Chapter 2

5 Managing equity aspects
A universal health system that sacrifices, partially at least, the principle of patients’ freedom
of choice, in favour of universal coverage of the population’s health care needs,
must necessarily focus on the equitative impact of out-of-pocket expenses (OOP) on
household budgets.
Due to the increasing scarcity of public financial resources, at least when compared to
the growth of need, the concept is strengthened because it becomes necessary to manage
a rationing process, whether explicit (changes to the LEA) or implicit (as is more frequently
the case). Understanding the equitative “sign” of the health policies adopted, is
a fundamental task from a social perspective.
For example, the return of co-payments, which is absolutely to be hoped for, with a view
to managing the issue of appropriateness from the points of view of both supply and
demand, entails financial effects on the families, which must be carefully assessed and
monitored.
The CEIS Health Report has now reached its third edition of monitoring the equity of our
NHS: Doglia and Spandonaro (see chapter 4.1) conclude that there is a “hard core” of
social unfairness, numerically represented by impoverished families and, at least in part,
by those incurring “catastrophic” expenses.
In the 2002-2004 period (to which the latest data made available by ISTAT refer), this hard
core consists of 11% of poor families, to which we must add 1,3% of impoverishment
due to health care. In other words, health costs cause an increase of about 10% in the
number of the poor. Then we must add over 4% of households which, although nominally
entitled to global coverage of their health needs, must nevertheless incur health carerelated
expenses that exceed the threshold proposed by the WHO, i.e. 40% of their
capacity to pay.
In absolute terms this is a sizable phenomena, since over 1.200.000 households are
involved. These households represent both a special area of weakness and a group of
citizens that cannot, or do not want, to exercise their right to care; they should obviously
become the focus of policy makers.
Old age is a powerful catalyst of weakness: over 60% of impoverished families include
elderly members: in other words, old age increases by 50% the likelihood of impoverishment
caused by out of pocket health expenditure.
The areas of care that most contribute to this phenomena are, for the poorer households,
pharmaceuticals and specialist services, but also dentistry and long term care for the
households that “can afford it”; for the last group, therefore, the phenomenon is greater
than it seems, because not having incurred health expenses does not necessarily mean
having received free treatment. The health problem may simply have been deferred (often
entailing higher direct and indirect costs in the future) or “met within the family”, with
costs that are not recognised.
Furthermore, it must be noted that direct expenditure by households include truly “private”
costs and the amount of co-payments for the NHS services, besides the “mixed”
ones, represented by so-called intra-moenia services (services privately provided by SSN
employees).
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CEIS Health Report 2006