Health equity is an overarching goal for health care reform around the world. Healthcare is the most commonly cited example of a commodity that ought to be distributed according to need [1
]. Numerous countries have endorsed a policy objective that access and use of healthcare should be based on need, not the ability to pay [2
]. However, health needs are greatly unmet in vulnerable groups in most societies. The Institute of Medicine (IOM) estimates that at least 18,000 Americans die prematurely each year because they lack health insurance to get appropriate healthcare [3
]. Poverty is associated with increased chronic diseases, not seeking medical care and premature death [4
]. The reasons women do not seek care in the case of obstetric emergencies including lack of knowledge, financial costs, attitudes of family members and religion [7
]. Many studies reveal that patient use of services tends to decline with distance [8
], or transport costs [10
]. Evidence is accumulating that financial, geographic, or cultural barriers contribute greatly to the phenomenon of health unmet [7
]. We are still far from “health for all”.
] emphasized that structural change in health services are needed to overcome the substantial barriers to access for vulnerable groups. Researchers point out that vertical equity is as one way of proceeding [13
].Equity in health has been conceptualized and defined in several ways. Two main forms of health equity are identified, vertical equity (people with greater health needs should receive more healthcare than those with lesser needs), and horizontal equity (equal treatment for equivalent needs). Most studies in the assessment of healthcare utilization have mainly focused on horizontal equity [17
] and as a consequence have tended to overlook vertical equity. However, as more and more discussion and inspiration, the meaning of health equity has expanded to creating equal opportunities for health. Allocation resource base on need become accepted way to assure that sicker people (imply he has higher need to restore the opportunity) will receive more health services regardless of extraneous circumstances such as race or level of income. Studies relevant to the vertical equity of healthcare utilization are scarce [13
], one major difficulty arises because of the fact that it is hardly to find a country with minimal barriers for its citizen to get health services to conduct the research. Vertical equity of healthcare utilization cannot be easily tested under conditions that barriers for healthcare use exist. Hence, the nearly barrier-free healthcare system in Taiwan became an ideal place to test the theory of vertical equity.
To achieve the goal of health for all and to eliminate financial barriers to health care services, the government of Taiwan launched the National Health Insurance (NHI) program to provide universal medical care coverage on March 1, 1995. Since then, the coverage rate has climbed steadily and reached 99% by the end of 2009 [23
]. The NHI program is a mandatory, single-payer social health insurance system. The program offers comprehensive benefits, including inpatient and ambulatory care, dental services, traditional Chinese medicine, physical rehabilitation, home nursing care, and preventive services to every insured. Citizens insured under the NHI program have the freedom of choosing any contracted facilities/institutions for his/her care need. No “gatekeeper” controls the utilization and no waiting list exists. The revenue for NHI relies on payroll-based premiums, government funding and out-of-pocket payments for services. A copayment fee ranging from US$ 2~12 normally charged for each clinical visit depending on the level of the facility. Those who cannot afford their premiums are eligible for assistance (including premium subsidies, relief fund loans, and sponsorship referrals) from the Bureau of National Health Insurance (BNHI). Copayments are also waived for the poor, veterans, and aborigines to ensure that health expenditures do not discourage patients from seeking necessary medical need [23
]. There is pro-poor inequality in the probability of visiting a doctor, but the distribution of total medical expenditure is progressive with income in Taiwan [7
Meanwhile, the geographic barriers to healthcare are relatively low. In order to balance medical resources, the Department of Health (DOH) also launched the Establishment of Medical Care Network in Taiwan in July 1985. The project divided the Taiwan area into 17 medical care regions, each of which served as the basic unit for developing medical manpower, facilities, and an emergency care network. These 17 medical regions were further subdivided into 63 sub-regions based on population density, geographic location, and transportation facilities. Each sub-region was equipped with regional or district hospitals, as well as primary medical care units. The Medical Care Network project also sought to distribute medical resources more evenly by restricting the establishment or expansion of hospitals in regions with plentiful medical resources and by setting up a Medical Care Development Fund to encourage the private sector to establish health care institutions in regions lacking sufficient medical facilities [24
]. Currently, the program focuses on setting up integrated medical care service and quality improvements. The BNHI also introduced an integrated delivery system (IDS) to improve services in remote mountainous areas and outlying islands.
As a result of these efforts, we can assume that Taiwan’s health system have an environment with minimal barriers to healthcare and is an ideal condition for testing the vertical equity hypothesis “people with greater health needs should receive more healthcare than those with lesser needs”. Thus, the purpose of the present study was to test the hypothesis that under Taiwan’s universal access health system, healthcare utilization is determined by health need.