Development of a measure of health care affordability applicable in a publicly funded universal health care system

Jeannie L. Haggerty, Jean-Frédéric Levesque


OBJECTIVE: Direct measures of health care affordability from the user perspective are needed to monitor equitable access to publicly funded health care in Canada. The objective of our study was to develop a survey-based measure of healthcare affordability applicable to the Canadian context.

METHODS: We developed items after focus group exploration of access and cost barriers in the healthcare trajectory. We administered an initial instrument by telephone to a randomly-selected sample of 750 respondents in metropolitan, rural, and remote settings in Quebec. After analysis we developed a new, self-administered version eliciting the frequency of problem access due to five affordability dimensions. This version was mailed to a subset of participants. We conducted exploratory and confirmatory factor analysis. We used ordinal logistic regression modelling to examine how individual items and the subscale score predicted indicators of difficult access. We looked for effect modification by income categories.

RESULTS: The five items load on a single construct with good internal consistency (α = 0.77). The overall score, 0 to 5, reflects the sum of problems with healthcare affordability due to direct and indirect costs. The item and subscale scores are sensitive to income status, with affordability problems more prevalent among low-income than high-income respondents. Each unit increase in the subscale score predicts increased likelihood of unmet needs (OR = 1.54), emergency room use (OR = 1.41), and health problem aggravation (OR = 1.80).

DISCUSSION: This subscale reliably and validly measures cost barriers to medically necessary services in Canada, and can potentially be applied in other settings with publicly funded health systems. It can be used to monitor and compare healthcare equity.


Primary health care; accessibility of health services; Canada; health care disparities; outcome and process assessment (health care)

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