Quantes vegades vas al metge?

Income-Related Inequalities in Health Service Utilisation in 19 OECD Countries, 2008-2009

 La comparació de la distribució de la renda amb la necessitat de salut és l'objectiu d'anàlisi d'un paper recent de l'OCDE referit a 19 països. Els conceptes bàsics:

Inequality and inequity of care are two key concepts. Here, inequality in health care utilisation refers to the differences in use that can be observed between individuals or population groups,whereas inequity refers to those differences remaining after adjustment for need for health care. In thisstudy, adjustment for need has been made for doctor visits only, with equal need assumed for dental visits and cancer screening. Horizontal equity is the principle that requires that people in equal need of health care are treated equally, irrespective of individual characteristics such as income, place of residence or race.

La probabilitat d'anar al metge al darrers 12 mesos es troba entre el 68% (USA) i el 91% (França). El més inequitatiu en accés és USA, i el menys Dinamarca. La inequitat en freqüencia de visites totals és màxima a Polònia, seguida d'USA i Espanya. La menor inequitat en freqüència torna a ser Dinamarca. La inequitat de freqüència a especialistes ve encapçalada per Espanya (i en el cas dels dentistes queda en segona posició).
El resum:

Horizontal inequities and inequalities in health care utilisation persist across the 19 OECD countries studied. After adjustment for needs for health care, the better-off are more likely to visit doctors - especially specialists - than those with lower incomes. With GP contacts, the scenario is different. In most countries, for the same level of need for health care, the worse-off are as likely as the better-off to contact a GP, and they visit more often. Income-related  inequalities in breast cancer screening appear in around half of all countries, with a higher rate among the better-off. Pro-rich inequalities in dental visits and in cervical cancer screening are present in almost all countries.

A la pregunta del dia, -quantes vegades vas al metge- cal respondre per aquí aprop, que depèn de si vas a l'especialista o al metge de família. En el primer cas, més concretament depèn de la butxaca, aquesta és la resposta de l'estudi. En el segon cas depén de la necessitat de resoldre un problema de salut. Comencen els jocs olímpics i ja s'ha adjudicat una medalla d'or i una altra de bronze.

PS. El desgavell del honoraris mèdics lliures a França, un excés de 2.400 milions d'euros en un any. A Le Monde. I a Le Monde diplomatique exploren altres vies per la sanitat pública (francesa).

PS. Els mercats encara són persones. Ho podeu contrastar Le Monde Diplomatique.

Les desigualtats justes

What does the empirical evidence tell us about the injustice of health inequalities?

En alguna ocasió he comentat que hi ha una indústria en l'anàlisi de les desigualtats en salut. Hi ha una producció continuada que no se sap ben bé on va ni quines implicacions pràctiques aporta, fins i tot és desconeix el consumidor de la recerca.
Hi ha una part necessària i fonamental de l'anàlisi que passa per la descripció, però el salt entre saber i què fer amb el que sabem és crucial. I aquí entren els mecanismes de causalitat, quines d'aquelles desigualtats són "injustes" i cal corregir. L'Angus Deaton ha fet un paper per posar ordre a les idees, cosa que s'agraeix, i diu:

Facts and correlations, without an understanding of causation, are neither sufficient to guide policy nor to make ethical judgments. Without getting causation right, there is no guarantee that interventions will not be harmful. It is also possible that an inequality that might seem to be prima facie unjust might actually be the consequence of a deeper mechanism that is in part benevolent, or that is unjust in a different way.

Després repassa diferents factors, origen, edat, sexe, raça, status socioeconòmic, etc. Destaco, especialment per a entusiastes:

The health inequalities literature frequently argues that differences in incomes cause health differences, a position that I have argued is largely mistaken. A related but different view is that differences in income are themselves a risk factor for the level of health (as well as for the levels of other good social outcomes), so that the rich as well as the poor are hurt by large income differences

I la seva conclusió:

Health inequalities are a matter of great moral concern. But whether we see them as an injustice, and whether and how we design policy to correct them, depends on how they come about. In this essay, I have argued that childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes. Among adults, the main priority should be the design of schemes that prevent the impoverishment that can come from ill-health, through loss of the ability to work, or through the costs of treatment.

Resta molt per fer i encara més per reconduir.

PS. Podeu consultar el Martmot Indicators aquí

Diferències en salut

New trends in health inequalities research: now it’s personal
M'ha interessat en Mackenbach al Lancet. Algú ho havia de dir, i pocs podien pensar que fos ell qui finalment ho fes tan explícit.
Les diferències en salut tenen a veure amb les persones a més de l'entorn social, ambiental i molts altres factors.
Aquest paràgraf esdevé clau:

Health inequalities researchers are no longer reluctant to include personal characteristics of individuals in their explanatory research. 10–20 years ago, this approach was unpopular because it was thought to detract from structural explanations of health inequalities, such as inadequate income, health risks in the environment, or no access to health care.
Some investigators feared that focusing on personal characteristics, such as lifestyle behaviours, personality traits, or cognitive ability, would reinforce politically conservative views, which suggest that social inequalities result from ignorance, irresponsibility, or other forms of irremediable individual failure

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Un avís per a navegants que encara resten ancorats a paradigmes rancis. Venint de qui ve cal tenir-lo en compte. Una precaució tant sols en la recomanable lectura de l'article, l'èmfasi en temes cognitius cal situar-lo en el punt just, i l'èmfasi en els nens és obvi. La responsabilitat envers la salut és en primer lloc individual.