All things being equal: Does it matter for equity how you organise and pay for health care? A review of the International Evidence

Abstract

Over the last 25 years, the health care systems of most high-income countries have experienced extensive—usually market-based—organizational and financial reforms. The impact of these system changes on health equity has been hotly debated. Examining evidence from systematic reviews of the effects of health care system organizational and financial reforms will add empirical information to this debate, identify any evidence gaps, and help policy development. Systematic review methodology was used to locate and evaluate published systematic reviews of quantitative intervention studies (experimental and observational) of the effects on equity in health care access and/or health status of health care system organizational and financial reforms (system financing, funding allocations, direct purchasing arrangements, organization of service provision, and health and social care system integration) in high-income countries. Nine systematic reviews were identified. Private insurance and out-of-pocket payments as well as the marketization and privatization of services have either negative or inconclusive equity effects. The evidence base on the health equity effects of managed care programs or integrated partnerships between health and social services is inconclusive. There were no relevant studies located that related to resource allocation reforms. The systematic review-level evidence base suggests that financial and organizational health care system reforms have had either inconclusive or negative impacts on health equity both in terms of access relative to need and in terms of health outcomes.