Health is not only an important aspect of our well-being, it is also integral to our opportunities and our quality of life. Good health is, however, not evenly distributed across the population (see information on health status). Several factors contribute to this, such as our age, our genes, our environment and living conditions, our employment and working conditions, our education, etc. While health inequalities might not be entirely avoidable, they can be mitigated by an effective and high-quality healthcare system.
Some people use more healthcare services than others, see a medical specialist more frequently, take more medicines, have more physiotherapy sessions, etc. As such, these differences are neither inherently negative nor positive. What we need to ask ourselves is firstly, what drives these inequalities and secondly, whether they are justified. These questions shift the perspective from (in)equality to (in)equity – another word for injustice, or unfairness. Some people use more healthcare services because of a chronic health condition. Others use less because they cannot afford them. When inequalities in healthcare use spring from differences in health (needs), they are generally considered desirable and justified. When they are related to socioeconomic differences (e.g. income, educational attainment, professional situation…), on the other hand, they are considered to be a major source of injustice in our society. This is why our public health insurance comprises several protection measures which aim to improve affordable access to care for financially less advantaged groups (see the section on financial accessibility).
Simply put, we need to distinguish between (in)equality and (in)equity in healthcare. Equality means that everyone is treated exactly the same. Equity, on the other hand, means that everyone receives healthcare services appropriate to their needs. Inequalities are, however, much easier to measure than inequities.
Socioeconomic inequalities were found for several indicators examined in other sections (e.g. financial accessibility, people-centredness, preventive care, etc.). This led us to the conclusion that people belonging to disadvantaged social groups have more financial difficulties in accessing healthcare services, are less likely to take part in cancer screening programmes, go to the dentist less often, and take more medication (antidepressants, polypharmacy).
Socioeconomic inequities were assessed for a selection of indicators on contacts with the healthcare system. Healthcare use was adjusted for differences in healthcare needs (following the methodology laid out in our thematic report on equity in access, use and financing of care, published in 2020. These are the indicators we will be focusing on in this section:
- Contacts with the healthcare system in adults (number of contacts and at least one contact): general practitioner, specialist or emergency department (EQ-1), general practitioner only (EQ-2), specialist only (EQ-3) and emergency department only (EQ-4);
- Contacts with the healthcare system in adults (number of contacts and at least one contact): inpatient hospitalisation (EQ-5);
- Contacts with the healthcare system: contacts with dentists (in adults) (EQ-6) and preventive contacts with dentists (in adults and children) (EQ-7).
The figure below gives an overview of the results for the 7 indicators on healthcare use analysed in this section. It shows whether a given subgroup uses more or less healthcare than could be expected after accounting for differences in health. Values around zero (grey) indicate the healthcare use in the subgroup is similar to that of the overall population. Positive values (blue) indicate a higher-than-average healthcare use, negative ones (orange/red coloured) a lower-than-average healthcare use.
Data source: own calculations based on EU-SILC (Statistics Belgium) / IMA-AIM / RIZIV-INAMI
Note: ** Healthcare needs in case of dental care are limited to age and sex; ^^ For children, education groups are based on the educational attainment of parents.
Contacts with the healthcare system over the past 12 months (population aged 18 years or more) (EQ-1, EQ-2, EQ-3, EQ-4)
This series of indicators analyses the likelihood of having had at least one contact with the healthcare system over the past 12 months, as well as the number of contacts (if any). We have considered both a composite indicator combining three care providers (GP, specialist, emergency department) and separate indicators for each care provider are considered. Healthcare use is assessed for a variety of population subgroups (defined e.g. by income level, educational attainment, employment, right to increased reimbursement, etc.).
Contacts for the three types of care providers are interesting to examine together. First, because it is good to have a medical contact on a regular basis, irrespective of the setting. Second, because while care provided by GPs, medical specialists and emergency departments (ED) serve different purposes, with GPs as primary care providers and specialist and emergency care as secondary care providers, there is also a certain level of overlap in the cases they treat.
Whether patients faced with a medical issue turn to one or the other will, of course, depend on a variety of medical factors like the type and severity of the problem, the level of urgency, but also financial or practical considerations. A consultation with a medical specialist is more expensive than with a GP, with official co-payments up to two or three times higher for specialist and a higher probability to pay supplements (see indicator A-8 under financial accessibility). Patients might also have to pay more upfront (and be reimbursed by the mutuality later) for a specialist consultation: while all physicians are allowed (but not obligated) to apply the “third-payer system” for all patients, GP must mandatorily apply it to patients entitled to increased reimbursement. A visit to the ED will typically not be charged upfront but billed at a later time, but it can sometimes be a very expensive option when the patient was not explicitly referred to emergency services.
Moreover, getting an appointment with a specialist can take days, weeks or sometimes months, while GPs can be accessed much faster, often the same day if necessary. EDs are walk-in centres and open 24/7, which makes them even more accessible for patients who feel – rightly or not – that their problem cannot wait.
To a certain extent, these three services can therefore be considered to be (partial) substitutes, and the preferred point of contact of specific population subgroups can shed a light on inequities in access to the medically most appropriate healthcare service. It can also reflect inequities in timely access to care, as a higher-than-average use of the ED in a given population can potentially be a sign that health issues have been allowed to deteriorate (e.g. because care was delayed due to financial reasons or waiting times) to the point of requiring immediate attention.
- The vast majority of the adult population (over 90% overall, over 95% in population groups with high care needs) had at least one contact with a GP, medical specialist or ED in the past 12 months. In 2021, about 89% consulted a GP, 66% consulted a specialist, 15% attended an ED, and a total of 93% of the population attended at least one of these three.
- After adjusting healthcare use for differences in needs, people who were faced with severe material deprivation, at risk of poverty, unemployed/inactive and singles between 18 and 65 years old were less likely to have had at least one contact with the healthcare system.
- Among people who had had at least one contact with either a GP, a medical specialist or an emergency department over the past 12 months, the average number of contacts increased from 9.2 in 2012 to 9.9 in 2021. The number of contacts was strongly associated with health status and, to a lesser extent, with the financial situation.
- After adjusting healthcare use for differences in needs, people who were unemployed, invalid, faced with severe material deprivation or at risk of poverty but without increased reimbursement had less contacts than others with the healthcare system.
- The right to increased reimbursement improved access to care. Contrary to other financially vulnerable groups, people entitled to increased reimbursement did not seem to be facing inequity in healthcare use overall (whether in likelihood of having at least one contact or in the number of contacts), even when they were at risk of poverty.
- In 2021, about 89% of the population consulted a GP over the past year (over 93% in subgroups with high care needs). There is an upward trend over time, except for people at risk of poverty but not entitled to increased reimbursement.
- After adjusting healthcare use for differences in needs, the likelihood of having consulted a GP over the past year was lower in people who were faced with material deprivation or at risk of poverty, unemployed/inactive, people belonging to the top income class and singles between 18 and 65 years old.
- Being entitled to increased reimbursement is not associated with inequities in GP access, even for those at risk of poverty. This suggests an improved accessibility for this group, that does not extend to other financially vulnerable groups.
- Among people with at least one GP contact, the average annual number of GP contacts increased from 6.2 in 2012 to 6.5 in 2021.The number of GP contacts is strongly associated with health status and, to a lesser extent, with the financial situation.
- After adjusting healthcare use for differences in needs, people who are unemployed, at risk of poverty but not entitled to increased reimbursement, highly educated or have a high income seem to have fewer GP contacts than others. People with a lower level of education, entitled to increased reimbursement and over 80 years old have more GP contacts than others.
- Some vulnerable groups are less likely to have had at least one contact with a GP on the one hand, but have more follow-up contacts once a first contact is made on the other hand. This might reflect the good accessibility of GP care, but it could also be a sign that those people struggle to access specialist care and turn to more affordable GP care instead.
- In 2021, 66% of the population consulted a medical specialist in the past year (about 80% in subgroups with high care needs). There is an upward trend over time for most population subgroups, with the exception of people facing severe material deprivation, people at risk of poverty but not entitled to increased reimbursement and self-employed workers.
- After adjusting healthcare use for differences in needs, the likelihood of having a contact with a medical specialist systematically increased with income and level of education. In addition, inequities were also found for people who are unemployed, living in severe material deprivation or at risk of poverty. The likelihood of having a contact with a medical specialist was also lower for people entitled to increased reimbursement, which means that access to specialist care is less equitably distributed than access to GP care for this group.
- Among people with at least one contact with a medical specialist, the average number of annual contacts increased from 4.3 in 2012 to 4.7 in 2021. There was little variation in the annual number of contacts based on income, educational attainment or financial vulnerability, and more important differences based on health status.
- After adjusting healthcare use for differences in needs, the number of contacts with medical specialists increased with the level of educational attainment and with the income level. Conversely, almost all financially vulnerable population subgroups have a lower average number of specialist consultations than expected based on their health status.
- Only a limited share of the population (15%) had one or more contacts with an emergency department over the past year. Lower educational attainment, lower income and poor self-assessed health were associated with a higher likelihood of having had one or more contacts with an ED over the past year.
- Among people who went to the ED at least once, the average number of annual contacts was around 1.3-1.4; about 75% of them only had one contact, 15% had two.
- After adjusting healthcare use for differences in needs, a lower income and a lower level of educational attainment were still associated with a higher likelihood of having at least one ED contact over the past year. People entitled of increased reimbursement and people living in households with severe material deprivation, in particular, were more likely to have at least one ED contact. There were only minor inequities in the number of ED contacts.
Contacts with the healthcare system: inpatient hospitalisation (population aged 18 years or more) (EQ-5)
- About 10% of the population had an inpatient admission in the past 12 months (between 20% and 30% in groups with high care needs), with a stable trend over time.
- Among people who were admitted to hospital at least once over the past year, the average number of inpatient hospitalisations was around 1.3-1.4 per year; about 75% of them had been admitted once, 15% twice.
- Admission rates in the lowest income/education group were twice as high as in the highest income/education group. However, no substantial inequities remained once healthcare use was adjusted for differences in needs. There were only minor differences in the needs-adjusted number of hospitalisations. This suggests that differences in use of inpatient care are mostly related to differences in healthcare needs, which is a positive finding.
Contacts with the healthcare system: dentists (EQ-6, EQ-7)
Regular (preventive) dental exams are recommended to all regardless of health status. However, as these contacts are often not linked to acute or urgent health issues, they are also more likely to be postponed or dropped when money is tight or when the added value of preventive care is not sufficiently understood. This makes dental contacts a valuable indicator of possible inequities based on factors like e.g. income, but also education level.
- Only half of the Belgian population had regular contacts with a dentist in the past 3 years.
- After correcting dental care use for age and gender (as no specific variables are available to correct for dental care needs), the likelihood of regular contacts with a dentist strongly increased with income and level of education. Inequities (i.e. lower contact rates) were found for all financially vulnerable population subgroups and particularly for people faced with severe material deprivation. Lower contact rates were also found for people entitled to increased reimbursement.
Regular preventive contacts with a dentist (population aged 18 years or more; population aged below 18 years) (EQ-7)
- The population adhering to regular preventive dental care has increased over time, from one quarter of the population in 2012 to one third since 2018.
- After correcting dental care use for age and gender, the likelihood of regular contacts with a dentist strongly increases with the income and education level. Inequities (i.e. lower contact rates) are found for all financially vulnerable population subgroups and particularly for those facing severe material deprivation. Lower contact rates are also found for those entitled to increased reimbursement.
- Among children, the rate of regular preventive dental contacts is very low in the youngest age group of 3-4 years old (6.7% in 2012 increasing to 11.3% in 2021), and increases in children aged 5 to 14 years (35.5% in 2012 increasing to 44.5% in 2021) and in adolescents aged 15 to 17 years (30.9% in 2012 increasing to 39.4% in 2021).
- After correcting healthcare use for age and gender, higher income and education levels of parents are strongly associated with higher contact rates in children and teenagers. Inequities (i.e. lower contact rates) are found for all financially vulnerable population subgroups, and in particular for children from households facing severe material deprivation and households at risk of poverty. Lower contact rates are also found for those entitled to increased reimbursement. Inequities are relatively stable over time.