Open Access Research article

Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria

Emiliano Albanese1, Zhaorui Liu2, Daisy Acosta3, Mariella Guerra4, Yueqin Huang2, KS Jacob5, Ivonne Z Jimenez-Velazquez6, Juan J Llibre Rodriguez7, Aquiles Salas8, Ana L Sosa9, Richard Uwakwe10, Joseph D Williams11, Guilherme Borges12, AT Jotheeswaran13, Milagros G Klibanski14, Paul McCrone1, Cleusa P Ferri1 and Martin J Prince1*

Author Affiliations

1 King's College London, Institute of Psychiatry, Health Services and Population Research Department, London, UK

2 Peking University, Institute of Mental Health. Beijing, China

3 Universidad Nacional Pedro Henriquez Ureña (UNPHU), Internal Medicine Department, Geriatric Section, Santo Domingo, Dominican Republic

4 Psychogeriatric Unit, National Institute of Mental Health "Honorio Delgado Hideyo Noguchi", Lima, Perú

5 Christian Medical College, Vellore, India

6 Internal Medicine Dept., Geriatrics Program, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico

7 Facultad de Medicina Finley-Albarran, Medical University of Havana, Havana, Cuba

8 Medicine Department, Caracas University Hospital, Faculty of Medicine, Universidad Central de Venezuela, Caracas

9 The Cognition and Behavior Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico

10 Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

11 Department of Community Health, Voluntary Health Services, Chennai, India

12 Instituto Nacional de Psiquiatria, Mexico City, Mexico, and the Universidad Autonoma Metropolitana, Mexico City, Mexico

13 Public Health Foundation of India, Delhi, India and King's College London, Institute of Psychiatry, Health Services and Population Research Department, London, UK

14 Policlinico 14 de Junio. Luyano. Municipio 10 de Octubre, Havana, Cuba

For all author emails, please log on.

BMC Health Services Research 2011, 11:153  doi:10.1186/1472-6963-11-153

Published: 28 June 2011



To describe patterns of recent health service utilisation, and consequent out-of-pocket expenses among older people in countries with low and middle incomes, and to assess the equity with which services are accessed and delivered.


17,944 people aged 65 years and over were assessed in one-phase population-based cross-sectional surveys in geographically-defined catchment areas in nine countries - urban and rural sites in China, India, Mexico and Peru, urban sites in Cuba, Dominican Republic, Puerto Rico and Venezuela, and a rural site in Nigeria. The main outcome was use of community health care services in the past 3 months. Independent associations were estimated with indicators of need (dementia, depression, physical impairments), predisposing factors (age, sex, and education), and enabling factors (household assets, pension receipt and health insurance) using Poisson regression to generate prevalence ratios and fixed effects meta-analysis to combine them.


The proportion using healthcare services varied from 6% to 82% among sites. Number of physical impairments (pooled prevalence ratio 1.37, 95% CI 1.26-1.49) and ICD-10 depressive episode (pooled PR 1.21, 95% CI 1.07-1.38) were associated with service use, but dementia was inversely associated (pooled PR 0.93, 95% CI 0.90-0.97). Other correlates were female sex, higher education, more household assets, receiving a pension, and health insurance. Standardisation for age, sex, physical impairments, depression and dementia did not explain variation in service use. There was a strong borderline significant ecological correlation between the proportion of consultations requiring out-of-pocket costs and the prevalence of health service use (r = -0.50, p = 0.09).


While there was little evidence of ageism, inequity was apparent in the independent enabling effects of education and health insurance cover, the latter particularly in sites where out-of-pocket expenses were common, and private health insurance an important component of healthcare financing. Variation in service use among sites was most plausibly accounted for by stark differences in the extent of out-of-pocket expenses, and the ability of older people and their families to afford them. Health systems that finance medical services through out-of-pocket payments risk excluding the poorest older people, those without a secure regular income, and the uninsured.