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A special issue of Healthcare (ISSN 2227-9032). This special issue belongs to the section "Health Policy".

Deadline for manuscript submissions: closed (30 April 2022) | Viewed by 44240

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Dr. Hossein Zare

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Johns Hopkins Bloomberg School of Public Health, University of Maryland Global Campus, Largo, MD 20774, USA
Interests: income inequality; disparities; justice inequality; place-based inequality; geographical inequality
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

If certain people are making money and becoming richer without actively causing harm to others, is that really a problem? Everyone agrees that poverty is a concerning issue, of course, but is it really concerning that rich people are making more and more money and accumulating more and more wealth? Is income inequality something we actually need to be worried about? These are just some of the questions that mainstream economists, some of whom think we are focusing way too much on inequality, have been asking in the last few years. Income inequality, as we all know, has recently shown alarming signs of increasing sharply, with the poor finding themselves stuck in poverty, which leads to another important question: What are the consequences of large income inequality? Does the discrepancy in incomes harm everyone in society or is it only poor people who suffer from it? Angus Deaton and Joseph Stiglitz —The Nobel Prize Economists—believe that those at the very top level of income “are plundering the poor and the middle classes […] by lobbying, by rewriting the rules […] by rewarding and being rewarded by their cronies in business and in government”. This statement may be true in the “market” as a “general term”, but it does not actually tell us how income inequality impacts the health industries and, most importantly, health outcomes.

The world is certainly a better place to live in today than it used to be, with some previously impoverished parts of world experiencing positive developments that are helping them to escape from income/health inequalities. There is, however, still a long way to go, and the issue of health and income inequality is not one that need only concern poor countries, but also rich and developed ones. The combination of poverty, health inequality, and racism has opened up gaps and led to an urgent need for a plan-to-action to fix an unequal world. In this Special Issue, we would like to examine in depth the several aspects of income/health inequality and their combinations with poverty, racism, and disparities. Some of the main areas to be covered in this issue include:

Poverty, income inequality, and health outcome;
Market, inequalities, and health outcome;
Lobbying, rent–seeking and health inequality;
Health inequality, poverty, and access to healthcare;
Health inequality in the modern world;
How to help those who are left behind.

Prof. Hossein Zare
Guest Editor

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Keywords

Income inequality
Health inequality
Racism and racial disparities
Poverty elevation

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Related Special Issue

Inequality in Health Systems and Health Outcomes in Healthcare (5 articles)

Published Papers (12 papers)

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Research

Jump to: Review

10 pages, 966 KiB

Open AccessArticle

Mortality-to-Incidence Ratio for Nasopharyngeal Carcinoma Is Associated with Health Expenditure

by Chen Dong, Jing-Tong Fu, Han-Ru Wu, Yu-Chi Chao, Ying-Ching Chen, Wen-Wei Sung, Wen-Jung Chen and Chih-Jung Chen

Healthcare 2022, 10(9), 1615; https://doi.org/10.3390/healthcare10091615 - 25 Aug 2022

Cited by 5 | Viewed by 2105

Abstract

Geographic and gender-specific disparity can be observed in nasopharyngeal carcinoma (NPC). While screening and more effective therapies, such as induction chemotherapy, could improve survival rates, they are costly. This study aims to explore the correlation between healthcare expenditure and the mortality-to-incidence ratio (MIR) in NPC. Data were obtained from the World Health Organization and the Global Cancer Observatory. The correlation was evaluated by Spearman’s rank correlation coefficient. Most new cases and deaths occur in Asia, and more males are affected than females. Our study shows that countries with higher MIRs have lower levels of health expenditure regardless of the NPC’s gender-specific incidence. Correspondingly, MIRs are all significantly negatively associated with current health expenditure (CHE) per capita and CHE as a percentage of gross domestic product (CHE/GDP) in both genders. CHE per capita and CHE/GDP have a significant impact on NPC outcomes. Moreover, economic status is a potential major factor in MIR differences between countries. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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11 pages, 3129 KiB

Open AccessArticle

Measuring the Inequalities in the Distribution of Public Healthcare Resources by the HRDI (Health Resources Density Index): Data Analysis from 2010 to 2019

by Jieyu Zhao, Yuchen Yang and Katsuhiko Ogasawara

Healthcare 2022, 10(8), 1401; https://doi.org/10.3390/healthcare10081401 - 27 Jul 2022

Cited by 8 | Viewed by 5321

Abstract

Background: In China, a developing country, the imbalance of development exists in different fields, and the inequalities in the distribution of healthcare services have garnered increasing attention. This study aimed to assess the healthcare services allocation and compare the latest distribution ratios of the essential healthcare indicators with the national requirement values announced by the government to research the level of healthcare development in China. Methods: Data were extracted from the Chinese Statistical Yearbook (2010–2019). The Healthcare Resource Density Index (HRDI) was used to evaluate equity in the demographic and geographical dimensions. The requirement values related to the ratio of doctors, nurses, and institution beds per thousand people were drawn from government documents. The data of healthcare serviceability indicators were compared with those requirements to check the situation of each province’s medical development. Results: From 2010 to 2018, there was a sustainable upward trend in government investment, however, a noticeable drop in the investment in northeast areas was seen. Although the HRDI of the institutions, beds, doctors, and nurses experienced some small fluctuations over the years, the developing areas in the middle-west areas had almost approached the level of developed east areas. There were only four provinces that met the requirements of the government in all three indicators (the ratio of institution beds, doctors, and nurses per thousand people). Conclusion: The equality of the distribution of healthcare services in China was unfair between the eastern and middle-western areas. The government launched the developing requirements and paid additional attention to narrowing the imbalance among different economic level regions to meet the needs of the local people. Although many provinces did not meet the requirements for medical resources in 2019, the distribution of healthcare services was approached relatively equitably countrywide. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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10 pages, 413 KiB

Open AccessArticle

Does an Overcrowded Emergency Department Reduce Moral Hazard? Lessons from Emergency Department Visits to Three Hospitals in an Israeli Metropolitan Area

by Fuad Basis, Aviad Tur-Sinai and Ziona Haklai

Healthcare 2022, 10(5), 915; https://doi.org/10.3390/healthcare10050915 - 15 May 2022

Viewed by 2190

Abstract

Metropolitan Haifa, Israel, has three hospitals: Rambam Health Care Campus, Bnai Zion Medical Center, and Carmel Medical Center. In 2007–2014, the length of stay at RHCC’s emergency department increased, while the number of visits decreased. We ask whether the increase in LOS is associated with the falling numbers of visits to other EDs, whether an increase in LOS induces more referrals to competing hospitals in the metropolitan area, and whether it pays to be a crowded ED in mitigating moral hazard. Average LOS at Rambam climbed from 3.5 h in 2000–2007 to 6.4 in 2008–2018. While the number of visits to Rambam decreased significantly, those to Bnai Zion increased significantly and quite linearly. A one-way ANOVA test reveals a statistically significant difference among the three hospitals. In addition, Rambam was significantly different from Carmel but not from Bnai Zion. When LOS stabilized at Rambam from 2016 to 2018 and increased at Bnai Zion, referrals to Rambam went up again. Policymakers should instruct all hospitals to publish LOS data, regulate referrals to EDs, and find an optimal LOS that will reduce competition, non-urgent visits, and moral hazard. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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10 pages, 276 KiB

Open AccessArticle

Romani Women and Health: The Need for a Cultural-Safety Based Approach

by Fernando Jesús Plaza del Pino, Oscar Arrogante, Juana Inés Gallego-Gómez, Agustín Javier Simonelli-Muñoz, Gracia Castro-Luna and Diana Jiménez-Rodríguez

Healthcare 2022, 10(2), 271; https://doi.org/10.3390/healthcare10020271 - 30 Jan 2022

Cited by 4 | Viewed by 4395

Abstract

The Romani are the main European ethnic minority. The Romani people’s situation of social vulnerability and their difficulties accessing the health system make their health indicators worse than those of the non-Romani population. The present study will delve into health beliefs, and experiences with health services and professionals, through the perspectives of Romani women. In this qualitative study, 16 women of different ages were interviewed in a city located in the South of Spain. Four themes emerged from the analysis of the data: the construction of the identity of Romani women, difficulties in life, health and disease beliefs and barriers to accessing the health system. We conclude that every project for the improvement of the health of the Romani community must take into account the active participation of Romani women and must consider the principles of Cultural Safety, by delving into the intercultural training of health professionals and addressing the social determinants of health which affect the Romani collective. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

12 pages, 1054 KiB

Open AccessArticle

Acceptability of Community-Based Tuberculosis Preventive Treatment for People Living with HIV in Zimbabwe

by Martin K. Msukwa, Munyaradzi P. Mapingure, Jennifer M. Zech, Tsitsi B. Masvawure, Joanne E. Mantell, Godfrey Musuka, Tsitsi Apollo, Rodrigo Boccanera, Innocent Chingombe, Clorata Gwanzura, Andrea A. Howard and Miriam Rabkin

Healthcare 2022, 10(1), 116; https://doi.org/10.3390/healthcare10010116 - 7 Jan 2022

Cited by 3 | Viewed by 3334

Abstract

As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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14 pages, 1236 KiB

Open AccessArticle

A Comparison of Country’s Cultural Dimensions and Health Outcomes

by Justin C. Matus

Healthcare 2021, 9(12), 1654; https://doi.org/10.3390/healthcare9121654 - 29 Nov 2021

Cited by 4 | Viewed by 3357

Abstract

Research comparing health care systems of countries, with a particular emphasis on health care spending and health care outcomes, has found unexplained differences which are often attributed to the countries’ cultures, yet these cultural dimensions are never completely identified or measured. This study examines if culture predicts a country’s population health, measured as life expectancy and health care spending. Using the Hofstede country-level measures (six dimensions) of culture as independent variables, two regression models to predict life expectancy and per capita health care using 2016 World Bank data were developed. The original data set included 112 countries which was reduced to a final total of 60 due to missing or incomplete data. The first regression model, predicting life expectancy, indicated an adjusted R square of 0.45. The second regression model, predicting per capita health care spending, indicated an adjusted R square of 0.63. The study suggests culture is a predictor of both life expectancy and health care spending. However, by creating a composite measure for all six culture measures, we have not found a significant association between culture and life expectancy and healthcare expenditure. The study is limited by small sample size, differences in geography, climate and political systems. Future research should examine more closely the relative influence of individualism on life expectancy and assumptions about models of socialized medicine. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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15 pages, 1963 KiB

Open AccessArticle

How Income Inequality and Race/Ethnicity Drive Obesity in U.S. Adults: 1999–2016

by Hossein Zare, Danielle R. Gilmore, Ciana Creighton, Mojgan Azadi, Darrell J. Gaskin and Roland J. Thorpe, Jr.

Healthcare 2021, 9(11), 1442; https://doi.org/10.3390/healthcare9111442 - 26 Oct 2021

Cited by 3 | Viewed by 3881

Abstract

Obesity is a major public health problem both globally and within the U.S. It varies by multiple factors, including but not limited to income and sex. After controlling for potential covariates, there is little evidence to determine the association between income and obesity and how obesity may be moderated by sex and family income. We examined the association between income and obesity in U.S. adults aged 20 years and older, and tested whether this relationship differs by race or ethnicity groups. For this analysis, we used data from the 1999–2016 National Health and Nutrition Examination Surveys (NHANES). Obesity was determined using Body Mass Index ≥ 30 kg/m²; the Gini coefficient (GC) was calculated to measure income inequality using the Poverty Income Ratio (PIR). We categorized the PIR into five quintiles to examine the relationship between income inequality and obesity. For the first set of analyses, we used a modified Poisson regression in a sample of 36,665 adults, with an almost equal number of men and women (women’s ratio was 50.6%), including 17,303 white non-Hispanics (WNH), 7475 black non-Hispanics (BNHs), and 6281 Mexican Americans. The models included age, racial/ethnic groups, marital status, education, health behaviors (smoking and drinking status and physical activities), health insurance coverage, self-reported health, and household structure (live alone and size of household). Adjusting for potential confounders, our findings showed that the association between PIR and obesity was positive and significant more frequently among WNH and BNH in middle and top PIR quintiles than among lower-PIR quintiles; this association was not significant in Mexican Americans (MAs). Results of GC in obese women showed that in comparison with WNHs (GC: 0.34, S.E.: 0.002), BNHs (GC: 0.38, S.E.: 0.004) and MAs (GC: 0.41, S.E.: 0.006) experienced higher income inequality, and that BNH obese men experienced the highest income inequality (GC: 0.45, S.E.: 0.011). The association between PIR and obesity was significant among WNHs and BNHs men in the 3rd, 4th and 5th PIR quintiles. The same association was not found for women. In treating obesity, policymakers should consider not only race/ethnicity and sex, but also strategies to reduce inequality in income. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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10 pages, 418 KiB

Open AccessArticle

Out-of-Pocket Spending for Cancer Medication, Financial Burden, and Cost Communication with Oncologists in the Last Six Months of Life in Israel

by Aviad Tur-Sinai, Netta Bentur and Damien Urban

Healthcare 2021, 9(9), 1120; https://doi.org/10.3390/healthcare9091120 - 30 Aug 2021

Viewed by 2028

Abstract

Honest communication between oncologists and patients is important in alleviating the financial burden of cancer care. This study explored patient–relative–oncologist communication regarding the affordability of out-of-pocket (OOP) medication and the extent to which this communication addresses itself to the families’ financial burden. A cross-sectional survey was conducted among primary caregivers of deceased cancer patients. About 43% of relatives said that they and/or the patients had paid out of pocket for medications during the last six months of the patient’s life. Most (73%) oncologists suggested an OOP medication without asking about financial ability, 43% hardly explained the advantages of an OOP medication, and 52% hardly explained any treatment alternatives. Older age and female gender were related to less communication about an OOP medication, and better education, greater affluence, and having private health insurance were related to more communication. About 56% of relatives said that OOP payment for medications inflicted a very heavy or heavy financial burden on patients and their households. Physicians’ interest in financial ability and giving explanation lightened the burden. Given the difficulty of explaining the complex interactions of cost and clinical outcomes, oncologists need to be better educated in skills that would enable them to communicate costs more openly and should consider the cost of a treatment when prescribing it. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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17 pages, 6893 KiB

Open AccessArticle

Spatial Disparities in Access to Healthcare Professionals in Sichuan: Evidence from County-Level Data

by Ning Zhang, Wei Ning, Tao Xie, Jinlin Liu, Rongxin He, Bin Zhu and Ying Mao

Healthcare 2021, 9(8), 1053; https://doi.org/10.3390/healthcare9081053 - 16 Aug 2021

Cited by 4 | Viewed by 2953

Abstract

As a southwestern province of China, Sichuan is confronted with geographical disparities in access to healthcare professionals because of its complex terrain, uneven population distribution and huge economic gaps between regions. With 10-year data, this study aims to explore the county-level spatial disparities in access to different types of healthcare professionals (licensed doctors, registered nurses, pharmacists, technologists and interns) in Sichuan using temporal and spatial analysis methods. The time-series results showed that the quantity of all types of healthcare professionals increased, especially the registered nurses, while huge spatial disparities exist in the distribution of healthcare professionals in Sichuan. The local Moran’s I calculations showed that high–high clusters (significantly high healthcare professional quantity in a group of counties) were detected in Chengdu (capital of Sichuan) and relatively rich areas, while low–low clusters (significantly low healthcare professional quantity in a group of counties) were usually found near the mountain areas, namely, Tsinling Mountains and Hengduan Mountains. The findings may deserve considerations in making region-oriented policies in educating and attracting more healthcare professionals to the disadvantaged areas. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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9 pages, 809 KiB

Open AccessArticle

Improvement the Healthcare Quality of Emergency Department after the Cloud-Based System of Medical Information-Exchange Implementation

by Ding-Chung Wu, Hong-Ling Lin, Chun-Gu Cheng, Chia-Peng Yu and Chun-An Cheng

Healthcare 2021, 9(8), 1032; https://doi.org/10.3390/healthcare9081032 - 11 Aug 2021

Cited by 5 | Viewed by 2332

Abstract

Background: The National Health Insurance has been implemented in Taiwan since 1995. The government established a medical information-exchange system to reduce duplicate medications and examinations, which have inhibited healthcare expenditures. The potential benefit of medical information exchange about healthcare quality in emergency departments (ED) was worthy of evaluating; Methods: The inquiry rate of cloud data for patients’ information in Taiwanese National Health Insurance Administration was defined as a factor, and the healthcare quality included the ratio of staying more than 48 h in the ED and the hospitalization rate within 8 h from ED by triage levels of 1, 2, and 3 in different levels of hospitals from 2013 to 2019. Poisson regression analysis was used to quantify time trends of the query rate of the MediCloud system, the rate of staying more than 48 h in ED, admission rate within 8 h in ED, and the effect of healthcare quality in ED after MediCloud system implementation; Results: The health information exchange decreased the rate of staying over 48 h in the ED of medical centers. It also improved the early hospitalization of urgent ED patients in regional hospitals; Conclusions: Through medical information exchange to understand patients’ current conditions, we can reduce crowding in the ED of medical centers and facilitate rapid hospitalization of urgent patients in regional hospitals. According to these findings, the government should establish medical information exchange to improve the healthcare quality of ED. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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14 pages, 1459 KiB

Open AccessArticle

Investigating Health Equity and Healthcare Needs among Immigrant Women Using the Association Rule Mining Method

by Ming-Hseng Tseng and Hui-Ching Wu

Healthcare 2021, 9(2), 195; https://doi.org/10.3390/healthcare9020195 - 10 Feb 2021

Cited by 4 | Viewed by 2586

Abstract

Equitable access to healthcare services is a major concern among immigrant women. Thus, this study investigated the relationship between socioeconomic characteristics and healthcare needs among immigrant women in Taiwan. The secondary data was obtained from “Survey of Foreign and Chinese Spouses’ Living Requirements, 2008”, which was administered to 5848 immigrant women by the Ministry of the Interior, Taiwan. Additionally, descriptive statistics and significance tests were used to analyze the data, after which the association rule mining algorithm was applied to determine the relationship between socioeconomic characteristics and healthcare needs. According to the findings, the top three healthcare needs were providing medical allowances (52.53%), child health checkups (16.74%), and parental knowledge and pre- and post-natal guidance (8.31%). Based on the association analysis, the main barrier to the women’s healthcare needs was “financial pressure”. This study also found that nationality, socioeconomic status, and duration of residence were associated with such needs, while health inequality among aged immigrant women was due to economic and physical factors. Finally, the association analysis found that the women’s healthcare problems included economic, socio-cultural, and gender weakness, while “economic inequality” and “women’s health” were interrelated. Full article

(This article belongs to the Special Issue Inequality in Health Systems)

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Review

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16 pages, 335 KiB

Open AccessReview

Disease-Specific Health Disparities: A Targeted Review Focusing on Race and Ethnicity

by Mark R. Cullen, Adina R. Lemeshow, Leo J. Russo, David M. Barnes, Yaa Ababio and Aida Habtezion

Healthcare 2022, 10(4), 603; https://doi.org/10.3390/healthcare10040603 - 23 Mar 2022

Cited by 27 | Viewed by 7734

Abstract

Background: Wide disparities in health status exist in the United States across race and ethnicity, broadly driven by social determinants of health—most notably race and ethnic group differences in income, education, and occupational status. However, disparities in disease frequency or severity remain underappreciated for many individual diseases whose distribution in the population varies. Such information is not readily accessible, nor emphasized in treatment guidelines or reviews used by practitioners. Specifically, a summary on disease-specific evidence of disparities from population-based studies is lacking. Our goal was to summarize the published evidence for specific disease disparities in the United States so that this knowledge becomes more widely available “at the bedside”. We hope this summary stimulates health equity research at the disease level so that these disparities can be addressed effectively. Methods: A targeted literature review of disorders in Pfizer’s current pipeline was conducted. The 38 diseases included metabolic disorders, cancers, inflammatory conditions, dermatologic disorders, rare diseases, and infectious targets of vaccines under development. Online searches in Ovid and Google were performed to identify sources focused on differences in disease rates and severity between non-Hispanic Whites and Black/African Americans, and between non-Hispanic Whites and Hispanics. As a model for how this might be accomplished for all disorders, disparities in disease rates and disease severity were scored to make the results of our review most readily accessible. After primary review of each condition by one author, another undertook an independent review. Differences between reviewers were resolved through discussion. Results: For Black/African Americans, 29 of the 38 disorders revealed a robust excess in incidence, prevalence, or severity. After sickle cell anemia, the largest excesses in frequency were identified for multiple myeloma and hidradenitis suppurativa. For Hispanics, there was evidence of disparity in 19 diseases. Most notable were metabolic disorders, including non-alcoholic steatohepatitis (NASH). Conclusions: This review summarized recent disease-specific evidence of disparities based on race and ethnicity across multiple diseases, to inform clinicians and health equity research. Our findings may be well known to researchers and specialists in their respective fields but may not be common knowledge to health care providers or public health and policy institutions. Our hope is that this effort spurs research into the causes of the many disease disparities that exist in the United States. Full article

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