title: Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria.
abstract: BACKGROUND
  To describe patterns of recent health service utilisation, and consequent out-of-pocket expenses among older people in countries with low and middle incomes, and to assess the equity with which services are accessed and delivered.
  
  
  METHODS
  17,944 people aged 65 years and over were assessed in one-phase population-based cross-sectional surveys in geographically-defined catchment areas in nine countries - urban and rural sites in China, India, Mexico and Peru, urban sites in Cuba, Dominican Republic, Puerto Rico and Venezuela, and a rural site in Nigeria. The main outcome was use of community health care services in the past 3 months. Independent associations were estimated with indicators of need (dementia, depression, physical impairments), predisposing factors (age, sex, and education), and enabling factors (household assets, pension receipt and health insurance) using Poisson regression to generate prevalence ratios and fixed effects meta-analysis to combine them.
  
  
  RESULTS
  The proportion using healthcare services varied from 6% to 82% among sites. Number of physical impairments (pooled prevalence ratio 1.37, 95% CI 1.26-1.49) and ICD-10 depressive episode (pooled PR 1.21, 95% CI 1.07-1.38) were associated with service use, but dementia was inversely associated (pooled PR 0.93, 95% CI 0.90-0.97). Other correlates were female sex, higher education, more household assets, receiving a pension, and health insurance. Standardisation for age, sex, physical impairments, depression and dementia did not explain variation in service use. There was a strong borderline significant ecological correlation between the proportion of consultations requiring out-of-pocket costs and the prevalence of health service use (r = -0.50, p = 0.09).
  
  
  CONCLUSIONS
  While there was little evidence of ageism, inequity was apparent in the independent enabling effects of education and health insurance cover, the latter particularly in sites where out-of-pocket expenses were common, and private health insurance an important component of healthcare financing. Variation in service use among sites was most plausibly accounted for by stark differences in the extent of out-of-pocket expenses, and the ability of older people and their families to afford them. Health systems that finance medical services through out-of-pocket payments risk excluding the poorest older people, those without a secure regular income, and the uninsured.
authors.affiliation: King's College London, Institute of Psychiatry, Health Services and Population Research Department, London, UK.
authors.forename: Emiliano
authors.initials: E
authors.lastname: Albanese
authors.forename: Zhaorui
authors.initials: Z
authors.lastname: Liu
authors.forename: Daisy
authors.initials: D
authors.lastname: Acosta
authors.forename: Mariella
authors.initials: M
authors.lastname: Guerra
authors.forename: Yueqin
authors.initials: Y
authors.lastname: Huang
authors.forename: K S
authors.initials: KS
authors.lastname: Jacob
authors.forename: Ivonne Z
authors.initials: IZ
authors.lastname: Jimenez-Velazquez
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Llibre Rodriguez
authors.forename: Aquiles
authors.initials: A
authors.lastname: Salas
authors.forename: Ana L
authors.initials: AL
authors.lastname: Sosa
authors.forename: Richard
authors.initials: R
authors.lastname: Uwakwe
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Williams
authors.forename: Guilherme
authors.initials: G
authors.lastname: Borges
authors.forename: A T
authors.initials: AT
authors.lastname: Jotheeswaran
authors.forename: Milagros G
authors.initials: MG
authors.lastname: Klibanski
authors.forename: Paul
authors.initials: P
authors.lastname: McCrone
authors.forename: Cleusa P
authors.initials: CP
authors.lastname: Ferri
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Prince
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003153:Community Health Services / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D003704:Dementia / Q000628:therapy*; D003906:Developing Countries; D005260:Female; D005382:Financing, Personal / Q000706:statistics & numerical data; D019538:Health Care Surveys; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D008297:Male