Following on from the previous post, which looked at why equity matters, this post makes it clear that inequity is built into our health system in many ways and at many levels.
A range of Croakey contributors have provided examples of health inequities. Because the inequities in Indigenous health are so well known, I asked them to include examples from other areas. Of course many of the examples they give are general and are an issue for all Australians, both Indigenous and non-Indigenous.
Carol Bennett, Consumers Health Forum:
“Try seeing a psychiatrist if you live in Gippsland, then try seeing one if you live in Surrey Hills in Melbourne. The ratio of psychiatrists to population in Surrey hills is roughly 100 times greater than the ratio of psychiatrists to population in Morwell. Professor Patrick McGorry should know that most of his peers choose to go where the living is easy while those with real mental health needs languish on the fringes.
Mental versus physical health is another area of inequity. It seems that if you have a chest pain or a tumour growing somewhere, the best of care will be provided to you. But if you suicidal you are most likely to be told to go away and come back when you have hurt yourself or someone else!”
Dr Mark Ragg, public health writer and publisher:
“The private health insurance rebate is an enormous source of inequity. Several billions of dollars of funding a year are going to people who don’t really need it. It has little to no effect on how busy the public hospitals are. It’s an industry support scheme coming from the health budget, and it should be abolished immediately. If a federal government wants to support private health care, supporting hospitals directly seems wiser than propping up an insurance scheme that funnels money towards the wealthy. And in general, the lack of equity in health status reflects the lack of equity in society. A more equal society would be a healthier one for all.”
Barbara Hocking, Sane Australia:
“People with mental illness have higher death rates from cancer than others – not because the prevalence is higher, but because they do not have the same access to screening services and treatments. They also do not have similar access to prevention activities such as quit smoking programs.
Disadvantaged Australians have appalling access to decent dental care, many going for years without teeth – which then makes them more susceptible to other infections, hard to get a job, find somewhere to live etc, etc…..”
Prue Power, Australian Healthcare and Hospitals Association:
“Dental care is an obvious example of an inequitable sector of the health system. Also worth bringing up would be the subsidies for private care, eg the PHI rebate and the Medicare tax offset. These provide benefits disproportionately to the affluent and are not allocated on the basis of most efficient use of resources (otherwise the subsidy would go where the services deliver the best outcomes).”
Professor Judith Dwyer, Flinders University:
“In the 1990s, there was hardly a woman over a certain age living north of Grand Junction Rd in Adelaide with an intact uterus. Not sure why, but it seemed that less drastic treatments for uterine problems were more available in more affluent areas; or perhaps these women were more compliant with the procedural predilections of their medical specialists. Why would that be?
Health inequity for Aboriginal people might be influenced by different factors than those that affect non-Aboriginal people. Having a job is a health benefit in the mainstream, but in Aboriginal communities where not being in a full-time job is the norm, having one seems to be associated with health risks, perhaps arising from stress. Why is this?”
Professor Mark Harris, Centre for Primary Health Care and Equity at the University of NSW:
“The following are examples of the “inverse care law” in Australia:-
• Between 1980 and 2000 in women there was the emergence of a social gradient in women in Australia in relation to smoking and obesity. The rates of smoking by the lower SES groups changed little, but the rates in the higher socioeconomic groups fell. The rates of obesity and overweight in the lower SES groups increased more rapidly than the higher SES groups over this period. This is in part due health promotion being taken up more readily by higher SES groups.
• The strongest predictors of access to multidisciplinary allied health care for patients with diabetes are hospitalization and SES. Higher SES groups have better access proportionate to need. There is a similar pattern for patients with mental illness and psychological services.
• Low socioeconomic group patients receive shorter consultations with GPs than higher socio-economic groups. This is largely because there are fewer GPs in low SES areas – GPs have less time to spend with each patient and are more likely to bulk bill (thus their income per patient seen is lower and they tend to see more patients to achieve parity with GPs in higher income areas).”
Gordon Gregory, National Rural Health Alliance:
“The rate of cancers in rural and remote areas is little different from what it is in the cities; but the survival rate is much poorer due to later diagnosis and/or treatment because of the tyranny of distance and the scarcity of specialist staff.
People who can afford private health insurance have wider choice of service and get 30% of the cost back; people on low incomes can’t afford to buy it.”
Professor Lesley Barclay, Northern Rivers University Department of Rural Health:
“How about the closure of rural maternity services or local birthing that means considerable expense now suffered by families who need to drive and stay hundreds of kilometres from their homes to await birth. This has meant a rapid decline in antenatal care and increase in planned and unplanned out of hospital birth. In large Indigenous communities this means up to 1 in 10 births in our current study do not have optimal professional help as we do not provide the services women want or find acceptable.
People with serious or chronic mental health problems lack both social equity and safe living and opportunities often for health equity and treatment
A personal one – I had a hip replacement on my private health insurance nearly 2 years ago. I would still be waiting if I did not have insurance. My life has been turned around by access to necessary surgery without having to wait until an overstretched health system could cope.”
Professor Mike Daube, Public Health Association of Australia:
“Prisoner health is a stunning example of lack of equity. All the other disadvantages, then left to the tender mercies of however States feel they should be handled, and by virtue of their prisoner status, deprived access to Medicare and PBS.
A different kind of inequity arises from promotional budgets. Alcohol and junk food companies in Australia spend over $1 billion each year on promotion. I reckon that real public education on those areas around the country would be lucky to get to $25m.”
Health economist Ian McAuley:
“Regional distribution, including in our suburbs, which are no less “regions” than, say, the Wimmera or the Darling Downs.
Co-payments – what you pay depends on your condition.
Complexity – “rationing by complexity”. Tends to favour those with ongoing chronic conditions over others.”
Michael Moore, Public Health Association of Australia:
“Socio-economic circumstances are a major factor in both subjecting children to second hand smoke or environmental/passive smoking (as there is greater levels of smoking – particularly around children) and the type of food available to children of lower socio-economic groups means a propensity to high energy/salt foods (with more sugar, fat and salt) when they are young. They do not begin life with an equal opportunity to good health as overweight in childhood plays such an important part in later cardiovascular health etc.”
Simon Willcock, Professor of General Practice, University of Sydney:
“I have two patients, a brother and sister, who are in their 50s (like me) and have allowed me to be their doctor for 20 years. We grew up in similar communities, but they have both suffered major health problems (physical, social and psychological). They are good people who have had none of the advantages that I had when growing up in terms of a supportive family and community. Getting services for these two is often challenging, but my frustration at the way they are disadvantaged as “marginalised” members of society is tempered by the regular acts of generosity that I see provided by some of the individuals who provide the services that they need – individual specialists, dentists, psychologists who put themselves out to help. If only this could be the norm for the marginalised members of our society, most of whom have suffered terribly.
The health economists have told us for several decades that effective preventive and primary care programs deliver much better benefit per dollar in terms of improved health outcomes for populations e.g. GPs provide more health benefit to populations than specialists, as cited by Barbara Starfield. So, if we believe in “evidence-based practice” why do those areas still suffer from less investment in service provision and research?”
Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney:
“Only one in eight people leaving Australian hospitals after cardiac or respiratory flare-ups receive adequate and continuing rehab that can cut their readmission rates in half and save lives.
Women in rural areas may have to choose more extensive, non-conserving breast surgery for cancer because radiotherapy is not available, even regionally, and we provide crap accommodation except in Perth for such women coming to the city for weeks of therapy.”
Professor Alan Rosen, psychiatrist:
“I am just back from consulting with Aboriginal Community Controlled Health Organisations, who are still losing too many of their young to suicide. “They should be burying us, but we are burying them”, they told me.
The major inequities in Australian Government’s health reform has been the forsaking of Mental Dental & Aboriginal Health. The result is dire for most families with severe mental illnesses but by far worst for Aboriginal communities.
If you are Aboriginal with a severe mental illness, you are likely to experience a “Quintuple Whammy” of disadvantage:
1. Indigenous Status
2. Severe mental illness
3. comorbidity with alcohol & drugs
4.Comorbid chronic physical illness, eg dental, cardiovascular, diabetes, & renal especially
5. Severe economic deprivation, +/or remote location
This combines the experience of loss of freedoms and colonisation by Indigenous peoples with the experience of colonisation of mentally ill individuals by psychiatric professionals and institutions.”
Professor Glenn Salkeld, Sydney School of Public Health, University of Sydney:
“There are two areas where a lack of equity compromises the chance of kids getting the best start in life. One is nutrition and the other is dental care. Harvey Sutton, the Foundation Director of the School of Public Health at the University of Sydney was one of the driving forces behind the free milk for kids at school program. The idea was to give every kid a chance at a nutritious start to the day. Sadly today many kids do not have access to fruit and vegetables as part of their regular diet (nor perhaps access to sport given the every growing cost of registering kids for weekend sport). Why can’t government find the money to support an infants/primary school ‘healthy eating’ program and subsidize the cost of weekend sport?
Dental care is unaffordable and inaccessible for many Australians young and old. Everyone should have access to a minimum level of dental care.”
Associate Professor Gawaine Powell-Davies, Centre for Primary Health Care and Equity, University of NSW:
“The distribution of GPs, and so the distribution of MBS funds (say between Woollahra and Campbelltown). The waiting time for knee replacements in the public and private sector. Access to health care for asylum seekers.”
Sebastian Rosenberg, Brain and Mind Research Institute, University of Sydney:
“The concept of equity is becoming increasingly compromised. While many health funding systems across the world now offer a range of mixed and sophisticated incentives (and sanctions), Australia relies primarily on flat fee for service arrangements under Medicare. This provides examples of growing inequity:
i) Fee for service payment arrangements have meant that people living in non-urban areas do not enjoy the same access to services as others in the community. Under FFS, there is no incentive for health professionals to work in non-urban areas and so populations living in these areas miss out on services (Better Access Program).
ii) Current funding policy has led to a situation in which all Australians are now paying more than ever for their own health care not from their tax contribution, but from their own pockets. These out of pocket costs are a real disincentive for many people, including the poor and the young (Better Access Program again). This moves health away from the shared public good to something only available to those who can afford care, as in the USA. This is ‘un-Australian’!
iii) Another example is the almost complete absence of multicultural mental health services. Even in big cities, there is an appalling lack of access to specialist mental health care in languages other than English. Huge populations are almost entirely unserviced.”
Dr Tim Woodruff, Doctors Reform Society:
“Geographical: Medicare rebates gradient from rich inner urban to rural and remote which is the exact opposite of the gradient for mortality ie need
Socio-economic status: gradient of mortality is exact opposite to spending on extended Medicare safety net.”
John Menadue, health policy expert:
“Mental health, particularly for people in rural and remote areas and jumping of waiting lists for elective surgery as a result of private health insurance.”
Health economist, Professor Gavin Mooney:
“The most obvious inequity is in the funding and delivery of health care to Aboriginal people, especially with respect to lack of cultural security but also institutional racism; otherwise in funding the tax rebate on private health insurance; in delivery the very existence of a private sector in health care.
Anecdotally, a young medical friend from Scotland, working at a major teaching hospital in Perth, was disgusted that consultants told racist jokes to the junior medics. She also worried that Aboriginal women were signing consent forms without knowing what was in them – and no one seemed to care.”
Elizabeth Harris, Centre for Health Equity Training Research and Evaluation, University of NSW:
“The inverse care law suggests that those with the greatest need are often least likely to get services – for example there are almost double the number of people with diabetes in low socioeconomic status areas but half the number of long GP consultations (a marker of quality). Similarly in early childhood services it is often those mothers at greatest risk that do not receive their universal home visit after the birth of their baby.”
Public health policy consultant Margo Saunders:
“I would suggest that gender issues represent a significant example of the lack of equity in health and the health system. Within Australia, there has been little recognition of how males and females are differentially impacted by the social, structural and systemic influences on health and how these should be taken into account when it comes to planning, delivering, communicating about, assessing and improving health. While Australia’s first National Male Health Policy (http://www.health.gov.au/malehealthpolicy) seeks to address some of these concerns (as will the revised National Women’s Health Policy), its impact may be limited given that it fails to acknowledge concepts of ‘masculinity’ as the filter through which men negotiate health, and there are as yet no identified pathways to ensure that the policy will be reflected in other health policies and frameworks.
Australia has nothing like the UK’s legislated ‘gender equality duty’ (http://www.equalityhumanrights.com/uploaded_files/gender_equality_duty_code_of_practice_england_and_wales.pdf), which some might argue actually relates to ‘equity’ – although there may be questions about whether the duty is limited to opportunities rather than outcomes. The duty mandates that public sector organisations, including the National Health Service, identify and address the differing needs of men and women in terms of policies, programs and decisions. The focus is on promoting equality of opportunity, which requires identifying and addressing existing barriers. According to the Men’s Health Forum, the requirement means, ‘fully integrating an awareness of male and female health needs strategically and operationally throughout an organisation… [and] moving beyond the assumption that ‘gender’ is limited to occasional awareness campaigns on sex-specific issues’ (http://www.menshealthforum.org.uk/node/19952).
Professor Nicholas Wilcken, cancer specialist, Sydney:
“There are two inequities I am most immediately concerned about. The first is the category of health need that gets put in the “elective” basket. Lots of people needing knee and hip replacements for example really can’t wait for as long as it takes the public health system to get to them. The second issue relates to my own area – we are (finally) identifying some anti-cancer drugs that really have a substantial effect, but they are very expensive, and the gap between when there is high quality evidence of efficacy and when/if these drugs get on the PBS is widening, so that the wealthy can get access to these but others can’t. Herceptin for early breast cancer is a good example both of the problem and also of everyone’s good intentions – halving the rate of recurrence with the smallest p values ever seen. The system moved pretty quickly, but there were still plenty of people who cashed in super or sold houses to get the drug before it got on the PBS.”
Dr Ruth Armstrong, medical editor:
“My anecdote is very personal, and it is a powerful motivator for me. I have an adopted Aboriginal sister who joined our family at age 2 and is 2 years younger than me. she lived with our family until she was 21, then married a tribal Aboriginal man and went to live in a remote Aboriginal community. My sister and I are basically the same age but, over the years, I have seen her health destroyed by a whole range of physical, mental, emotional, social and spiritual assaults. My own good health, when seen in contrast, is an affront. Her access to remedial healthcare in times of crisis has actually been reasonably good but most would agree that this is just a fraction of what it takes to be healthy. When I look at our children I fear that the inequity is far from over.”
Stay tuned…the third and final post in this series is coming up – would a more transparent system be a fairer system?