The Stratifying Effect of Healthcare Systems. An International Comparison of Inequalities in Healthcare Utilization and Quality of Life

Research question/goal: 

This study investigated how the differences in the institutional organization of access to the healthcare system matters for population health, inequalities, trust, and healthcare costs in advanced, industrialized countries. Within the project, we developed a new theoretical framework for understanding social rights in the context of the healthcare system based on access to services. It highlights gatekeeping and cost sharing systems as two major institutional regulations for accessing ambulatory healthcare in advanced industrialized countries.In the first part of the project, specific institutional indicators were collected and using a cluster analysis we demonstrated four healthcare access regimes within Europe. In the second part, we analysed trends in institutional access regulations in seventeen OECD countries between 1990 and 2010. The third part of the project dealt with the implications of these access regulations for a variety of outcomes. This empirical investigation included both a pooled-cross-sectional time series analysis of country-level infant mortality data, as well as a multi-level analysis of inequalities in doctor visits, and a cross-national comparison of trust in the healthcare system using cross-national survey data.The central finding then is that institutional differences in access regulations shape individuals’ perceptions of the healthcare system, their actions as well as health outcomes.  More specifically, gatekeeping systems might be able to provide multiple benefits including reduced healthcare costs, lower inequalities in service use, and trust of citizens while cost sharing systems seem not only to have limited impact on costs, but include risks for inequalities and negative implications for citizens’ trust in the healthcare system.

Fact sheet

CDSS, Studienstiftung des Deutschen Volkes
2009 to 2014
Data Sources: 
Comparative survey data, institutional data on health systems
Geographic Space: 
Europe, US