Socioeconomic inequalities in health care utilization in Paraguay: Description of trends from 1999 to 2018.

OBJECTIVE

Paraguay's health care system is characterized by segmented provision and low public spending, with limited coverage and asymmetries in terms of access and quality of care. The present study provides national estimates of income-related inequality in health care utilization and trends in the country over the past two decades.

METHODS

Using data from the Paraguayan Permanent Household Survey, we estimated socioeconomic inequality in health care use during the period 1999-2018. We used poverty-to-income ratio as the socioeconomic stratifier and defined health care use as having reported a health problem and subsequent health care use in the last 90 days before interview. Inequality was summarized by rank- and level-based versions of the Concentration Index for binary outcomes.

RESULTS

Inequalities affecting those with lower incomes were present in all years assessed, although the magnitude of these inequalities declined over time. Inequality as expressed by the rank-based index decreased from 0.209 (95%CI 0.164; 0.253) in 1999 to 0.032 (95%CI -0.010; 0.075) in 2018. The level-based index decreased from 0.076 (95%CI -0.029; 0.182) in 1999 to 0.024 (0.002; 0.045) in 2018. Trends in both indices were generally stable from 1999 to 2009, with a noticeable decrease in 2010. The sharpest decreases relative to the 1999 baseline were observed in the period 2010-2018, reflecting changes in health care use and income distribution. Stratification by area, sex and older people suggest similar trends within subgroups.

CONCLUSIONS

Decreases in inequality coincide temporally with increments in public health expenditure, removal of user fees in public health care facilities and the expansion of conditional cash-transfer programmes. Future research should disentangle the role of each of these policies in explaining the trends described.