A study of Norway’s health care system concluded that regional differences in waiting times constitute the most serious inequity in access to health care - more serious, for example, than the distribution of physicians or hospital beds. What is true of Norway is probably also true of other developed countries. For example:

• The number of British kidney patients receiving dialysis or a transplant in 1989 averaged 305 people per million population in the four metropolitan areas in and around London.
• The number was only 239 in the northern region of Yorkshire and 174 in the western region of West Midlands.

These differences are greater than the regional differences in health care spending per person or other measures of health inputs. There are many reasons to believe that rural patients are at a disadvantage when health care is rationed. The most serious form of rationing is rationing of access to modern medical technology. Often this technology is available only at major hospitals in large cities. This need not be a problem if rural patients can purchase care with their own money or through public or private health insurance. Rationing by waiting, on the other hand, discriminates against rural patients.

For one thing, it often means that care is given to patients who are available when an opening appears in the surgery schedule. Urban patients who live close by thus have an advantage over rural patients who may have to travel considerable distances, requiring both time and inconvenience.

For another thing, success in obtaining care often depends on the politics of bureaucracy. A patient who is represented by a physician in a rural area will tend to be at a disadvantage vis-à-vis a patient represented by a physician who lives nearby and is a colleague of the hospital staff. Urban patients also have access to political and personal relationships that may be important in dealing with bureaucratic obstacles - opportunities not generally available to rural patients.

Finally, wherever there is non-price rationing, people will attempt to move to the head of the waiting lines by paying illegal bribes. In Hungary, the practice of "tipping" has become institutionalized, and each year physicians receive tips equal to about 40 percent of their official total income. In Japan an illegal "gift" of $1,000 to $3,000 can get a patient admitted sooner and insure treatment by a senior specialist at a Tokyo University hospital. In most countries, rural residents probably know less about the mechanics of currying physicians’ favors.

Rural Patients in Britain.

"Britain spends the most in those regions where the need is smallest."

One way to appreciate the magnitude of these inequalities is to consider them in relation to the growing private health care sector. If the goal of the NHS is to equalize access, one would expect the service to devote more resources to those areas least well served by the private sector. In fact, the British government tends to spend the most in the metropolitan areas where private sector alternatives are most abundant.

"British urban regions with the most private hospital beds tend to receive the most government spending."

Table I lists the regions of England by the number of private beds available per person. Although the correlation is not perfect, in general the more private beds a region has, the greater its odds of also enjoying above-average public hospital spending. For example, as Figure I shows:

• The North East Thames region, which has the largest number of private beds per person, also enjoys the greatest amount of NHS hospital spending, the second highest amount of NHS capital spending and the third highest growth in NHS capital spending over the past decade.
• The Northern region " which has the least private hospital beds per person " has only average NHS hospital spending, the second lowest NHS capital spending and the fourth lowest growth in capital spending.
• The Trent region " which has the second lowest number of private beds per person " has the second lowest NHS hospital spending per person and the very lowest NHS capital spending per person, and is the only region that experienced a decrease in capital spending over the past decade.

Rural Patients in Canada.

• Among Canadian provinces, the number of people per physician varies from a low of 471 in British Columbia to a high of 1,273 in the Northwest Territories - a difference of almost three to one.
• Although there are 469 people per physician in Ontario on the average, there are more than four times that number in each of northern Ontario’s rural counties.

As noted above, health care in Canada tends to be hospital-based, with modern technology restricted to teaching hospitals and outpatient surgery discouraged. Moreover, specialists and major hospitals tend to be in major cities. As in other countries, rural residents often travel to the larger cities for medical care. How often does that happen? A major new study produced at the University of British Columbia provides the answer.

Since doctors are paid on a fee-for-service basis in Canada, fee-for-service income is a good measure of the value of services actually rendered to patients. By using physician billing data, Canadian researchers determined the regional hospital district in which each patient lived - even if the service was provided in some other district. As Table II and Figure II show:

• Overall, people living in British Columbia’s two largest cities (Vancouver and Victoria) receive about 37 percent more physician services per capita than those living in the 28 rural districts of the province.
• Urban residents receive 55 percent more services from specialists per capita than rural residents, and for specific specialities the discrepancies are even greater.
• On the average, urban residents are 5 1/2 times more likely to receive services from a thoracic surgeon, 3 1/2 times more likely to receive the services of a psychiatrist and about 2 1/2 times more likely to receive services from a dermatologist, an anesthesiologist or a plastic surgeon.

• An 80-year-old man in Vancouver is 524 times more likely to receive the services of an anesthesiologist than if the same man were living in the Sunshine Coast district (pop. 17,049).
• A small child with a skin rash is 22 times more likely to see a dermatologist if the child is living in Vancouver than in the East Kootenay district (pop. 50,660).
• A baby girl is 10 times more likely to see a pediatrician for any reason if she is living in Vancouver rather than Peace River (pop. 51,252).
• A 40-year-old woman is almost nine times as likely to have plastic surgery if she is living in Vancouver rather than Bulkley-Nechako (pop. 36,952).
• A 40-year-old woman with a mental disorder is 12 times more likely to see a psychiatrist if she is living in Vancouver rather than Fraser-Fort George (pop. 88,250).

Rural Patients in Latin America.

• Although more than half of Brazil’s population lives in rural areas, residents of urban areas experience nine times more medical visits, 15 times more related services, 2.7 times more dental visits and 4.5 times more hospitalizations.
• Overall, the Brazilian government spends five times less on inpatient care and 13 times less on outpatient care in rural areas.

Brazil is not unique. In neighboring Venezuela, government-provided health care is theoretically free to everyone. Yet the vast majority of health care services are provided in the cities. Similarly, a doctor in Bolivia is seven times more likely to practice in an urban area (where less than half the population resides) than in the countryside. And in Mexico " where health care is a constitutional right " 35 percent of the population (mainly in the cities) consumes 85 percent of the country’s health care resources.

Rural Patients in Communist Countries.

"In the Soviet Union, life expectancy in rural areas has been falling."

Despite the fact that the Soviet Union was committed to the principle of equal access to health care for over 70 years, there is evidence that inequality in access to medical resources and health outcomes grew.

• In the 1960s, infant mortality rates were virtually the same, on the average, among urban and rural areas.
• In the 1970s and 1980s, infant mortality rates continued to fall in the cities but began to rise in rural areas.
• Between 1960 and 1987, life expectancy at birth fell so much in rural areas that by 1986-87 there was a two year difference in life expectancy between urban and rural areas.