IDEAS home Printed from
   My bibliography  Save this paper

Horizontal Inequity in Access to Healthcare Services and Educational Level in Spain


  • Roberto Montero Granados

    () (Universidad de Granada. Deparment of Applied Economics)

  • José Jesús Martín Martín

    (Universidad de Granada. Deparment of Applied Economics)

  • Juan de Dios Jiménez Aguilera

    (Universidad de Granada. Deparment of Applied Economics)


The aim of this study is to measure horizontal equity in the use of healthcare services in Spain, proposing two methodological innovations. First by defending it as equality of access for equal need, irrespective of educational level, unlike the prevailing methodological approach to horizontal equity which relates it to income. Second, by estimating it by means of the slope index of the inequality of characteristics, analagous to the inequity index proposed by Kakwani, Wagstaff and van Doorslaer (1997; HIWV) but presenting some methodological advantages, the greater robustness of the data available on educational level than of those on income, and the possibility of isolating the net effect of the educational level on the use of healthcare by controlling for other variables. The methodology is designed in three parts: (1) estimation of the relationship between the educational level and the use of healthcare services by means of a model of the likelihood of demand for healthcare services, commonly used in the literature; (2) estimation of the relationship between educational level and health by approximating a production function of individuals' health according to their personal characteristics and other factors conditioning health; and (3) estimation of the slope index of inequality as a measure of horizontal inequity, using educational level instead of income as the criterion for ranking individuals. The data base used was a sample of 55,598 observations from the Survey of disabilities, handicaps and state of health of 1999, carried out in Spain. No significant statistical association was found between educational level and use of healthcare services. On the other hand, the relationship between educational level and health, with the three proxy variables used (perception of health, days of limitation and number of chronic illnesses) shows a positive correlation, i.e. an increase in educational level is associated with a greater probability of enjoying better health. Horizontal inequity, measured by the proposed slope index of inequality, gives a range of statistically significant values between 13.91% and 9.40%, depending on cases, i.e. the significant inverse relationship between state of health and educational level is not reflected proportionally in healthcare use, implying that, with greater need, the access of individuals with a lower educational level to public healthcare services is the same as for the rest. These results suggest that the educational level may be a variable to consider when characterizing the healthcare needs of a population in a defined geographical area, at least from the normative characterization of horizontal equity proposed

Suggested Citation

  • Roberto Montero Granados & José Jesús Martín Martín & Juan de Dios Jiménez Aguilera, 2008. "Horizontal Inequity in Access to Healthcare Services and Educational Level in Spain," FEG Working Paper Series 08/03, Faculty of Economics and Business (University of Granada).
  • Handle: RePEc:gra:fegper:08/03

    Download full text from publisher

    File URL:
    Download Restriction: no

    References listed on IDEAS

    1. Wagstaff, Adam, 1986. "The demand for health : Some new empirical evidence," Journal of Health Economics, Elsevier, vol. 5(3), pages 195-233, September.
    2. Grossman, Michael, 1972. "On the Concept of Health Capital and the Demand for Health," Journal of Political Economy, University of Chicago Press, vol. 80(2), pages 223-255, March-Apr.
    3. Wagstaff, Adam, 2002. "Inequality aversion, health inequalities and health achievement," Journal of Health Economics, Elsevier, vol. 21(4), pages 627-641, July.
    4. Victor R. Fuchs, 1982. "Time Preference and Health: An Exploratory Study," NBER Chapters,in: Economic Aspects of Health, pages 93-120 National Bureau of Economic Research, Inc.
    5. Haveman, Robert & Wolfe, Barbara & Kreider, Brent & Stone, Mark, 1994. "Market work, wages, and men's health," Journal of Health Economics, Elsevier, vol. 13(2), pages 163-182, July.
    6. Mark C. Berger & J. Paul Leigh, 1989. "Schooling, Self-Selection, and Health," Journal of Human Resources, University of Wisconsin Press, vol. 24(3), pages 433-455.
    7. Sickles, Robin C & Taubman, Paul, 1986. "An Analysis of the Health and Retirement Status of the Elderly," Econometrica, Econometric Society, vol. 54(6), pages 1339-1356, November.
    8. van Doorslaer, Eddy & Wagstaff, Adam & Bleichrodt, Han & Calonge, Samuel & Gerdtham, Ulf-G. & Gerfin, Michael & Geurts, Jose & Gross, Lorna & Hakkinen, Unto & Leu, Robert E., 1997. "Income-related inequalities in health: some international comparisons," Journal of Health Economics, Elsevier, vol. 16(1), pages 93-112, February.
    9. Sergi Jiménez-Martín & José Labeaga & Maite Martínez-Granado, 2004. "An empirical analysis of the demand for physician services across the European Union," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 5(2), pages 150-165, May.
    10. van Doorslaer, Eddy & Wagstaff, Adam & van der Burg, Hattem & Christiansen, Terkel & De Graeve, Diana & Duchesne, Inge & Gerdtham, Ulf-G & Gerfin, Michael & Geurts, Jose & Gross, Lorna, 2000. "Equity in the delivery of health care in Europe and the US," Journal of Health Economics, Elsevier, vol. 19(5), pages 553-583, September.
    11. John Bound, 1991. "Self-Reported Versus Objective Measures of Health in Retirement Models," Journal of Human Resources, University of Wisconsin Press, vol. 26(1), pages 106-138.
    12. Sergi Jiménez-Martín & José M. Labeaga & Maite Martínez-Granado, 2002. "Latent class versus two-part models in the demand for physician services across the European Union," Health Economics, John Wiley & Sons, Ltd., vol. 11(4), pages 301-321.
    13. Propper, Carol, 2000. "The demand for private health care in the UK," Journal of Health Economics, Elsevier, vol. 19(6), pages 855-876, November.
    14. Anderson, Kathryn H. & Burkhauser, Richard V., 1984. "The importance of the measure of health in empirical estimates of the labor supply of older men," Economics Letters, Elsevier, vol. 16(3-4), pages 375-380.
    15. Kemna, Harrie J. M. I., 1987. "Working conditions and the relationship between schooling and health," Journal of Health Economics, Elsevier, vol. 6(3), pages 189-210, September.
    16. Kakwani, Nanak & Wagstaff, Adam & van Doorslaer, Eddy, 1997. "Socioeconomic inequalities in health: Measurement, computation, and statistical inference," Journal of Econometrics, Elsevier, vol. 77(1), pages 87-103, March.
    Full references (including those not matched with items on IDEAS)

    More about this item


    Education and health; Healthcare needs; Horizontal Inequity; Logistic regression ; Ordinal regression; Regional funding;

    JEL classification:

    • C21 - Mathematical and Quantitative Methods - - Single Equation Models; Single Variables - - - Cross-Sectional Models; Spatial Models; Treatment Effect Models
    • H42 - Public Economics - - Publicly Provided Goods - - - Publicly Provided Private Goods
    • H77 - Public Economics - - State and Local Government; Intergovernmental Relations - - - Intergovernmental Relations; Federalism
    • I12 - Health, Education, and Welfare - - Health - - - Health Behavior
    • I20 - Health, Education, and Welfare - - Education - - - General

    NEP fields

    This paper has been announced in the following NEP Reports:


    Access and download statistics


    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:gra:fegper:08/03. See general information about how to correct material in RePEc.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: (Juliette Milgram Baleix.). General contact details of provider: .

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service hosted by the Research Division of the Federal Reserve Bank of St. Louis . RePEc uses bibliographic data supplied by the respective publishers.