Economía y salud
BOLETÍN INFORMATIVO - Año 2014. Abril. nº 79
En este número Temas

Con acuse de recibo
Reseña libros
Jornadas AES
Buzón de sugerencias

Inequity in long-term care use and unmet need: two sides of the same coin

While inequity in health care use in developed countries is well documented in the literature, little is known about the distribution of access to long-term care services across the socioeconomic spectrum. This is especially relevant in a context of an ageing population and multi-morbid patients. The recent published working paper by García-Gómez and colleagues (García-Gómez P, Hernández-Quevedo C, Jiménez Rubio D, Oliva J (2014). Inequity in long-term care use and unmet need: two sides of the same coin. HEDG Working Paper 14/02. The University of York) contributes to this literature, using a rich Spanish dataset for 2008 and utilization and unmet needs variables to measure access to long-term care services by the disabled population. Spain provides a relevant case study, as universal coverage is provided for since the 2006 Dependency Law. Results show that, while those better-off tend to use a larger share of formal services, provided by professionals, as well as community care services and some home care services, informal care is concentrated among the worse-off. Variation is also found depending on whether subjective or a more objective measure of unmet needs is analysed. Further, the study shows how inequities in access to LTC services remain for those individuals with universal access to these services.

To contribute to the dynamism of the Bulletin, we have asked several national and international experts for a comment on this study, including their views on the empirical strategy, the main results and their transferability to other contexts in Europe. The comments that we received are compiled below.

Of course, this is just a first step to contribute to the debate within the Bulletin! Readers are encouraged to participate by providing their comments on these and other issues they may consider relevant, using the template provided at the end of this contribution.

Cristina Hernández-Quevedo


García-Gómez and colleagues present a series of interesting findings on the use of long-term care (henceforth, LTC), on unmet need and on horizontal inequity in use and unmet need of LTC. I would like to comment on one of the interesting aspects of their analysis: the finding that universal coverage does not guarantee equal access to LTC services.

This study concludes that alternative measures of inequity yield different conclusions about whether the inequity is pro-poor or pro-rich and about the degree of inequity. Yet, in most cases, the sign and the significance of the results are the same regardless of whether they are estimated for i) the entire sample of dependent respondents or ii) the most severely disabled respondents only, for whom universal coverage had been introduced in 2006. This finding means that inequity has persisted after the introduction of the Dependency Act. In Bakx et al. (forthcoming), we reached a similar conclusion: even though both the Netherlands and Germany have universal coverage, access to formal LTC is more difficult in Germany than in the Netherlands. In the case of the Netherlands and Germany, other system features such as eligibility rules and coverage generosity and, indirectly, social preferences, make a difference.

Inequity in LTC use may persist despite universal coverage for a number of reasons. Universal coverage may for example not remove all financial barriers to access to LTC. While co-payments are income-dependent and relatively low in the Netherlands, in Germany they are fixed and high and may therefore be a much larger barrier for low-income households. Indeed, a large share of the difference in formal LTC use between the Netherlands and Germany is the result of a difference between both countries in the relationship between income and LTC use: while in Germany income is a major determinant of formal LTC use, in the Netherlands it does not play any role (Bakx et al., forthcoming). When co-payments for public LTC services are high, some individuals may forego applying for these services at all or, if cash benefits are available and can be spent freely, choose to spend them on other things. A second reason that inequity in LTC use persists may be that the supply of formal LTC or informal care is uneven. When the introduction of universal coverage is not accompanied by an increase in supply of LTC in areas where demand goes up, old and possibly inequitable patterns of use may persist.

García-Gómez and colleagues do not discuss which (combination of) factors may cause the persisting inequity in Spain, yet their detailed analysis provides some first insights in this issue, as income and region of residence show up as important predictors of LTC use. Future extensions that include this type of detailed analyses of the contributions of each of the determinants of LTC use may shed more light on what might be done to close the gap.


Bakx P, De Meijer C, Schut F and Van Doorslaer E. Forthcoming. Going formal or informal, who cares? The influence of public long-term care insurance. Health Economics.

Pieter Bakx, Institute for Health Policy and Management, Erasmus University Rotterdam


The establishment in 2007 of the National System for Autonomy and Assistance for Situations of Dependency (SAAD) was a very important achievement for the Spanish society. It was hailed as the fourth pillar of the Welfare State. Although its full implementation has been hampered by the well-known budget limitations experienced in the last years, it still remains a very important element of support for the people that benefit from it (753.842 persons by 31 December, 2013). However, nothing is known about the level of equity or inequity of the distribution of its benefits, or of the delivery of services for the disabled provided by other public or private entities. This is why this research is very relevant.

The study follows a very careful methodology. One of the most interesting aspects is, precisely, the distinction between all the disabled and those -with more severe disability- already covered by the Dependency Act at the time of the survey. Apart from this, it is especially noteworthy the variety of indicators of long-term care services analysed, as well as the alternative measures of unmet need used. 

About the results, it is worrisome to find out that, in effect, LTC services and unmet need are two sides of the same coin, since unmet need (measured objectively) is disproportionally concentrated in the poorer sections of the population, while the use of formal LTC services goes the other way around, showing a clear pro-rich inequity. And it is even more worrisome the finding that this largely holds true even for individuals with universal coverage under the Dependency Act. The case of home care (extended) could surely be explained by the mixed nature of public and private services included in this category, but the case of community care type 2 services requires further investigation. Maybe, the fact that it is the least frequently used service (4% of all disabled, according to the descriptive statistics provided by the authors) implies a shortage of observations in the case of the subsample of universally covered. Or there could be measurement errors, given that the questions about this type of services are mixed with questions about other types of services in the survey questionnaire.

Finally, some suggestions are listed below (for this or future studies following the same line of research):

  • As part of the descriptive statistics, it would be useful to include a table or graph with the distribution of disability (both the full sample and the subsample) by income deciles.
  • Try to distinguish between private and publicly financed services.
  • Analyse the reasons for the existence of unmet need.

Marisol Rodríguez, University of Barcelona


This paper aims to measure inequity in the use of long-term care services and the existence of unmet needs by the disabled population in Spain. The paper focused on a generally overlooked, yet very important, type of health services and population group, which are increasingly posing a higher burden on ageing societies. Furthermore, the study compares a number of approaches, finding in some cases conflicting results, when inequity in health care provision is measured by looking at utilisation of services or when subjective and objectives measures of unmet needs are used as the variables of interest. In the title of the paper, the authors wonder whether these approaches might be “two sides of the same coin” but, even when this study makes an important contribution by comparing the results based on these different perspectives, the question remains largely unanswered. This is not a trivial issue as some surveys, such as the EU-SILC, have decided to stop collecting data on health care utilisation and now only collect information on unmet need measures to characterise equity in health care. There are both conceptual and methodological factors that should be taken into account when choosing measures of utilisation or (subjective or objective) indicators of unmet needs as the focus to quantify barriers to health services. The extent to which the variables commonly available in surveys, such as age, gender and indicators of health status, are capable of accurately represent individuals’ need for health care provision is normally argued to be the reason for moving to indicators of perceived (or defined) unmet need. However, in the so-called subjective measures of unmet need, individual’s preferences and perceptions come into play, while in the so-called objectives measures of unmet need is the norm imposed by the analyst what will define what represent a need for care that has not been satisfied. One and each of these approaches have its pros and cons. Finally, it is worth noting in this brief commentary, that the methods traditionally used to measure horizontal inequity in health care use, which involve controlling for a series of need variables, have in some previous studies been applied in exactly the same fashion, even when the focus was on measures of unmet needs. This paper instead, and rightly in my opinion, recognises that “it is difficult to justify that it is appropriate that individuals with different levels of need have different levels of unmet needs”. In other words, if we control for need variables, as we do when looking at utilisation variables, and the sicker have greater levels of unmet needs, we would be ignoring an important part of the variation of unmet needs which is hardly legitimate. The use of the plain corrected concentration index, as the authors use, that does not control for need variables, seems more appropriate in this context. 

Laura Vallejo Torres, Universidad de La Laguna


Since the approval of the Royal Decree 20/2012, July 13th, the Spanish System for Autonomy and Assistance for Situations of Dependency (SAAD) is living in hardship. Nevertheless, this does not prevent measuring the level of equity and satisfaction in the use of long-term care (LTC) services.

At the moment, the only available evidence on the satisfaction of those receiving LTC services from the SAAD has been provided by the Spanish Ministry of Health, Social Policy and Equality (2011). According to this report, 78% of recipients were satisfied with the LTC services received. Further, home care, day centers and tele-care were the most valued services, with an average rate of 4.7 points over 5.

This paper constitutes an excellent analysis of unmet needs using data from the Disability and Dependency Survey for 2008. Due to the gradual implementation of the SAAD, at the time of the survey, only people qualified as highly dependent became eligible for receiving LTC services. The analysis is enriched by the use of two unmet needs indicators: one based on respondent’s subjective assessment and the other based on the absence of support despite at least one daily living activity. Results reveal that the distribution of unmet needs depends on the type of indicator used as well as on the specific LTC service considered.


Ministry of Health, Social Policy and Equality (2011) [Ministerio de Sanidad, Politica Social e Igualdad (2011)]. Government Report for the Evaluation of the Promotion of Personal Autonomy and Assistance for Persons in a Situation of Dependency [Informe del Gobierno para la evaluación de la Ley de autonomía personal y atención a las personas en situación de dependencia]. Available at: LINK; accessed 17 March, 2014

Cristina Vilaplana Prieto, Facultad de Economía y Empresa, Universidad de Murcia

Deja tu opinión:

E-mail: (No visible)
¿Cuál es el número de en medio?
3 7 (9) 1 6

TecnoCampus Mataró-Maresme
Edifici TCM2 | P2. O3.

Av. Ernest Lluch, 32
08302 Mataró (Barcelona)

Tel. 93 755 23 82

Editores del boletín: Carlos Campillo ( y Cristina Hernández Quevedo (

Editora de redacción: Cristina Hernández Quevedo (

Comité de redacción:
José Mª Abellán Perpiñán, Pilar García Gómez, Manuel García Goñi, Ariadna García Prado, Miguel Ángel Negrín, Vicente Ortún.

Han colaborado en este número: José María Abellán, Pieter Bakx, Josep María Borràs, Manuel Correa Gómez, Patricia Cubí-Mollá, Manuel Flores, Ariadna García Prado, Àlex Guarga, Pere Ibern Regás, Guillem López Casasnovas, Ángel López Nicolás, Celia Muñoz, Enrique Oltra Rodríguez, Vicente Ortún, Marisol Rodríguez, Joan Subirats, Marta Trapero-Bertran, Laura Vallejo Torres, Cristina Vilaplana Prieto.