Access to Healthcare and Its Inequality: Analytical and Spatial Perspectives
Measuring health care access and its inequality: A decomposition approach – Abatemarco A., Aria M., Beraldo S., Collaro M., 2024 – Economic Modelling
Immigrants’ clusters and unequal access to healthcare treatments – Di Giacomo M., Perucca G., Piacenza M., Turati G. 2024 – Regional Science and Urban Economics
Inequalities in access to and use of health services are a major concern for policymakers in many countries. This is despite health and healthcare being recognised as human rights in various pieces of legislation, including international treaties and national constitutions. In Italy, for instance, art. 32 of the Constitution recognises that ‘the Republic safeguards health as a fundamental right of the individual and as a collective interest and guarantees free medical care to those in need’. Despite this, not all individuals enjoy the same opportunities to obtain appropriate and timely care. Disparities persist across income, education, geography, and citizenship status, challenging the ability of national health systems to fulfil their equity commitments.
Recent debates have emphasised the need to move from outcome-based measures of healthcare performance to the broader and more demanding notion of equality of opportunity. This principle implies that every person should have the same effective chance to access adequate treatment before the onset of illness, regardless of social, economic, or cultural background. It invites a shift from assessing inequalities after illness occurs (ex-post) to evaluating the conditions that enable or hinder access ex-ante.
Within this broader framework, inequalities may originate from multiple sources. On one side, structural and economic barriers – such as uneven territorial distribution of healthcare providers or income-related constraints – limit individuals’ potential access to quality services. On the other, linguistic and cultural barriers can impair communication between patients and medical staff, affecting both the utilisation and the appropriateness of treatments. These two complementary dimensions of inequality provide the motivation for the two studies discussed below, which respectively focus on structural–economic and cultural–linguistic barriers to healthcare access.
Building on the idea that equality in healthcare must be assessed in terms of opportunities rather than final outcomes, in a recent article entitled “Measuring health care access and its inequality: A decomposition approach”, published in Economic Modelling (2024), Antonio Abatemarco, Massimo Aria, Sergio Beraldo, and Michela Collaro develop a theoretical and empirical framework to measure potential access.
In its original formulation, the principle of equality of opportunity establishes that the position individuals occupy within the social hierarchy should be the result of a competitive process open to all. When applied to the healthcare domain, this normative standard can be interpreted either as a prescription aimed at ensuring that every person achieves the highest possible position in the hierarchy of health, or as an aspiration to guarantee the most appropriate care in case of need. These two ideals clearly differ: although the second is less ambitious, it is far more realistic, and therefore better suited to guide public policy.
Traditionally, equality of opportunity in healthcare has been understood through the principle of horizontal equity, according to which equal treatment should correspond to equal need. In academic practice and public debate, the tendency has been to assess the utilization of healthcare services – i.e. hospitalizations, visits, procedures – assuming that use is a direct indicator of access. However, this approach conflates equality of opportunity with equality in service utilization. The latter depends on numerous individual factors (preferences, cultural beliefs) that do not necessarily reflect unequal opportunities. Those who refuse a therapy or vaccination as a matter of personal choice do not suffer an unjust inequality if access to the service is effectively guaranteed. Conversely, those who cannot obtain treatment due to lack of financial resources or inadequate service quality experience deprivation even under a system of universal coverage.
The research proposed by Abatemarco, Aria, Beraldo, and Collaro is based on an innovative approach to assessing equality of opportunity in healthcare, grounded in a conception of justice that demands for everyone to be granted the same possibilities to pursue their own life plans. From this perspective, access to healthcare represents a prerequisite for the effective exercise of other fundamental rights. Consistently, at the normative level, the framework requires that before the onset of a health need, every individual should have the same chances of accessing appropriate care, regardless of their characteristics (place of residence, age, sex, disability, income, wealth, etc.).
Unlike the ex-post approach, which examines inequalities after the need has emerged, this framework evaluates potential access. Healthcare equity is therefore understood as the guarantee of equal opportunities for access ex-ante, rather than equal utilization ex-post.
The core of the method lies in the monetization of barriers to access. Instead of focusing on individual persons, it considers plausible sets of characteristics that an individual may possess. Each combination of characteristics is plausibly associated with a different cost of access to services and a specific endowment of economic resources that can be mobilized. Access is guaranteed only when the cost of access is lower than the available resources.
It is evident, however, that not all individuals with the same set of characteristics can mobilize the same amount of resources for healthcare. Therefore, by reconstructing the distribution of available resources by sets of characteristics, it becomes possible to identify the share of the population that could afford adequate treatment should a health need arise. In other words, the methodology makes it possible to calculate, for each type of individual, the probability of non-access to healthcare services, as well as to quantify the monetary resources that would be necessary to ensure access for that type of individual.
The methodology allows not only for measuring inequality of opportunities in healthcare access, but also for decomposing it into its main determinants and quantifying their relative impacts – thus distinguishing between supply-side factors (such as the territorial distribution of providers) and demand-side factors (such as local healthcare spending capacity).
To demonstrate the practical applicability of their theoretical framework, the authors analyse the case of breast cancer surgery within the Italian National Health Service. This procedure, although universally guaranteed, is characterized by striking territorial inequalities in both availability and quality of facilities. Among the many hospitals performing the surgery, only eight meet all the quality standards set by the Ministry of Health (annual number of surgeries ≥ 150; proportion of surgeries performed in departments with more than 135 cases ≥ 80%; readmissions within 120 days ≤ 8%; proportion of resection surgeries with simultaneous reconstruction ≥ 70%). Almost all of these are located in Central and Northern Italy, with the result that, for many citizens, the cost required to obtain care at such high-standard facilities is considerable.
By estimating the average cost of access (out-of-pocket medical expenses, transport, and accommodation for an accompanying person during a four-day hospital stay) and comparing it with the distribution of potentially available economic resources – derived from the Bank of Italy’s Survey on Household Budgets – a map of access probabilities can be obtained that reveals sharply marked disparities across the country.
Regarding the determinants of the observed inequality, and adopting a regional perspective, the analysis shows that more than half of the inequality is explained by differences in average healthcare spending capacity (≈53%), while a further 29% derives from disparities in spending capacity within regions. Supply-side factors play a smaller role, mainly linked to local production inefficiencies (≈19%), while the presence of inadequate local providers is negligible or even slightly compensatory.
This approach offers a new tool for evaluating the equity of healthcare systems, complementary to traditional indicators. Its strength lies in its ability to distinguish what depends on individual preferences from what depends on structural conditions that limit freedom of choice. From a public policy perspective, this distinction makes it possible to precisely identify the factors that most critically affect equality of opportunity and which need to be addressed in order to improve it.
More broadly, a principle of substantive justice is reaffirmed: inequality should be measured not only in terms of final health outcomes, but also in terms of the distribution of effective opportunities for access. This represents a change of perspective: equality in the right to health does not coincide with the formal gratuity of services, but with the concrete possibility, for every citizen, to access them on equal terms.
Beyond territorial and economic disparities discussed above, other forms of inequality arise from cultural and linguistic barriers that affect how different population groups interact with healthcare systems. Indeed, inequalities are particularly salient for disadvantaged groups, such as those with low incomes or low education levels, as well as those with an immigrant background. The investigation of inequalities affecting people with an immigrant background is relatively understudied, despite being very important for the current policy debate on issues related to immigration and access to and sustainability of public healthcare systems. This is because, in many countries, the number of foreigners has increased significantly only in recent decades, because of growing international economic and political integration. In Italy, for example, the foreign population increased from 356 thousand in 1991 (0.62 per cent of the total population) to 5.422 million in 2025 (9.20 per cent of the total population). The issue is particularly complex, as immigrants are highly heterogeneous in many respects, including the language they speak, their cultural background, the economic development of their country of origin, and the type of settlement they choose in their destination country.
In what ways do these elements of heterogeneity affect the quality of medical treatment received by patients with different immigrant backgrounds? Another recent study by Marina Di Giacomo, Giovanni Perucca, Massimiliano Piacenza, and Gilberto Turati, entitled ‘Immigrants’ clusters and unequal access to healthcare treatments’ and published in Regional Science and Urban Economics (2024), addresses this challenging question.
The study is based on the idea that there are multiple channels through which different immigrant backgrounds may affect the quality of healthcare received. Language barriers are an obvious example of this: difficulties in understanding the rules and prescriptions of healthcare providers are likely to result in lower-quality treatment for patients. This, in turn, has important policy implications. To safeguard the fundamental right to health in a context of a rapidly growing foreign population, healthcare systems must be accessible to all new user groups, regardless of their background.
In this study, the quality of medical treatment is assessed using two criteria. The first is the occurrence of caesarean sections (CS), which is a standard proxy for inappropriateness when controlling for the woman’s clinical conditions. While CS can be essential for the health of the woman and the newborn in some cases, it has been associated with increased maternal mortality, maternal and infant morbidity, complications in subsequent deliveries and increased financial costs, raising concerns about the medical appropriateness of the procedure. The second measure of poor quality uses information from the Robson classification system, which categorises all women admitted for delivery into one of ten mutually exclusive groups based on a few basic obstetric variables. The occurrence of a caesarean section for low-risk women (LR-CS) more accurately identifies cases of poor healthcare provision.
The study aims first to investigate whether non-native women undergo C-sections significantly more frequently than Italian natives, both CS and LR-CS. Secondly, the paper tests whether these differences are heterogeneous across non-native women with different ethnic backgrounds. The research hypothesis is that the greater the difference between the mother’s background and that of the natives, the greater her probability of receiving a C-section or a low-risk C-section.
The distance between two distinct cultural backgrounds is certainly a multifaceted concept, encompassing many different dimensions. This paper identifies five of these dimensions conceptually and empirically: i) linguistic distance, ii) distance in women’s empowerment (femicides distance), iii) distance in formal institutions (civil liberties distance), iv) distance in economic development (development distance) and v) religious distance.
The empirical analysis is based on a detailed micro-dataset covering women who gave birth in all public hospitals within the administrative borders of Piedmont, a large, wealthy north-western Italian region, between 2010 and 2017. The sample includes 264,700 observations, 27.3% of which correspond to women with non-Italian citizenship.
The empirical results suggest that there are no differences in the use of caesarean sections between native and non-native women once individual risk factors, socio-economic status and fixed effects (for time and hospital) are controlled for. However, there are clear heterogeneous patterns among non-native women of different nationalities. Notably, women from Africa, South-East Asia and the Americas are more likely to undergo a caesarean section than Italian women.
This heterogeneity by nationality indicates that cultural distances play a significant role in explaining differences in the quality of healthcare received. Figure 1 shows the estimated coefficients and their 95% confidence intervals for the five dimensions of cultural distance in relation to the probability of receiving a CS or a LR-CS. Since the distance measures have been standardised to have a mean of zero and a standard deviation of one, the coefficients are directly comparable.
The results show that all distance measures increase the probability of a CS and LR-CS procedure. Development distance, measured as the difference in per capita GDP between the country of origin of the non-native and Italy, has the greatest impact: an increase of one standard deviation in distance increases the likelihood of a CS or LR-CS procedure by approximately 0.03. Following this are the coefficients for Femicides-Dist (0.02 for both CS and LR-CS), Civil Liberties-Dist (0.01 for both CS and LR-CS), Language-Dist (0.006 for CS and 0.007 for LR-CS) and Religious-Dist (0.004 for CS and 0.005 for LR-CS), which are smaller in size.
A possible mechanism that could explain these findings is discussed: larger cultural distances make it more difficult for migrants to connect with and communicate with medical staff, thereby increasing the likelihood of undergoing a caesarean section (including inappropriate ones). To support this interpretation, four indirect tests are proposed: the location choice of non-native mothers in urban versus non-urban areas; the size of the immigrant community of the woman’s nationality in the same municipality; the woman’s previous childbirth experience; and the nationality of the woman’s partner.
The findings tend to support the occurrence of the hypothesised mechanism, showing that living in an urban area in the presence of a large community of migrants of the same nationality exacerbates the role of linguistic and socio-cultural distance. This suggests a sort of ‘segregation’ effect. Large communities in large urban centres prevent migrants from integrating with the local population. However, previous childbirth experience and a native partner reduce the need for effective communication of the mother with medical staff and are associated with a lower likelihood of an inappropriate C-section.
These findings carry substantial policy implications. Since inequalities in access to appropriate birth deliveries – and health care services in general – are related to communication difficulties, it is necessary to improve the interaction between immigrants and medical staff. Examples of tools that could improve immigrants’ ability to process information and communicate more effectively with medical staff include providing cultural mediators in hospitals, offering ad hoc training to medical staff, simplifying administrative procedures and teaching migrants the host country’s language.
Together, the two studies discussed above reveal how structural, economic, and socio-cultural barriers interact to shape healthcare inequality. The first highlights the spatial and financial dimensions of unequal opportunity, proposing a method to quantify and decompose access gaps before the onset of illness. The second uncovers how linguistic and cultural differences may undermine the quality of care among different immigrant groups, even under universal coverage. Both studies converge on a shared conclusion: achieving genuine equity in healthcare requires moving beyond formal rights in order to remove practical, informational, and socio-cultural barriers. Ensuring equal access thus requires not only the redistribution of financial resources but also the removal of communication and cultural barriers that hinder effective inclusion, so that the universal right to health becomes a right effectively realised by all.
Go to the published article by Abatemarco, Aria, Beraldo, and Collaro
Go to the published article by Di Giacomo, Perucca, Piacenza, and Turati