Pergamon PII: S027'r-9536(96)00338-3 Soc. Sci. Med. Vol. 45, No. 2, pp. 213-220. 1997 © 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.01) + 0.00 SOCIOECONOMIC INFQUITY IN HEALTH CARE: A STUDY OF SERVICES UTILIZATION IN CURA(~AO JANTINA F. ALBERTS, ~* ROBBERT SANDERMAN,: J. MARIETTA EIMERS ~ and WlM J. A. VAN DEN HEUVEL 2 'Medical and Public Health Service of Curagao, Epidemiology and Research Unit, Curacao, Netherlands Antilles and 2Northern Centre for Health Care Research, University of Groningen, Groningen, The Netherlands Abstract--The aim of this study is to examine whether there is socioeconomic equity in health care util- ization in Curaqao, Netherlands Antilles. We explore how educational level is related to utilization of GPs, specialists, hospitals, dentists and physiotherapists, taking into account the effects of sex, age and inequalities in health. The study also examines whether these relationships vary according to the unit of analysis: probability (or incidence) of services ttse versus overall volume of contacts. The data were de- rived from the Curacao Health Study, a health interview survey among a random sample (N = 2248) of the non-institutionalized population aged 18 and over. The results indicate that there is socioeco- nomic inequity in the probability of health care utilization in Curaqao. People with a higher educational level are more likely to consult a specialist, dentist or physiotherapist, and are also more likely to be hospitalized. This is not only the case when the mediating effects of socioeconomic inequalities in health (need) are taken into account, but also before adjustment for health inequalities. In other words: there appears to be both vertical inequity (i.e. greater needs for services are not met by greater use) and hori- zontal inequity (i.e. similar needs for care are not met by similar levels of services use). The observed inequalities in use of specialists and hospitals contrast with findings from international research. The volume of health services use (i.e. the numbers of consultations) appears to be hardly connected with a person's position in the SES hierarchy; only dental services are used more extensively by higher edu- cated individuals. © 1997 Elsevier Science Ltd Key words--health care utilization, equity, need, Curaqao INTRODUCTION Equity in health and equal access to health care are major targets in most health policies. Understanding of the causes of inequalities in health and care utilization is a prerequisite :For designing adequate policies (Lairson et al., 1995). The target of equal access is based on the prin- ciple that health care should be provided according to need, and not according to factors such as ability to pay for care (Whitehead, 1992). Health policy in Curaqao has pursued equity of access to health care through the removal of financial barriers to access; the island has a mixed public and private health care system designed to cover the entire population. Public financed care, provided by government- employed physicians and health care workers, is guaranteed for inhabitants with a substandard level of income. However, it is not likely that removal of financial barriers alone guarantees equal accessibil- ity to health care; other non-price related factars may differ among population groups, which create *Author for correspondence. Northern Centre for Health Care Research, University of Groningen, A. Deusinglaan 1, 9713 AV Groningen, The Netherlands. barriers to equal access (Wouters, 1992; Newbold et al., 1995). Inequalities in health and access to care are strongly interwoven with socioeconomic inequal- ities. Socioeconomic status (SES) can be seen as a multidimensional indicator of certain interrelated demographic, economic and sociocultural attributes, which determine the individual's power, esteem or prestige in the stratified structure of society (Berkel- van Schaik and Tax, 1990). These attributes point to the resources that are available to individuals, their physical as well as social environment and as- sociated behavior patterns. The relationships between SES and health status have been well documented in the international research literature for many years. A lower SES is consistently found to be related to higher rates of morbidity and shorter life expectancy (Hay, 1988; House et al., 1990; Marmot et al., 1991; Van der Lucht, 1992; Lahelma et al., 1994). Also in Curacao lower SES is associated with a poorer physical health status, higher morbidity rates, more psycho- logical problems, and a poorer perceived health (Koopmans et al., 1995; Alberts et al., 1996). Findings on the relationships between SES and health care utilization are more scarce and less clear. In the 1970s Andersen and Aday (1978) 213