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Does anyone care about the inequities in health?

An exam paper for a health subject recently asked second-year university students to define equity. “It’s the amount of possessions you have,” was one reply.

I heard this story today but wish I’d heard it yesterday. It would have been good to include in a talk that I gave to an Australian Institute of Health and Welfare dinner last night, which argued that the health sector needs a major injection of transparency to help reduce inequities, in both health outcomes and health care.

The dinner was marking today’s launch of the Institute’s latest report card on Australia’s health, which shows, as you’d expect, significant health gaps between the haves and have nots.

Much of the talk was based upon suggestions from Croakey contributors, whom I’d asked to define equity and why it matters, for examples of inequities in health, and for areas requiring greater transparency.

You can read their responses in this and the following two posts.

What is equity and why does it matter?

Carol Bennett, Consumers Health Forum

“There are many examples of inequity in health, but perhaps the biggest is access to appropriate health care based on socio economic status.
If you live in the leafy affluent suburbs of a major metropolis in Australia, chances are you will have access to a full range of specialists who are also engaged in your community, know their fellow health providers and are aware of the range of options to support your treatment. We know poor health outcomes are much more likely for people living in the lowest socio economic areas.  There is undoubtedly a bias towards treating rich people in the private system leaving the public system dealing with often more complex issues, but with fewer resources. Access to health care based on socio economic status needs to be tackled if we are to improve real health outcomes.”

***
Professor Mark Harris, Centre for Primary Health Care and Equity at the University of NSW:

“Equity can be defined in a number of ways.  Most broadly it involves the value of fairness.  A more limited definition of equity is equality of access and use proportionate to need.  Thus it is unfair if Aboriginal people have equal access (which of course in many cases they do not) because they have greater health need – equity would imply greater access proportionate for this group in the population.  A more radical definition involves equality of health outcomes – this is a bit more problematic to measure and achieve given the great number of factors that can affect outcomes.   This definition would see the differentials in outcomes for Indigenous people as being inequitable. This is obviously important and something that we should all be striving to achieve. The first definition is clearly something that we can hold health services accountable for. The second is something that the whole society is accountable for (and probably requires a longer time frame to achieve).”

***
Health economist Professor Gavin Mooney:

“I would define equity as ordinary, informed  citizens want it defined. This definition is from a Citizens’ Jury in Perth: See www.gavinmooney.com

Equal access for equal need, where equality of access means that two or more groups face barriers of the same height and where the judgment of the heights is made by each group for their own group; and where nominally equal benefits may be weighted according to social preferences, such that the benefits to more disadvantaged groups may have a higher weight attached to them than those to the better off.”

***

Professor Peter Sainsbury, University of Sydney:

He provided a very useful slide presentation, titled “Is it right that poor people die young?” as well as this definition:

“Ideally and in ‘lay’ terms something like: equity is the absence of preventable and unfair differences in access to health services, health status and life expectancy within a society that are due to any personal or social characteristics (eg age, gender, income level, place of residence, ethnic background, socioeconomic status, employment status). In the reverse, a health inequity is a difference in access to health services, health status and life expectancy that is due to a personal or social characteristic and is potentially preventable and is considered unfair by most of society.

Health equity matters because (1) health is a fundamental resource for life and individuals and groups should not be unnecessarily disadvantaged by poor health caused by preventable reasons, (2) Australians have a general notion of fairness and are upset by examples of preventable unfairness, (3) despite generally improving levels of health and life expectancy in Australia some social groups are not experiencing the same improvements and are lagging behind in health status – they are missing out on the bonanza!, (4) failure to achieve health equity results in preventable suffering and preventable health care expenditure.”

***

Sebastian Rosenberg, Brain and Mind Research Institute, University of Sydney:

“Since the advent of Medicare in particular, Australians have a shared expectation of access to a high quality health system, regardless of their own personal circumstances (wealth, postcode etc). This expectation is built on the concept of health as a public good, a common investment in a shared safety net of services, funded by fair contributions under a fair tax system where you pay according to your income. This concept of equity is important to Australia because it reflects the nation’s concerns about a fair go for all and about ensuring the best services should be available even, or particularly, for those most vulnerable to illness.

The concept of a public good has been compromised by successful governments’ willingness to use public funds to support the private health insurance industry, without evidence to indicate any benefit to the public hospital system, waiting lists, research, medical training etc. This has been a monstrous impost on the taxpayer and reduced the pool of funds available for public health care.”

***

John Menadue, health policy expert:

“Equity in health is the provision of quality care to everyone regardless of location. It is important in the recognition of the human rights of every person. It is also important for social solidarity, the binding of the whole community together.”

***

Barbara Hocking, Sane Australia:

“I’m a Pollyanna! So – everyone living in Australia to have equal access to prevention, early intervention and treatment services for all (physical and mental) health conditions, regardless of income and education levels, disability, racial or religious background and, as much as is possible where they live. This latter point is the really challenging one in Australia where distances and population density do make it very tricky.”

***

Prue Power, Australian Healthcare and Hospitals Association:

“Our health system should reflect our values as a community. We don’t have a good sense of what our community values in relation to health care are because unlike other countries we haven’t made an effort to find out (compare the NHHRC’s approach to consultation with the Canadian Romanow Commission which focused much more on values and principles). However, when smaller scale consultation projects on underlying health system principles and values have been carried out (for example Citizen’s Juries) they have always emphasised the importance of equity within health care.

Defining equity is complex. Rather than getting bogged down in the minutiae of formal definitions it is more important to reflect the actual experience of consumers, rather than an ‘official’ or administrative position, when defining equity. For example, if assessing whether or not Medicare is equitable it is more important to look at the experiences of consumers with Medicare-funded services rather than the fact that officially all Australians have the same entitlements. If someone is unable to access a Medicare-funded service because it is too far away and they don’t have transport or because it is not culturally appropriate for them, the service is not equally accessible. So a definition of equity along the lines of “equal access to health care” or “equal opportunity to access health care” would work – as long as ‘access’ is defined in a broad sense.”

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Dr Mark Ragg, public health writer and publisher:

“Equity is a fair go – equal access to equal services irrespective of ability to pay, socioeconomic status, educational level, geography, ethnicity and anything else you can think of. It matters because it influences health, and there seems to me no reason why any one person should be healthier than another simply because they are wealthier.”

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Elizabeth Harris, Centre for Health Equity Training Research and Evaluation, University of NSW:

“There are three main ways this is understood in Australia: Equity of access to services (GPs, hospitals etc and opportunities for health work, housing); equity in the distribution of resources so that resources are allocated on the basis of need not history or prejudice such as the under investment in mental health; and equity in outcomes that is patterns of systematic difference between population groups are seen as avoaidable and unfair, for example, Aboriginal health.

There is a social gradient – so we are all affected by unfairness and there is evidence that the wider the gap between the top and bottom, the more likely all of us are negatively affected (for example US Mortality rates). Also if we want a cohesive society we need need a fair and just society. Equity requires a values discussion.”

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Professor Judith Dwyer, Flinders University:

“Equity in health means everyone having the same chance for a long healthy life. Equality can’t happen, because biology is not fair. But equity would mean the preventable differentials in healthy life and life expectancy were removed. Equitable access to health care is one way of pursuing this goal.”

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Margo Saunders, public health policy consultant:

“As others will no doubt point out, there are differences between inequities and inequalities in health and in their relationship to social determinants.  Exactly what those differences are has been the subject of considerable discussion and debate.

The WHO Commission on Social Determinants of Health (http://www.who.int/social_determinants/en/) was charged with recommending interventions and policies ‘to improve health and narrow health inequalities through action on social determinants’.  The Commission was of the view that where inequalities in health are avoidable but are not avoided, they are inequitable, and that social justice requires action to achieve health equity.

The 2008 UK conference which followed the release of the Commission’s report was entitled, ‘Closing the gap in a generation: health equity through action on the social determinants of health’ – referring to health equity, not inequality.

The International Journal for Equity in Health is devoted, not surprisingly to issues around that topic (http://www.equityhealthj.com/).  In her editorial introducing the special issue of the Health Sociology Review on Social Equity and Health in 2007, Toni Schofield of the University of Sydney fudges the distinction, perhaps deliberately, between inequity and inequality.  She refers to ‘health inequities or inequalities’ as an issue which ‘has emerged as one of the most pressing issues of global health governance’ (http://hsr.econtentmanagement.com/archives/vol/16/issue/2/article/479/).

In relation to defining equity in health, an excellent starting point is Braveman and Gruskin’s 2003 article, Defining equity in health (http://jech.bmj.com/content/57/4/254.full.pdf), which explains that:

‘Equity in health means equal opportunity to be healthy, for all population groups. Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalising the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts. This refers to the distribution and design not only of health care resources and programmes, but of all resources, policies, and programmes that play an important part in shaping health, many of which are outside the immediate control of the health sector. … Not all health inequalities necessarily reflect inequity in health, which implies unfair processes in the distribution of resources and other conditions that affect health.’

Braveman and Gruskin also argue that, while ‘inequity in health’ is commonly understood to involve inequalities that are unjust, unfair and avoidable, the notion of avoidability should not be used as a criterion to define equity in health. Their reasons include: ‘unjust’ and ‘unfair’ imply avoidability; addressing some health inequities may require fundamental changes in underlying social and economic structures; and the issue begs the question: ‘avoidable by whom?’.

In her May 2009 paper for the National Preventive Health Taskforce (http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf), Dr Sharon Friel of the ANU’s National Centre for Epidemiology and Population Health, refers to inequities in the context of people’s health-related behaviours and their various environments:

‘What, and how much, people eat, drink and smoke and how they expend energy are responses to their socio-political, socio-economic, socio-environmental and sociocultural environments. … The harmful health consequences of these behaviours, and the inequity in their social distribution, are … indicative of both market failure (since the outcome is not good for both parties – the seller and buyer) and failure by government to protect the health of all its citizens.’

I suspect that Dr Friel is really talking about health inequalities rather than inequities, given her statement that,

‘Health inequities exist between the top and bottom socio-economic status quintile of the Australian adult population for a number of these and their associated behavioural risk factors.’
and reference to
‘the marked inequities in health between and within countries are indicators of societal, market and development failure.’

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Michele Kosky, Health Consumers Council, WA:

“My definition of equity is that those who should benefit most should benefit first and most. This was developed by a Citizens Jury in about 2004 that I helped facilitate with Gavin Mooney..
It matters because there are groups of the usual suspects in disadvantage who find the health system incomprehensible, prejudiced and basically unkind !!We think the Australian health system would be greatly improved with adoption of the virtues of kindness and helpfulness at all stages and every level…”

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Professor Simon Willcock, Professor of General Practice, University of Sydney:

“To me equity is about every person in the country (and the whole issues of national boundaries is in itself a little awkward, isn’t it?) having access to the things that we agree are essential components of good health care – these include good living conditions, healthy food, easy access to health providers (including dentists!), education and community advocacy. Not a particularly innovative list, but based on what we know are the real determinants of health outcomes for individuals and communities. Important but infrequent health problems, including for example access to organ transplantation or expensive cancer treatments, should also be equitably distributed, but must rank lower in the economic priorities of a country if resources are finite.

Why does it matter? I’m very much a believer that in societies where the gaps are smallest between those with the most and those with the least (be it health, money, education etc.) have populations that enjoy more satisfying lives (there is some evidence for this e.g. in the “happiness index” where countries like Denmark rate very highly). Just as importantly, inequity fosters resentment, rebellion and susceptibility to radicalism. We like to think that we are isolated from these issues in our corner of the world, but history has a tendency to repeat itself and the world has never been more “global”.”

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Health economist Ian McAuley:

“Equity in health outcomes is very hard. The theoretical gold standard is for outcomes which are not dependent on socioeconomic status. That’s clearly impossible because of the interrelationship of factors.

Equity in access is still hard, but we can come closer. No barriers based in financial means. A regional distribution of resources based on need, not income. A fair market – where resources are in short supply, discouragement of queue jumping.”

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Michael Moore, Public Health Association of Australia:

“The most obvious response is not only equal access to health care but (perhaps more importantly) equality of opportunity to grow up in an environment which provides the same opportunities as others to set the appropriate conditions for a healthy life and a long and healthy life.”

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Gordon Gregory, National Rural Health Alliance:

“The most important equity is fairness in terms of health outcomes: in a genuinely equitable health system, differences in health (proxy: life expectancy) should be due only to non-preventable, unmanageable factors such as genetic inheritance, occupation (there will be more premature deaths in forestry and fishing than in banking??) and gender.

The situation in which DALYs lost are greater among people on low income, in particular regions, and with particular lifestyles, is amenable to some change through a national effort working on the social and economic determinants of health  – including their difference across regions.

The inequity in health with which we are mostly concerned is access to health services – a second order issue compared with social and economic determinants. Inequity does matter in the Australian context because there is evidence that the gap is getting wider, and we pride ourselves on being a nation in which equity rules (equity is related to a fair go for everybody). [ I have heard it said not that the rich are getting richer and the poor poorer but, rather, that the rich are getting richer and the poor more numerous.]”

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Professor Lesley Barclay, Northern Rivers University Department of Rural Health:

“Because equity alters health outcomes, it is more than simply a social justice issue. As health professionals, I hope we have both a concern for social justice but an informed sense of how lack of equity influences what happens in health. Not the least is that equity influences our decisions and professional activities.”

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Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney:

“Equity is the value that we feel has been offended when we observe differences in the human condition that strike us as unfair. Differences in height are not inequitable whereas differences in access to mental health services according to wealth or attractiveness are inequitable.”

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Glenn Salkeld, Sydney School of Public Health, University of Sydney:

“Equity in health is about providing an equal opportunity for everyone to achieve health and happiness. The notion of a fair go in health means looking at individuals and community’s capacity to benefit and redirecting resources to those who need it most.

Equity matters because we it affects us all and because we care. An equitable society is one where everyone is better off. Equity is sustainable – inequity is not sustainable.”

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Associate Professor Gawaine Powell-Davi