Unmet need for health care: the case of foreigners living in Italy
Annalisa Busetta^ and Valeria Cetorelli*
^Department of Economics, Business and Statistics, University of Palermo. E-mail: [email protected] *Department of Social Policy, London School of Economics. E-mail: [email protected]
Abstract
Italy has a public and universal health care system that covers -in principle- both regular and irregular migrants’ health care demand. However, the concrete shows that migrants in Italy experience specific inequalities in health and access to health care, that overlap the existing geographical disparities in the access to care across the country. This study aims to compare self-perceived unmet need among foreigners living in Italy assessing whether it varies from one foreign-national group to the other. In particular, we study the self-reported unmet need as an indicator of access to health care, exploring its reasons. Data used for the analysis come from the Italian special Survey of Income and Living Conditions (IT-SILC) carried on households with foreigners in 2009.
Keywords: Italy, Unmet health care needs, Foreign population
1. Introduction
In Italy health is a right for everyone1, migrants included, independently of their juridical condition. Nevertheless, in practice, a high level of inequality affecting access to healthcare services is noted when comparing the Italian and migration population. The recent study of Cavalieri (2013) showed that strong geographical disparities exist in the rates of self-perceived unmet medical needs and that some population groups (e.g. women, low-income individuals, immigrants…) “are more vulnerable than others to experiencing unmet health needs and to reporting some categories of reasons”. Moreover the existing inequalities in the access to care across the country has been increased -in the last two decades- by the progressive decentralization of health services to regional governments. As far as we know there are no published studies2 that have analyzed unmet health care needs of foreign populations in Italy. This study intends to fill the existing gap in the literature by investigating the effect of demographic, socio-economic and health status variables on the unmeet needs declared by foreigners looking also to the disparities between foreigners nationalities.
1 The Italian constitution maintain that (art. 32) “The Republic protect health as fundamental right of the individual and as collective interest, and guarantees free medical care to the indigent”. 2 The unpublished work by Giannoni (2010) studies the inequity in the access to both medical and dental services looking to the differences among natives and foreign population using data from the standard IT-Silc survey. She shows that being foreigners is a source of inequity that overlaps income and geographical inequity. 2. Data and descriptives analysis
In this research we study the self-reported unmet need as indicator of access to health care. This indicator is included in the Italian special Survey of Income and Living Conditions (IT-SILC) carried by Istat on a sample of 6,000 households with at least one foreign member drawn from Italian civil register of resident. This survey had been designed to reflect the distribution of the larger foreigner citizenships so that it allows for the analysis of the 13 main citizenships. We consider that an individual experienced a situation in which his/her needs were unmeet when he/she declare a situation of “unmet need for dental examination or treatment” or of “unmet need for medical examination or treatment” excluding those individuals’ who declare that “there was no occasion when the person really needed examination or treatment”.3 We analyze only foreigners individuals (i.e. non-Italian citizens) who answer the question on unmeet need for health care4 showed that 18.8% of foreigners declare a situation of unmeet need (95% CI 17.8 - 19.8). This high percentage of unmeet need is even greater when we look at the relevant differences among national groups (the percentage of individuals who declared unmet needs varies from the minimum of 11.2% among Filipinos to 36.4% for Macedonians).
Graph 1- Percentages of individuals reporting any unmeet need for health care by citizenship (95% confidence interval)
35,0
30,0
25,0
20,0
15,0
10,0
5,0
0,0 Philippines India China Other non Perù Other EU Poland Ucraina Albania Ecuador Romania Moldova Tunisia Macedonia Morocco EU country country Source: Istat (2009) Italian special Survey of Income and Living Conditions Note: Weighted sample used.
3 Note that the choice to use the subjective assessment of unmet needs is based on the idea the individual is the best judge of his/her health status and of whether he/she has received appropriate health care. 4 We exclude individuals that have missing values on the question on unmet needs so that the sample is reduced to 5,768 households and 9,837 individuals. Here we adopt a classification of the main reason5 for not getting medical care (Cavalieri, 2013) into four categories according to the nature of the stated reason: availability, accessibility, acceptability and other.6 The analysis of the main reason of unmet need, both for medical examination or treatment or dental examination or treatment, showed a prevalence of accessibility problems, in particular for dentist treatment (respectively 63.3% and 76.1%), followed by reason of acceptability (19.4% and 10.8%), availability (10.6% and 8.1%), and other (6.8% and 5.0%). The analysis of accessibility of health services for the foreign population is complex and depends on a multitude of factors that relate to the health system and also to the patients themselves. Moreover beyond this general framework there are big differences among nationalities with foreigners from Philippines and Ecuador recording smallest problems of accessibility.
Graph 2 - Distribution of individuals who declared unmeet need for health care by reason and citizenship
Medical examination or treatment Dentist examination or treatment
accessability availability acceptability other accessability availability acceptability other
Philippines 22.9 35.0 10.0 32.1 Philippines 60.8 0.0 8.2 31.0 Ecuador 39.7 23.1 37.2 0.0 Ecuador 63.3 24.9 8.9 2.9 Perù 51.6 16.0 12.3 20.1 Ucraina 66.4 12.0 15.3 6.4 Ucraina 52.7 7.7 33.5 6.2 Tunisia 67.9 18.1 14.0 0.0 India 53.0 0.0 30.5 16.5 India 70.2 11.3 9.3 9.3 Other EU 59.9 18.1 18.6 3.4 Other EU 70.2 4.6 18.1 7.0 China 61.6 9.8 8.9 19.7 Poland 73.3 5.3 12.3 9.1 Albania 62.7 6.6 29.0 1.7 Other no EU 74.9 10.6 10.1 4.5 Romania 63.5 9.4 21.7 5.4 Romania 75.1 7.2 12.9 4.8 Poland 64.1 5.1 13.8 17.0 China 75.9 6.9 6.7 10.5 Other no EU 66.1 10.8 12.7 10.4 Albania 81.3 4.5 10.5 3.7 Morocco 69.0 12.0 15.5 3.5 Macedonia 82.6 10.4 7.00.0 Moldova 71.8 4.0 17.9 6.3 Morocco 83.8 8.8 4.0 3.5 Tunisia 72.4 0.0 27.6 0.0 Perù 86.5 0.0 7.6 5.9 Macedonia 83.4 4.1 12.5 0.0 Moldova 87.5 4.28 4.8 3.5
Source: Istat (2009) Italian special Survey of Income and Living Conditions Note: Weighted sample used. Multiple responses were not allowed.
3. Method and preliminary findings
The objective of our analysis is to determine if the differences in unmeet needs, showed in the previous paragraph, hold true once we control by the individual and household characteristics usually reported from the literature. In order to do so, we estimate a logit model where unmet needs is the response variable and a wide set of characteristics are included as control variables. In particular we
5 An alternative classification consider if the reasons of the “unmeet need” is important from a policy perspective -such as the individual could not afford because are too expensive, long waiting lists, or there are travelling-related problems (e.g. no means of transportation, too far)- or are due to personal problems or choices -fear of doctor/hospitals/examination/ treatment, could not take time because of work, care for children or for others, wanted to wait and see if problem got better on its own-, or finally to insufficient information (don’t know any good doctor or specialist). 6 The “availability” category includes “waiting list ” response (as indicator of unavailability of the service at the time required), the “accessibility” includes financial and transportation problems (as indicators of barriers to accessibility), “acceptability” includes all the personal choices concerning attitudes, personal beliefs and competing responsibilities and finally “other” response is separately classified. control for individual socio-demographic characteristics (such as sex, age and its squared, educational level, labour force status), for individual need factors (self-assessed health status, having -or not- any chronic condition or/and limitation in daily activities) and for household characteristics (household income, no. of adults in the household and no. of children in the household). Due to the relevant geographical differences highlighted from the literature we also control information on macro-region of residence in Italy. Coherently with the general literature on unmeet needs seems that also among foreigners living economic difficulties, regardless of the measure included in the model (income, material deprivation, etc.), is associated with higher probabilities to declare unmeet needs. As expected having bad (or very bad) self-reported health condition, like so having limitations in daily activities because or suffer from a chronic (long-standing) illness, lead up to an higher probability of having unmet need for health care. From the preliminary analysis is evident that the significant differences among national groups (Philippines with the lowest probability and Albania, Romania, Macedonia, Moldova and morocco with the highest one) remain almost unchanged also when we control for the individual and household characteristics. This preliminary results reveals the need of health and social policies that point to a better integration of some foreign groups and to the real affirmation of health as a right for all.
References Cavalieri M. (2013), Geographical variation of unmet medical needs in Italy: a multivariate logistic regression analysis, International Journal of Health Geographics, 12:27 Giannoni M. (2010) Migrants inequalities in unmet need for access to health care in Italy, Paper presented at 15° Aies Conference– Moncalieri (TO), http://www.coripe.unito.it/files/giannoni.pdf Istat (2011a) I redditi delle famiglie con stranieri, Statistiche report 22 dicembre 2011. Istat (2011b) Households with foreigners: indicators of economic distress. Notes for the press - 28 February 2011. Istat, Rome. Istat (2013a) Cittadini non comunitari regolarmente soggiornanti, Statistiche report 30 luglio 2013. Istat (2013b) La popolazione straniera residente in italia - Bilancio demografico, Statistiche report 26 luglio 2013.