX4 | Percentage of spending dedicated to concerts | |
EX5 | Percentage of spending on intermediate consumption | |
EX6 | Percentage of public health expenditure on staff remuneration for training of residents | |
EX7 | Percentage of pharmacy spending | |
Resources (mode B) | RE1 | Medical personnel in specialized care per 1000 inhabitants |
RE2 | Primary care medical staff per 1000 people assigned | |
RE3 | Skilled care nurses per 1000 inhabitants | |
RE4 | Primary care nurses per 1000 people assigned | |
RE5 | Running hospital beds per 1000 inhabitants | |
RE6 | Day hospital posts per 1000 inhabitants | |
RE7 | Operating theaters per 100,000 inhabitants | |
RE8 | Operating computed tomography (CT) equipment per 100,000 inhabitants | |
RE9 | Nuclear magnetic resonance (NMR) per 100,000 inhabitants | |
Extent of use (mode B) | EU1 | Frequency of specialized attention consultations per 1000 inhabitants/year |
EU2 | Frequency of hospital admissions per 1000 inhabitants/year | |
EU3 | Number of days of average hospital stay | |
EU4 | Surgical intervention rate per 1000 inhabitants/year | |
EU5 | Outpatient surgery percentage | |
EU6 | CT usage rate per 1000 inhabitants/year | |
EU7 | NMR usage rate per 1000 inhabitants/year | |
Mortality (mode B) | MO1 | Age-adjusted mortality rate for Alzheimer’s disease per 100,000 inhabitants |
MO2 | Age-adjusted death rate from cancer per 100,000 inhabitants | |
MO3 | Age-adjusted mortality rate for diabetes mellitus per 100,000 inhabitants | |
MO4 | Age-adjusted death rate from cerebrovascular disease per 100,000 inhabitants | |
Economic driver | ED1 | Gross domestic product (GDP) per capita |
Construct and Associated Indicators | Men | Women | ||
---|---|---|---|---|
Mean | Standard Deviation | Mean | Standard Deviation | |
Patient satisfaction (PS) | ||||
PS1 | 6.572 | 0.439 | 6.533 | 0.461 |
PS2 | 7.365 | 0.424 | 7.481 | 0.402 |
PS3 | 7.293 | 0.425 | 7.275 | 0.442 |
Expenses (EX) | ||||
EX1 | 1415.785 | 167.139 | 1415.785 | 167.139 |
EX2 | 58.902 | 4.901 | 58.902 | 4.901 |
EX3 | 13.969 | 1.748 | 13.969 | 1.748 |
EX4 | 7.314 | 5.210 | 7.314 | 5.210 |
EX5 | 22.867 | 4.437 | 22.867 | 4.437 |
EX6 | 3.235 | 0.908 | 3.235 | 0.908 |
EX7 | 18.546 | 3.034 | 18.546 | 3.034 |
Resources (RE) | ||||
RE1 | 1.698 | 0.221 | 1.698 | 0.221 |
RE2 | 0.778 | 0.106 | 0.778 | 0.106 |
RE3 | 2.931 | 0.446 | 2.931 | 0.446 |
RE4 | 0.661 | 0.108 | 0.661 | 0.108 |
RE5 | 2.497 | 0.457 | 2.497 | 0.457 |
RE6 | 0.274 | 0.128 | 0.274 | 0.128 |
RE7 | 6.438 | 1.016 | 6.438 | 1.016 |
RE8 | 1.136 | 0.260 | 1.136 | 0.260 |
RE9 | 0.558 | 0.224 | 0.558 | 0.224 |
Extent of use (EU) | ||||
EU1 | 1619.646 | 244.892 | 1619.646 | 244.892 |
EU2 | 91.937 | 15.430 | 91.937 | 15.430 |
EU3 | 7.897 | 0.976 | 6.600 | 0.703 |
EU4 | 69.709 | 14.584 | 69.709 | 14.584 |
EU5 | 39.609 | 8.462 | 41.537 | 8.251 |
EU6 | 72.408 | 17.468 | 72.408 | 17.468 |
EU7 | 28.395 | 14.788 | 28.395 | 14.788 |
Mortality (MO) | ||||
MO1 | 9.477 | 2.407 | 12.645 | 3.127 |
MO2 | 213.869 | 20.038 | 100.495 | 6.233 |
MO3 | 12.611 | 6.219 | 10.081 | 5.540 |
MO4 | 36.937 | 9.981 | 28.790 | 8.318 |
Economic driver (ED) | ||||
ED1 | 22.987 | 4.578 | 22.987 | 4.578 |
(A) Outer Loadings | ||||||||
Indicator | Men | Women | ||||||
PS1 | 0.881 | 0.883 | ||||||
PS2 | 0.901 | 0.899 | ||||||
PS3 | 0.867 | 0.876 | ||||||
(B) Construct Reliability and Average Variance Extracted | ||||||||
Composite | Cronbach’s Alpha | Dijkstra–Henseler’s Rho | Composite Reliability (CR) | AVE | ||||
Variable | Men | Women | Men | Women | Men | Women | Men | Women |
Patient satisfaction | 0.860 | 0.864 | 0.874 | 0.875 | 0.914 | 0.916 | 0.780 | 0.785 |
(C) Discriminant Validity (Fornell–Larcker Criterion) | ||||||||
Group | Variable | DE | EX | MO | RE | PS | EU | |
Men | DE | 1.000 | ||||||
EX | 0.305 | n.a. | ||||||
MO | −0.459 | −0.700 | n.a. | |||||
RE | 0.309 | 0.778 | −0.781 | n.a. | ||||
PS | 0.185 | 0.598 | −0.505 | 0.618 | 0.883 | |||
EU | 0.311 | 0.580 | −0.692 | 0.818 | 0.447 | |||
Women | DE | 1 | ||||||
EX | 0.339 | n.a. | ||||||
MO | −0.551 | −0.703 | n.a. | |||||
RE | 0.351 | 0.768 | −0.775 | n.a. | ||||
PS | 0.131 | 0.566 | −0.454 | 0.580 | 0.886 | |||
EU | 0.337 | 0.535 | −0.656 | 0.809 | 0.395 | |||
(D) Discriminant Validity (HTMT Criterion) | ||||||||
PS→DE | Original Sample | Sample Mean | CI Lo2.5% | CI Hi97.5% | ||||
Men | 0.193 | 0.208 | 0.129 | 0.275 | ||||
Women | 0.140 | 0.162 | 0.083 | 0.182 |
Variables | VIF | Weights | t | CI 2.5% | CI 97.5% | Loadings |
---|---|---|---|---|---|---|
Expenses | ||||||
EX1 | 1.385 | 0.542 *** | 7.265 | 0.395 | 0.686 | 0.731 *** |
EX2 | 3.559 | 0.282 *** | 2.797 | 0.094 | 0.491 | 0.604 *** |
EX3 | 1.292 | 0.202 *** | 3.073 | 0.068 | 0.327 | 0.073 ‡ |
EX4 | 1.363 | −0.126 ** | 2.292 | −0.233 | −0.018 | −0.156 ** |
EX5 | 2.536 | 0.038 ‡ | 0.371 | −0.189 | 0.223 | 0.552 *** |
EX6 | 1.610 | 0.293 *** | 3.867 | 0.157 | 0.454 | 0.456 *** |
EX7 | 2.316 | −0.323 *** | 3.637 | −0.494 | −0.143 | −0.754 *** |
Resources | ||||||
RE1 | 4.345 | 0.311 *** | 3.556 | 0.155 | 0.502 | 0.799 *** |
RE2 | 3.704 | 0.109 ‡ | 1.426 | −0.036 | 0.264 | 0.304 *** |
RE3 | 3.604 | 0.191 ** | 2.451 | 0.044 | 0.354 | 0.723 *** |
RE4 | 4.674 | 0.151 * | 1.646 | −0.028 | 0.331 | 0.358 *** |
RE5 | 1.797 | −0.488 *** | 6.725 | −0.626 | −0.341 | 0.162 * |
RE6 | 1.831 | 0.254 *** | 5.309 | 0.171 | 0.362 | 0.703 *** |
RE7 | 3.412 | 0.226 *** | 2.828 | 0.074 | 0.386 | 0.733 *** |
RE8 | 2.734 | −0.018 ‡ | 0.278 | −0.149 | 0.098 | 0.636 *** |
RE9 | 2.210 | 0.337 *** | 4.938 | 0.211 | 0.479 | 0.807 *** |
Extent of use | ||||||
EU1 | 1.751 | 0.518 *** | 6.545 | 0.364 | 0.665 | 0.808 *** |
EU2 | 2.487 | −0.103 ‡ | 0.837 | −0.353 | 0.129 | 0.511 *** |
EU3 | 2.521 | −0.350 *** | 3.566 | −0.535 | −0.152 | −0.538 *** |
EU4 | 3.226 | 0.005 ‡ | 0.049 | −0.171 | 0.240 | 0.667*** |
EU5 | 1.619 | −0.014 ‡ | 0.188 | −0.163 | 0.132 | 0.323 *** |
EU6 | 3.039 | 0.433 *** | 4.880 | 0.270 | 0.619 | 0.809 *** |
EU7 | 3.222 | 0.123 ‡ | 1.324 | −0.056 | 0.313 | 0.782 *** |
Mortality | ||||||
MO1 | 1.162 | −0.194 ** | 2.457 | −0.347 | −0.038 | −0.028 |
MO2 | 1.694 | −0.016 ‡ | 0.152 | −0.232 | 0.187 | 0.772 *** |
MO3 | 1.018 | 0.619 *** | 7.125 | 0.438 | 0.771 | 0.636 *** |
MO4 | 1.648 | 0.784 *** | 9.966 | 0.638 | 0.947 | 0.777 *** |
Variables | VIF | Weights | t | CI 2.5% | CI 97.5% | Loadings |
---|---|---|---|---|---|---|
Expenses | ||||||
EX1 | 1.385 | 0.579 *** | 7.947 | 0.435 | 0.721 | 0.755 *** |
EX2 | 3.559 | 0.323 *** | 3.010 | 0.118 | 0.542 | 0.601 *** |
EX3 | 1.292 | 0.196 *** | 2.838 | 0.057 | 0.329 | 0.075 ‡ |
EX4 | 1.363 | −0.094 ‡ | 1.444 | −0.223 | 0.030 | −0.100 |
EX5 | 2.536 | −0.046 ‡ | 0.391 | −0.296 | 0.167 | 0.489 *** |
EX6 | 1.610 | 0.285 *** | 3.648 | 0.149 | 0.453 | 0.411 *** |
EX7 | 2.316 | −0.323 *** | 3.526 | −0.497 | −0.143 | −0.773 *** |
Resources | ||||||
RE1 | 4.345 | 0.323 *** | 4.063 | 0.185 | 0.503 | 0.839 *** |
RE2 | 3.704 | 0.027 ‡ | 0.337 | −0.137 | 0.179 | 0.299 *** |
RE3 | 3.604 | 0.217 *** | 2.687 | 0.070 | 0.378 | 0.767 *** |
RE4 | 4.674 | 0.204* | 1.947 | 0.009 | 0.415 | 0.385 *** |
RE5 | 1.797 | −0.380 *** | 5.368 | −0.516 | −0.239 | 0.254 *** |
RE6 | 1.831 | 0.267 *** | 5.528 | 0.182 | 0.374 | 0.731 *** |
RE7 | 3.412 | 0.222 *** | 2.568 | 0.063 | 0.403 | 0.750 *** |
RE8 | 2.734 | −0.072 ‡ | 1.063 | −0.220 | 0.052 | 0.633 *** |
RE9 | 2.210 | 0.315 *** | 4.152 | 0.171 | 0.466 | 0.816 *** |
Extent of use | ||||||
EU1 | 1.743 | 0.438 *** | 5.549 | 0.293 | 0.587 | 0.826 *** |
EU2 | 2.288 | 0.068 ‡ | 0.617 | −0.159 | 0.293 | 0.593 *** |
EU3 | 1.785 | −0.077 ‡ | 0.823 | −0.251 | 0.112 | −0.211 ** |
EU4 | 3.189 | 0.172 ‡ | 1.405 | −0.053 | 0.418 | 0.724 *** |
EU5 | 1.708 | −0.037 ‡ | 0.488 | −0.118 | 0.180 | 0.465 *** |
EU6 | 3.021 | 0.323 *** | 3.489 | 0.146 | 0.510 | 0.818 *** |
EU7 | 3.088 | 0.220 ** | 2.299 | 0.044 | 0.423 | 0.792 *** |
Mortality | ||||||
MO1 | 1.082 | −0.139 * | 1.835 | −0.282 | 0.013 | −0.102 |
MO2 | 1.208 | −0.006 ‡ | 0.076 | −0.170 | 0.153 | 0.313 *** |
MO3 | 1.161 | 0.608 *** | 7.420 | 0.446 | 0.758 | 0.749 *** |
MO4 | 1.058 | 0.671 *** | 11.369 | 0.558 | 0.785 | 0.794 *** |
(A) Direct Effects | |||||||
Effects | Path | t | CI 2.5% | CI 97.5% | f2 | VIF | |
ED→PS | −0.029 ‡ | 0.560 | −0.130 | 0.070 | 0.001 | 1.278 | |
EX→PS | 0.302 *** | 3.109 | 0.101 | 0.488 | 0.058 | 2.684 | |
RE→PS | 0.391 *** | 3.829 | 0.181 | 0.583 | 0.074 | 3.102 | |
MO→PS | −0.002 ‡ | 0.016 | −0.205 | 0.197 | 0 | 3.539 | |
R2 = 0.417; Q2 = 0.306 | |||||||
EX→RE | 0.778 *** | 31.679 | 0.714 | 0.816 | 1.535 | 1 | |
R2 = 0.605; Q2 = 0.212 | |||||||
RE→EU | 0.818 *** | 33.768 | 0.757 | 0.857 | 2.022 | 1 | |
R2 = 0.669; Q2 = 0.289 | |||||||
RE→MO | −0.781 *** | 32.697 | −0.821 | −0.724 | 1.566 | 1 | |
R2 = 0.610; Q2 = 0.203 | |||||||
(B) Specific Indirect Effects | |||||||
Effects | Path | t | CI 2.5% | CI 97.5% | |||
EX→RE→MO | −0.608 *** | 19.574 | −0.658 | −0.531 | |||
RE→MO→PS | 0.001 ‡ | 0.016 | −0.155 | 0.163 | |||
EX→RE→MO→PS | −0.001 ‡ | 0.016 | −0.531 | 0.129 | |||
EX→RE→PS | 0.304 *** | 3.811 | 0.137 | 0.451 | |||
EX→RE→EU | 0.636 *** | 21.679 | 0.564 | 0.683 | |||
(C) Total Indirect Effects | |||||||
EX→MO | −0.608 *** | 19.574 | −0.658 | −0.531 | |||
EX→PS | 0.305 *** | 3.842 | 0.132 | 0.448 | |||
EX→EU | 0.636 *** | 21.679 | 0.564 | 0.683 | |||
RE→PS | 0.001 ‡ | 0.016 | −0.155 | 0.163 |
(A) Direct Effects (Path Coefficients) | |||||||
Effects | Path | t | CI 2.5% | CI 97.5% | f2 | VIF | |
ED→PS | −0.108 * | 1.746 | −0.227 | 0.016 | 0.013 | 1.467 | |
EX→PS | 0.310 *** | 2.803 | 0.078 | 0.514 | 0.059 | 2.621 | |
RE→PS | 0.377 *** | 3.512 | 0.157 | 0.579 | 0.068 | 3.367 | |
MO→PS | −0.004 ‡ | 0.031 | −0.243 | 0.234 | 0 | 3.521 | |
R2 = 0.382; Q2 = 0.282 | |||||||
EX→RE | 0.768 *** | 30.480 | 0.700 | 0.806 | 1.434 | 1 | |
R2 = 0.589; Q2 = 0.215 | |||||||
RE→EU | 0.809 *** | 33.118 | 0.745 | 0.846 | 1.894 | 1 | |
R2 = 0.655; Q2 = 0.287 | |||||||
RE→MO | −0.775 *** | 32.131 | −0.817 | –0.721 | 1.503 | 1 | |
R2 = 0.601; Q2 = 0.192 | |||||||
(B) Specific Indirect Effects | |||||||
Effects | Path | t | CI 2.5% | CI 97.5% | |||
EX→RE→MO | −0.595 *** | 19.476 | −0.645 | −0.522 | |||
RE→MO→PS | 0.003 ‡ | 0.031 | −0.181 | 0.191 | |||
EX→RE→MO→PS | −0.002 ‡ | 0.030 | −0.142 | 0.149 | |||
EX→RE→PS | 0.289 *** | 3.534 | 0.117 | 0.442 | |||
EX→RE→EU | 0.621 *** | 21.257 | 0.548 | 0.666 | |||
(C) Total Indirect Effects | |||||||
EX→MO | −0.595 *** | 19.476 | −0.645 | −0.522 | |||
EX→PS | 0.291 *** | 3.436 | 0.107 | 0.443 | |||
EX→EU | 0.621 *** | 21.257 | 0.548 | 0.666 | |||
RE→PS | 0.003 ‡ | 0.031 | −0.181 | 0.191 |
Construct | Configuration Invariance (Same Algorithms for Both Groups) | Compositional Invariance | Partial Measurement Invariance Established | Equal Mean Assessment | Equal Variance Assessment | Full Measurement Invariance Established | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Correlation Original | 5% | Difference | CI 2.5% | CI 97.5% | Equal | Difference | CI 2.5% | CI 97.5% | Equal | ||||
DE | Yes | 1.000 | 1.000 | Yes | −0.212 | 0.212 | −0.226 | 0.219 | |||||
EX | Yes | 0.996 | 0.952 | Yes | −0.267 | 0.261 | −0.281 | 0.282 | |||||
MO | Yes | 0.998 | 0.941 | Yes | 0.087 | −0.199 | 0.171 | Yes | -0.013 | −0.320 | 0.297 | Yes | Yes |
RE | Yes | 0.993 | 0.972 | Yes | −0.178 | 0.201 | −0.254 | 0.238 | |||||
PS | Yes | 1.000 | 0.999 | Yes | −0.069 | −0.180 | 0.191 | Yes | -0.024 | −0.246 | 0.256 | Yes | Yes |
EU | Yes | 0.961 | 0.952 | Yes | −0.127 | −0.176 | 0.193 | Yes | 0.048 | −0.239 | 0.243 | Yes | Yes |
Relationship | Men | Women | Difference | p-Value | Significant |
---|---|---|---|---|---|
Panel A. Direct Effects (Path Coefficients) | |||||
ED→PS | −0.029 | −0.108 | 0.079 | 0.319 | No |
EX→PS | 0.302 | 0.310 | −0.008 * | 0.951 | Yes |
RE→PS | 0.391 | 0.377 | 0.014 | 0.931 | No |
MO→PS | −0.002 | −0.004 | 0.002 * | 0.991 | Yes |
EX→RE | 0.778 | 0.768 | 0.011 | 0.765 | No |
RE→EU | 0.818 | 0.809 | 0.009 | 0.797 | No |
RE→MO | −0.781 | −0.775 | −0.006 | 0.850 | No |
Panel B. Specific Indirect Effects | |||||
EX→RE→MO | −0.608 | −0.595 | −0.013 | 0.763 | No |
RE→MO→PS | 0.001 | 0.003 | −0.002 * | 0.991 | Yes |
EX→RE→MO→PS | 0.001 | 0.002 | −0.001 * | 0.992 | Yes |
EX→RE→PS | 0.304 | 0.289 | 0.015 | 0.903 | No |
EX→RE→EU | 0.636 | 0.621 | 0.016 | 0.711 | No |
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Valls Martínez, M.d.C.; Ramírez-Orellana, A.; Grasso, M.S. Health Investment Management and Healthcare Quality in the Public System: A Gender Perspective. Int. J. Environ. Res. Public Health 2021, 18, 2304. https://doi.org/10.3390/ijerph18052304
Valls Martínez MdC, Ramírez-Orellana A, Grasso MS. Health Investment Management and Healthcare Quality in the Public System: A Gender Perspective. International Journal of Environmental Research and Public Health. 2021; 18(5):2304. https://doi.org/10.3390/ijerph18052304
Chicago/Turabian StyleValls Martínez, María del Carmen, Alicia Ramírez-Orellana, and Mayra Soledad Grasso. 2021. "Health Investment Management and Healthcare Quality in the Public System: A Gender Perspective" International Journal of Environmental Research and Public Health 18, no. 5: 2304. https://doi.org/10.3390/ijerph18052304
APA StyleValls Martínez, M. d. C., Ramírez-Orellana, A., & Grasso, M. S. (2021). Health Investment Management and Healthcare Quality in the Public System: A Gender Perspective. International Journal of Environmental Research and Public Health, 18(5), 2304. https://doi.org/10.3390/ijerph18052304