OBJECTIVES:To estimate disparities in quality-adjusted life expectancy (QALE) across social deprivation subgroups in China using the County-level Social Deprivation Index 2020 (CSDI 2020). METHODS:Mortality data from the 2021 Chinese Death Surveillance System were linked with a national EQ-5D-5L health utility survey. Mortality underreporting was calibrated using model life tables and benchmarked against official statistics. Health utilities were modeled using ordinary least squares regression incorporating age-deprivation interactions. QALE was estimated via the Sullivan method. Additional analyses examined the interaction between geographic regions and deprivation quintiles. RESULTS:QALE declined progressively as social deprivation increased. The national QALE gap at birth between the least- and most-deprived quintiles was estimated to be at least 7.73 quality-adjusted life-years (QALYs) (95% CI: 7.12-8.32), with 77.4 QALYs in the least-deprived group versus 69.6 QALYs in the most deprived. Men experienced larger disparities (7.98 QALYs) than women (7.31 QALYs). Sensitivity analyses confirmed a robust gradient, with gaps ranging from 7.45 to 8.71 QALYs. When accounting for region-deprivation interactions, this disparity widened to 10.65 QALYs between the least-deprived Eastern and most-deprived Western subgroups. CONCLUSIONS:Substantial, graded inequalities in QALE exist in China, significantly compounded by regional development gaps. These findings provide a critical empirical foundation for equity-informed health policy and distributional cost-effectiveness analysis.

This study investigated the Australian general public's views on trade-offs between reducing health inequalities and improving total health. It elicited relative equity weights, comparing inequalities in life expectancy at birth across three equity-relevant dimensions: income (comparing poorest versus richest fifth), ethnic (comparing Indigenous versus non-Indigenous), and geographic (comparing rural/remote versus major cities). A benefit trade-off exercise was administered via online survey to a sample of Australian adults (n = 3105) using quota sampling to ensure population representativeness across key demographic variables (age, gender, state of residence, household income and education level). When comparing income groups, 88% (95% Confidence Interval (CI): 82%-92%) of the respondents were health inequality averse, with 42% (95% CI: 34%-51%) demonstrating extreme inequality aversion. When considering Indigenous status, 85% (95% CI: 79%-90%) showed inequality aversion, and 40% (95% CI: 31%-49%) displayed extreme aversion. Lastly, looking at different geographic locations, 74% (95% CI: 66%-80%) of the respondents were inequality averse, with 37% (95% CI: 29%-46%) showing extreme inequality aversion. The relative equity weights were calculated, allowing for varying baseline inequalities in life expectancy - proportional gaps of 10.8%, 5.1% and 6.3%, respectively. The results imply that the public is willing to weight incremental health gains to the poorest fifth five times more than to the richest fifth, six times more for Indigenous versus non-Indigenous, and four times more for people living in rural and remote areas compared to major cities.

OBJECTIVES:Making health programs more equitable sometimes reduces their health benefit per unit of cost. Policy makers therefore need to understand public preferences for reducing health inequalities; however, this evidence has been restricted to Europe, with no estimates available in Asia. Thus, this study aimed to gauge health inequality aversion in Japan in comparison with the UK populations. METHODS:National online survey of Japanese adults (aged 18-69), using a Japanese version of a UK benefit trade-off questionnaire, involving pairwise policy choices with different levels of health benefit and inequality. Attitudes toward reducing health inequality were classified using the same approach as the original UK study. Regression analyses were conducted to explore heterogeneity by age, gender, income, education, and geographic region. RESULTS:On average, respondents in the analytic sample (n = 473) weighed health gains to the poorest fifth of people approximately 6 times more highly than health gains to the richest fifth; 76.9% had positive health inequality aversion. Health inequality aversion was higher in the poorest fifth of respondents and in the northern region of Japan, but otherwise was not closely correlated with other characteristics. There was a higher proportion of invalid responses in Japan (67.9%) than the United Kingdom (47.0%). CONCLUSIONS:Most people in Japan appear willing to forgo gains in total population health to reduce health inequality, such as in the United Kingdom. However, more research is needed to understand the high rate of inconsistent responses to the online version of this questionnaire, which was even higher in Japan than in the United Kingdom.

Background Public health research and prevention policies often use the small area Index of Multiple Deprivation (IMD) at neighbourhood level to proxy individual socio-economic status because it is readily available. We investigated what household income adds to IMD in early childhood for predicting adverse health in adolescence.Methods Using data from the Millennium Cohort Study, we analysed IMD and self-reported equivalised household income (ages 0-5) to predict outcomes at age 17: poor academic achievement, psychological distress, poor health, smoking, and obesity. Predictions were compared using IMD quintile groups alone, household income quintile groups alone, and both together.Results Household income was a stronger and more consistent predictor of age 17 outcomes than IMD and revealed inequalities within neighbourhoods. Decreasing household income showed steep gradients in educational attainment and smoking across all IMD quintiles, and moderate gradients in obesity, psychological distress and poor health in most quintiles. IMD did not predict smoking or psychological distress within any income group, or educational attainment within the poorest income group.Conclusions Household income is associated with inequality gradients within all quintiles of neighbourhood IMD. Early childhood public health strategies should consider household income in combination with neighbourhood deprivation.

Inequalities exist in hospitalisation rates, which are undesirable and costly for health systems; with higher rates in populations with lower levels of income, education or residing in socioeconomically marginalised neighbourhoods where ill-health is more prevalent and preventive care is more limited. Objectives:To understand which interventions reduce, maintain or increase socioeconomic inequalities in hospitalisations or readmissions to aid efforts of policymakers and practitioners working to improve health equity and reduce hospital pressures. Design:Systematic review. Eligibility criteria:Intervention studies in any Organisation for Economic Co-operation and Development (OECD) country, involving individuals of any age, published in any language which reported the differential impact across socioeconomic group (any classification) for three categories of intervention (population-level, health service or integrative interventions) on hospitalisation or readmission outcomes (all cause or condition specific). Data extraction and synthesis:An electronic search of MEDLINE, Embase, CINAHL, Cochrane CENTRAL and Web of Knowledge was conducted covering 24 years (from 1 January 2000 to 1 April 2024), supplemented with full citation searches of included studies, website searches and expert consultation. Risk of bias was assessed using the EHPP tool, direction of effect classified and narrative synthesis conducted. Results:From 25 618 records screened, 36 studies met the inclusion criteria, conducted in eight countries with 42% of these published in the past 5 years. Studies employed a range of study designs and 88% were rated as either moderate or strong quality. A range of equity impacts of interventions on hospitalisations and readmissions were observed; 6 interventions increased inequalities, 7 maintained, 10 had mixed or inconclusive impacts, and 13 studies reported effective interventions for reducing inequalities. Interventions successful at reducing inequalities were those implemented and enforced across entire populations and systems and supportive interventions tailored to the varied needs and contexts of people from different socioeconomic groups. Conclusions:Socioeconomic disadvantage was variously measured making comparison of equity impacts across studies complex. Policymakers and practitioners cannot assume that interventions implemented to reduce hospitalisations or readmissions will necessarily reduce prevailing and costly healthcare inequalities; it is imperative that the equity impacts of interventions are consistently monitored. To improve equity of hospital outcomes, investment in population health and integrative activity addressing the social determinants of health, alongside health service interventions, is required. PROSPERO registration number:CRD42019153666.

Objectives:Socioeconomic disadvantage increases the risk of acute illnesses and injuries requiring hospital admission, some of which are avoidable. This systematic review aimed to identify the impact of interventions on hospital admissions in socioeconomically disadvantaged populations and identify knowledge gaps. Design:Systematic review (PROSPERO, CRD42019153666). Data sources:We searched MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), Cochrane CENTRAL (Wiley) and the Web of Knowledge platforms. Eligibility criteria:Studies published between 1 January 2000 and 1 April 2024. We included quantitative studies that included a socioeconomically disadvantaged population, conducted studies in countries members of the Organisation for Economic Co-operation and Development (OECD) with universal healthcare and reported on hospital admission or readmissions. Data extraction and synthesis:We assessed study quality using the Effective Public Health Practice Project tool. We summarised studies using a narrative synthesis approach and present findings using vote counting as a measure of effect. Results:We included 20 studies of interventions targeted towards socioeconomically disadvantaged populations. Their impacts on hospitalisations of interventions, grouped under three domains-(1) population level health and social policy, (2) health and care service-based interventions and (3) integrative interventions-were mixed. Through vote counting, we found some evidence that social policy interventions targeting socioeconomically disadvantaged groups have an important impact on hospitalisations, especially those focused on improved housing and income. Conclusions:While ongoing efforts to ensure that healthcare interventions improve the equity of access, experience and outcome are warranted, social policy interventions that address the wider determinants of health, such as housing, income and education, hold promise for controlling rates of hospital admissions in socioeconomically disadvantaged groups. This underscores the value of multi-sectoral action to reduce inequalities. Future studies should explore the long-term outcomes of interventions, particularly integrative ones, which may bring benefits in the long term but not so much in the short term. PROSPERO registration number:CRD42019153666.

INTRODUCTION:Undiagnosed chronic disease has serious health consequences, and variation in rates of underdiagnosis between populations can contribute to health inequalities. We aimed to estimate the level of undiagnosed disease of 11 common conditions and its variation across sociodemographic characteristics and regions in England. METHODS:We used linked primary care, hospital and mortality data on approximately 1.3 million patients registered at a GP practice for more than one year from 01/04/2008-31/03/2020 from Clinical Practice Research Datalink. We created a dynamic state model with six states based on the diagnosis and mortality of 11 conditions: coronary heart disease (CHD), stroke, hypertension, chronic obstructive pulmonary disease, type 2 diabetes, dementia, breast cancer, prostate cancer, lung cancer, colorectal cancer, and depression/anxiety. Undiagnosed disease was conceptualised as those who died with a condition but were not previously diagnosed. This was combined with observed data on the incidence of diagnosis, the case fatality rate in the diagnosed, and an assumption about how that rate varies with diagnosis to estimate the number of undiagnosed disease cases over the total number of disease cases (underdiagnosis) in each population group. We estimated underdiagnosis by year, sex, 10-year age group, relative deprivation, and administrative region. We then applied small-area estimation techniques to derive underdiagnosis estimates for health planning areas (CCGs). RESULTS:Levels of underdiagnosis varied between 16% for stroke and 69% for prostate cancer in 2018. For all diseases, the level of underdiagnosis declined over time. Underdiagnosis was not consistently concentrated in areas with high deprivation. For depression/anxiety and stroke, underdiagnosis was estimated to be higher in less deprived CCGs, whilst for CHD and T2DM, it was estimated to be higher in more deprived CCGs, with no apparent relationships for other conditions. We found no uniform spatial patterns of underdiagnosis across all diseases, and the relationship between age, deprivation and the probability of being undiagnosed varied greatly between diseases. DISCUSSION:Our findings suggest that underdiagnosis is not consistently concentrated in areas with high deprivation, nor is there a uniform spatial underdiagnosis pattern across diseases. This novel method for estimating the burden of underdiagnosis within England depends on the quality of routinely collected data, but it suggests that more research is needed to understand the key drivers of underdiagnosis.

Objectives Disparities in health and healthcare between more and less socially advantaged groups are pervasive, multidimensional, and far-reaching. The material and social conditions in which people are born, grow, work, live, and age are systematically associated with their health and with the volume, quality, and outcomes of care received by the vast majority of the general population, as well as by specific marginalized populations. The field of health economics and outcomes research (HEOR) has an important role in supporting health equity goals. This publication aimed to act as a “primer” for conducting health equity research within the field of HEOR, establishing foundational understanding of key concepts. Methods The ISPOR Special Interest Group on Health Equity Research was established in 2021 to advance equity-informative methods and data to better enable researchers to empirically investigate—and ultimately reduce—unfair social differences in health. This publication was developed by the ISPOR Special Interest Group leadership team with input from the group membership. Results The resultant publication provides an overview of health equity research methods and data considerations as they relate to HEOR-relevant topics including clinical trials, real-world evidence and economic evaluation. Reflecting the current body of research on health equity in HEOR, particular focus is given to the latter. It also brings together a list of core reference material to support future learning. Conclusions This report provides the HEOR community with a tailored “state of play” overview of health equity, to support development of foundational understanding and inspire increased engagement.

OBJECTIVES:Health inequality aversion parameters are used in distributional cost-effectiveness analysis, direct equity-based weighting to reflect societal preferences for improving total health ("efficiency"), and reducing health inequality between more and less socially advantaged groups ("equity"). We elicited a health inequality aversion parameter for the US population. METHODS:We adapted a benefit trade-off (BTO) instrument used in a UK study. Participants comprised the adult general public from June to December 2023. The online survey comprised (1) demographics and health views questions, (2) instructional videos, and (3) BTO exercise. The BTO asked participants to trade off quality-adjusted life expectancy from the better-off to worse-off quintiles of the US population, described by indicators of social vulnerability. Response patterns were classified into 15 ranks with corresponding inequality aversion parameters and implied equity weights. RESULTS:Among 1864 complete responses, inequality aversion was assessed for 1290 participants. The sample approximated US Census data for gender, race/ethnicity, and income. The median Atkinson parameter was 12.12, the corresponding equity weight was 6.7, and 88% were willing to trade off total health to reduce health inequality. Multivariable regression indicated no significant subgroup variation in trade-off responses by age or region; however, lower income groups and ethnic minority groups were slightly more averse to health inequality. CONCLUSIONS:The inequality aversion statistics derived from this sample illustrate support for more robust and routine integration of equity concerns into healthcare decisions in the policy and health technology assessment arenas to advance distributional cost-effectiveness analysis in the United States.

OBJECTIVE:The lack of an up-to-date area deprivation index for China is a major barrier to health inequality monitoring and evaluation in the world's most populous country. This study aimed to develop the County-Level Social Deprivation Index 2020 for China from the most recent census data and analyze its relation to health outcomes. METHODS:On the basis of the 2020 census data, 14 indicators for 2844 counties were selected across 5 domains, including income, employment, housing, education, and urban-rural location. The index was created using principal component analysis with oblique rotation. Associations between deprivation quintile groups and life expectancy and infant mortality were examined, with extensive sensitivity analyses around alternative indicators and weighting methods. RESULTS:The new deprivation index was based on a weighted sum of 3 components that altogether explained 74% of the variation in the 14 indicators. Counties in the Eastern region tended to be less deprived, whereas counties in the Southwestern region tended to be more deprived. The life expectancy was 4.51 years shorter, and the infant mortality was 5.18% higher for counties in the most deprived quintile than those in the least deprived quintile. The grouping result and the association with the health outcomes were consistent across the primary and sensitivity analyses. CONCLUSIONS:The County-Level Social Deprivation Index 2020 for China reveals a clear social gradient in life expectancy and infant mortality across deprivation quintile groups. It can be used to help monitor health inequalities, identify high-need populations and quantify health inequality impacts in China.

Objectives: The Incredible Years Teacher (R) Classroom Management (IY-TCM) intervention is associated with short-term improvements in mental health difficulties in young people. The aim was to estimate the long-term impact and cost-effectiveness of the IY-TCM intervention compared with no intervention. Methods: An existing health economic model (LifeSim 1.0) was used to translate short-term changes in the Strength and Difficulties Questionnaire (SDQ), based on the Supporting Teachers and childRen in Schools cluster randomized controlled trial of the IY-TCM intervention in schools, into estimated medium- and long-term effects using multiple longitudinal data sets. LifeSim 1.0 was adapted to incorporate teacher-reported SDQ and account for individual heterogeneity. Cost-effectiveness analyses were conducted using the trial-based intervention cost with subgroup analyses on deprivation, conduct scores and parental depression in the simulated baseline population. Results: Regression analyses show significant predictor variables for intervention effectiveness, including deprivation and baseline SDQ. LifeSim results indicate small gains in long-term outcomes, and cost-effective analyses estimated that the IY-TCM intervention could be costeffective, but there was a large amount of uncertainty (net monetary benefit = 10 pound, Estimated CI = 2 134 pound, 156) pound. Benefits and certainty of cost-effectiveness were greater for some subgroups, such as those with high conduct scores at baseline (net monetary benefit = 206 pound, Estimated CI = 26 pound, 318) pound. Conclusions: IY-TCM could be cost-effective, but there was a large amount of uncertainty around costs and benefits. Greater benefits for pupils with difficulties at baseline suggest that the intervention may be more cost-effective for schools in more deprived areas with high levels of conduct problems.

UK adolescents and young adults are facing increasing rates of mental health problems and extremely difficult economic circumstances. There is strong evidence that interventions to increase income during adolescence can mitigate conditions such as anxiety and depression. However, policymakers lack quantified risk differences in the probability of mental illness between different income groups by which to establish the prospective scale of mitigation. Here, we estimate risk differences using two longitudinal cohort studies: Millennium Cohort Study (cohort members born between 2000 and 2002) and Next Steps (born 1989–1990). We quantify the association between income and risk of depression at age 14, serious mental illness at age 17, and non-psychotic mental illness at age 25. We also conduct sensitivity analysis using numerous other markers of socioeconomic (SES) status. We estimate that those living in the poorest quintile group of households have a greater probability of mental health problems than the richest at ages 14, 17, and 25. We find that other markers of SES status—subjective financial strain, cohort member assessed wealth relative to friends, occupational class, and education—display steeper associations with mental health symptoms relative to associations between mental health symptoms and income. Our findings are likely to be conservative underestimates since they are likely to be attenuated by well-known and large measurement errors in both mental health problems and living standards during adolescence.

Following the development of a value of vaccination (VoV) framework for health technology assessment/cost-effectiveness analysis (HTA/CEA), and identification of three vaccination benefits for near-term inclusion in HTA/CEA, this final paper provides decision makers with methods and examples to consider benefits of health systems strengthening (HSS), equity, and macroeconomic gains. Expert working groups, targeted literature reviews, and case studies were used. Opportunity cost methods were applied for HSS benefits of rotavirus vaccination. Vaccination, with HSS benefits included, reduced the incremental cost-effectiveness ratio (ICER) by 1.4–50.5% (to GBP 11,552–GBP 23,016) depending on alternative conditions considered. Distributional CEA was applied for health equity benefits of meningococcal vaccination. Nearly 80% of prevented cases were among the three most deprived groups. Vaccination, with equity benefits included, reduced the ICER by 22–56% (to GBP 7014–GBP 12,460), depending on equity parameters. Macroeconomic models may inform HTA deliberative processes (e.g., disease impact on the labour force and the wider economy), or macroeconomic outcomes may be assessed for individuals in CEAs (e.g., impact on non-health consumption, leisure time, and income). These case studies show how to assess broader vaccination benefits in current HTA/CEA, providing decision makers with more accurate and complete VoV assessments. More work is needed to refine inputs and methods, especially for macroeconomic gains.

Background Reductions in local government funding implemented in 2010 due to austerity policies have been associated with worsening socioeconomic inequalities in mortality. Less is known about the relationship of these reductions with healthcare inequalities; therefore, we investigated whether areas with greater reductions in local government funding had greater increases in socioeconomic inequalities in emergency admissions. Methods We examined inequalities between English local authority districts (LADs) using a fixed-effects linear regression to estimate the association between LAD expenditure reductions, their level of deprivation using the Index of Multiple Deprivation (IMD) and average rates of (all and avoidable) emergency admissions for the years 2010-2017. We also examined changes in inequalities in emergency admissions using the Absolute Gradient Index (AGI), which is the modelled gap between the most and least deprived neighbourhoods in an area. Results LADs within the most deprived IMD quintile had larger pounds per capita expenditure reductions, higher rates of all and avoidable emergency admissions, and greater between-neighbourhood inequalities in admissions. However, expenditure reductions were only associated with increasing average rates of all and avoidable emergency admissions and inequalities between neighbourhoods in local authorities in England's three least deprived IMD quintiles. For a LAD in the least deprived IMD quintile, a yearly reduction of 100 pound per capita in total expenditure was associated with a yearly increase of 47 (95% CI 22 to 73) avoidable admissions, 142 (95% CI 70 to 213) all-cause emergency admissions and a yearly increase in inequalities between neighbourhoods of 48 (95% CI 14 to 81) avoidable and 140 (95% CI 60 to 220) all-cause emergency admissions. In 2017, a LAD average population was similar to 170 000. Conclusion Austerity policies implemented in 2010 impacted less deprived local authorities, where emergency admissions and inequalities between neighbourhoods increased, while in the most deprived areas, emergency admissions were unchanged, remaining high and persistent.

Abstract Background Understanding the prevalence of diseases and where it is detected and recorded in healthcare settings is important for planning effective prevention and care provision. We examined inequalities in the prevalence of 205 chronic conditions and in the care setting where the related diagnoses were recorded in the English National Health Service. Methods We used data from the Clinical Practice Research Datalink Aurum linked with Hospital Episode Statistics for 12.8 million patients registered with 1406 general practices in 2018. We mapped diagnoses recorded in primary and secondary care in the previous 12 years. We used linear regressions to assess associations of ethnicity, deprivation, and general practice with a diagnosis being recorded in primary care only, secondary care only, or both settings. Results 72.65% of patients had at least one diagnosis recorded in any care setting. Most diagnoses were reported only in primary care (62.56%) and a minority only in secondary care (15.24%) or in both settings (22.18%). Black (− 0.08 percentage points (pp)), Asian (− 0.08 pp), mixed (− 0.13 pp), and other ethnicity patients (− 0.31 pp) were less likely than White patients to have a condition recorded. Patients in most deprived areas were 0.27 pp more likely to have a condition recorded (+ 0.07 pp in secondary care only, + 0.10 pp in both primary and secondary care, and + 0.10 pp in primary care only). Differences in prevalence by ethnicity were driven by diagnostic recording in primary care. Higher recording of diagnoses in more deprived areas was consistent across care settings. There were large differences in prevalence and diagnostic recording between general practices after adjusting for patient characteristics. Conclusions Linked primary and secondary care records support the identification of disease prevalence more comprehensively. There are inequalities in the prevalence and setting of diagnostic recording by ethnicity, deprivation, and providers on average across conditions. Further research should examine inequalities for each specific condition and whether they reflect also differences in access or recording as well as disease burden. Improving recording where needed and making national linked records accessible for research are key to understanding and reducing inequalities in disease prevention and management.

Abstract Background The prevalence of childhood mental health problems is increasing. School-based interventions have the potential to reduce poor mental health and mental health inequalities. Our aim was to estimate the long-term costs and benefits of the Incredible Years Teacher® Classroom Management (IY-TCM) intervention in primary schools compared to no intervention. Methods LifeSim, an existing microsimulation model, was used to estimate the lifetime costs and benefits of IY-TCM by linking short-term changes in SDQ based on a previous trial in primary schools (Cluster RCT: 2075 children aged 4-9 years with a 30-month follow-up) to long-term health, social, economic and wellbeing outcomes. Benefits were measured in quality adjusted life years and wellbeing adjusted life years. We examined subgroup based on deprivation, conduct scores and parental depression. Results Microsimulation modelling estimated small gains in lifetime outcomes including reduced conduct disorder in adolescence and depression in adulthood. Estimates indicate IY-TCM could be cost-effective with a large amount of uncertainty (Net monetary benefit (NMB)=£21, Estimated CI = -£195, £240). IY-TCM was estimated to be more cost-effective for those with high deprivation (NMB = £231, Estimation CI - -£99, £231) and high conduct problem scores (NMB=£315, Estimated CI = £45, £483). Total net social benefit for a typical year size group was estimated to be £111m. Conclusions IY-TCM could be cost-effective compared to no intervention with a large estimated social benefit supporting wider implementation of IY-TCM, but results indicate a large amount of uncertainty. Greater benefits and higher certainty of cost-effectiveness for children with conduct problems and those living in a deprived area suggest IY-TCM has the potential to reduce mental health inequalities and may be more cost-effective for schools with higher deprivation and/or a high prevalence of conduct problems. Key messages • The Incredible Years Teacher Classroom Management intervention for mental health in primary schools could be considered cost-effective but there is a large amount of uncertainty. • Greater benefits for children with conduct problems and those living in a deprived area indicates the intervention has the potential to reduce mental health inequalities.

The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.