Equity in Healthcare

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Discuss the concept of equity in terms of the role of government and the financing and delivery of health care. Use a country of your choice to illustrate your answer.

Health

The World Health Organization (WHO) defines health as “a state of complete lack of physical, mental and social well-being and not merely a lack of disease or infirmity” This definition dates back to 1948 whilst it has been widely accepted; However, with the aging population, growing rates of chronic disease and changing approaches to health and wellbeing an updated definition may be beneficial.

Integrative health is an extension of the WHO definition of health and is defined as “a state of wellbeing of mind, body & spirit that reflects aspects of the individual, community and population” (Witt, Chiaramonte et al. 2017)

According to their definition integrated health is determined by

  1. Individual biological factors, behaviors, social values and public policy
  2. The physical, social and economic environments
  3. The integrated healthcare system that involves the active participation of the individual and the healthcare team in applying a broad spectrum of preventative and therapeutic approaches (Witt, Chiaramonte et al. 2017)

The two main areas of health are physical & mental health.
Physical health incorporates both structural health (sound bones, muscles, organs and the other structures within the body) and chemical health (having the correct balance of chemicals within the body)

Mental health refers to peoples cognitive and emotional well-being.

There are many factors that affect ones physical and mental health which are often referred to as the determinants of health as defined by the WHO and they include:

  • Socioeconomic status
  • Education
  • Physical environment
  • Employment status
  • Culture
  • Genetics
  • Gender

Equity in health

Equity in healthcare has been described as the “absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage” (Leeder 2003) whilst the WHO describes it as “people’s needs, rather than their social privileges, guiding the distribution of opportunities for well-being” (WHO 1996)

According to the principals of equity in health care who you are and how much money you earn should not define the level of care you receive (Braveman and Gruskin 2003).

Therefore to achieve equity in health within the population the government should ensure that resources are distributed and processes are designed in ways most likely to move towards equalizing the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts (La Rosa-Salas and Tricas-Sauras 2007).

Worldwide “universal health coverage” is one of the main drivers in achieving equity in healthcare systems.
The WHO defines Universal health coverage (UHC) as a system “that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”.

Whilst many countries have “universal coverage (including the United Kingdom & Australia) those systems are still not without inequities and there are many barriers to the equity within those healthcare systems.

Geography is arguably the most common barrier to equity in healthcare across the world; as described by the determinants of health where someone is born, raised or lives can have a distinct impact on their health.
According to Rice & Smith (2001) geography and its effects on health equity can be broken into three categories.
Firstly, they described “area effects on health” which can be defined as the physical environment, local economic conditions, social support conditions such as public transport, local cultural factors. Shortfalls in social support systems including but not limited to local schools, public transport and social care can impact the health of the local community. Local cultural factors may also have an effect on lifestyle and subsequently impact on the health in a community. Local geographical areas may experience unique health issues and would subsequently also require unique responses to them (Rice and Smith 2001).
Secondly “Area effects on Health care production” Healthcare delivery will vary substantially between rural and metropolitan areas, with it becoming more increasingly costly to deliver equal level of care the further you move away from metropolitan areas leading to reduced services provided in rural areas. Having limited services in rural areas also leads to individuals having to travel further to gain access to required services, this may then limit healthcare utilization for people living in rural and remote areas (Rice and Smith 2001).
Finally, they discussed “Area effects on health care utilization”, whereby people are more likely to utilize health services if they live in an area where there is a high provision of services. Rural areas have lower levels of hospital utilization and subsequently generally have poorer health outcomes.  (Rice and Smith 2001)

The socioeconomic status of an individual, family, community or populace has shown to have drastic impacts of the health of the population.  Smoking prevalence is often higher among disadvantaged groups, whilst they may also be at greater risk due to the health complications associated with smoking (Hiscock, Bauld et al. 2012). Those in lower socioeconomic status have also been linked with increased rates of chronic disease (Adler and Ostrove 1999). Rates of uptake of private health insurance as well as utilization of healthcare services are often lower in those disadvantaged or lower socioeconomic statuses (Dunlop, Coyte et al. 2000).

The structure of the health care system itself or the public health infrastructure can and does act as a barrier to health care equity this includes, outdated facilities, waiting lists in emergency or for things like elective surgery (Leeder 2003).

There are also significant differences in the healthcare needs of men and women which stem primarily but not entirely from biological factors. Social inequalities between the genders is an important factor when determining the health potential of an individual.

Many of the health problems faced by women are unrelated to biological factors and are related to social discrimination and inequalities meanwhile men are often socially compelled to risk taking behavior leading men being more likely to die in a car accident or in dangerous sporting activities (Doyal 2000).

Governmental ideologies can have a significant effect on healthcare equity “governments which are committed to corporatism, rationalism, and cost cutting as a means to achieve greater efficiency can make beliefs that publicly funded healthcare services cannot cope come true”(Leeder 2003) whilst hi levels of government funding for healthcare does not necessarily guarantee equity in the healthcare system.

The role of Government in delivering healthcare

According to (Frieden 2013) governments have a “responsibility to implement effective public health measures” through promoting free and open information, protecting individuals from harm from groups or other individuals and taking societal action to protect and promote health.

Government investment in healthcare has been described as “ethically desirable and economically rational” (Leeder 2003)

When governments fail to implement appropriate public health measures society suffers (Frieden 2013) Whilst governments who do implement appropriate health care there are can be many benefits to society, the overall health of the population improves with individuals leading longer and healthier lives, resulting in increased productivity and therefore potentially improvements to the economy (Frieden 2013).

Governments achieve this through, the funding of the healthcare system, creating and implementing public health policy, through law, legislation and regulation reform. Some recent Australian examples of this are the Tobacco plain packaging laws, regulation around parents not receiving welfare benefits when their children are not vaccinated and smoking bans in many public areas.

In Australia, all three levels of government are responsible for contributing to the universal healthcare system. The federal government has limited input into service delivery however they are responsible for funding and providing support to the states, health professions, subsidizing primary care via the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) whilst also providing funds for state services. (Mossialos, Wenzl et al. 2016)

The state governments have oversight for the public hospitals, ambulance services, public dental care, community health services, and mental health care. They also contribute their own funding in addition to that provided by federal government (Mossialos, Wenzl et al. 2016).

Local governments contribute the delivery of community health initiatives and preventive health programs, such as immunization and the regulation of food standards(Mossialos, Wenzl et al. 2016).

Equity in financing of healthcare

Investing in healthcare has been frequently used as a marker for a countries economic strength, in Australia total health expenditure in 2013–2014 was estimated at $155 billion which represented approximately 9.8 percent of gross domestic product (GDP) this compares to 10.7% in Canada and 11.0% in New Zealand (Mossialos, Wenzl et al. 2016).

With 68% of all health funding provided by the governments, the federal government supplying 41% and the states/territories 27%, whilst individuals out of pocket expenses accounts for (18%), private health insurers 8.3% and accident compensation systems providing 6.1%. (2016. “Australia’s Health System.” Retrieved 6/4/17, 2017, from http://www.aihw.gov.au/australias-health/2016/health-system/#t3)

In Australia the government raises its funds for the health care system mainly via tax based revenue system of both general tax and earmarked tax revenue (Stabile and Thomson 2014). The benefits of a taxed based revenue system include allowing for economies of scale in administration, pooled risks across the population and having greater purchasing power these combined generally result in a more equitable system.

However, a tax based system has its downside or weaknesses including; health services can consume ever increasing proportion of health care spending, this is a growing issue in Australia with the ageing population and the rise of chronic disease.

Whilst healthcare funding can also be greatly influenced via the political process and political ideologies.

The federal government funds Medicare, a universal public health insurance program providing free or subsidized access to care for Australian citizens, residents with a permanent visa, and New Zealand citizens following their enrollment in the program and confirmation of identity (Mossialos, Wenzl et al. 2016).

Due to rising health care costs in 1984 the Australian Government introduced the Medicare levy to supplement the standard taxation revenue, due to the growing health care costs in Australia. The standard Medicare levy is set at 1.5% of an individual’s taxable income.

To ease the strain on the public health system the government also incentivizes people to obtain private health insurance they do this via two mechanisms.

Firstly via the Medicare levy surcharge which was introduced in 1997, it is an addition to the standard Medicare levy whereby if an individual’s income is over the threshold set by the government (currently $90,000) and that individual does not take out private health insurance they will be charged the levy.

The surcharge is calculated at the rate of 1% to 1.5% of your income for Medicare Levy Surcharge purposes. It is in addition to the Medicare Levy of 2% (2016)“Medicare Levy Surcharge ” https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/

Secondly in 1999 the government decided introduce an incentive scheme to make private health insurance more affordable via the private health insurance rebate.  This is a government contribution towards the cost of insurance premiums, whilst it determines an individual’s eligibility via means testing (2016) “Private health insurance rebate” https://www.ato.gov.au/individuals/medicare-levy/private-health-insurance-rebate/.  

Barriers to equity within the Australian healthcare system

The number of clinics bulk-billing declining out of pocked expenses rising for those seeking primary care through ones GP, this may reduce health care utilization especially for people of a low socioeconomic status (Leeder 2003) due to rising out of pocket expenses for attending primary care facilities.

The private health insurance rebate has been implicated in decreasing equity within the Australian health care system by preferentially distributing government spending to those with private health insurance and therefore commonly people of a higher socioeconomic status (Leeder 2003)

In Australia one of the main barriers to achieving equity in healthcare is the geography and the nature of the population distribution with the many rural and remote communities scattered across more than 7½ million square kilometers and which are home to more than 7 million Australians (Humphreys and Wakerman 2008). Meanwhile Medicare has been described as a “metropolitan system” with rates of bulk billing by general practitioners lower in rural areas than in metropolitan areas (Leeder 2003).  Regional and remote areas also have reported lower rates of private health insurance (Armstrong, Gillespie et al. 2007)

Recruiting and retention of health professionals to rural and remote areas is a major issue it has been shown to have 60% less practicing allied health professionals per 100,000 population than in capital cities (Struber 2004) this will significantly affect the range and quality of services in local communities.

In Australia, it could be easily argued that those with that are the least likely to experience equity within the health system are Indigenous Australians.

The life expectance difference between indigenous and non-indigenous Australians has not changed since the 1980’s and remains a gap of at least eleven to twelve years (Phillips, Morrell et al. 2014) One of the main reason for the large difference in life expectancy is the social disadvantage experienced by indigenous Australians (Marmot 2011).

In the Australian Indigenous population non-communicable diseases explains 70% of the health gap between indigenous and non-indigenous Australians (Vos, Barker et al. 2009).  Tobacco, obesity, physical inactivity, high blood cholesterol and alcohol are the main contributing risk factors (Vos, Barker et al. 2009). Whilst the Indigenous Australians residing in remote areas have been shown to experience a disproportionate amount of the health gap compared with more metropolitan areas, the majority of the health gap occurs in non-remote areas (Vos, Barker et al. 2009)

Racial discrimination has also been shown to have a distinct impact on the health (both mental and physical) and well-being of Indigenous Australians (Larson, Gillies et al. 2007).

Whilst those relying on the public health system for elective surgeries for example hip and knee replacements, who will also likely be those of a lower socioeconomic status will inventively be waiting much longer for the procedure than those with the appropriate level of private health insurance coverage / those of a higher socioeconomic status. The rates at which people are waiting on waiting lists is increasing as well, according to the Australian institute of health and welfare the amount of time within which 90% of patients were admitted for the awaited procedure increased from 250 days in 2011-12 to 260 daysin 2015-16 (AIHW 2016).

Conclusion

“When equity is at work sick individuals who seek help have their needs met. There is no compulsion or competition. No one is told “your need is too great; we can’t afford to treat you – unless you can pay for it yourself” (Leeder 2003)

According to the principals of equity in healthcare it is the government’s role to ensure resources are distributed and processes developed to equalize the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts.

Having a universal health care system does not guarantee equality in the benefits of health care and this is shown within Australia and its health care system (Korda, Butler et al. 2007).

(2016). “Australia’s Health System.” Retrieved 6/4/17, 2017, from http://www.aihw.gov.au/australias-health/2016/health-system/#t3.

(2016). “Medicare Levy Surcharge “. Retrieved 6/4/17, from https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/.

(2016). “Private health insurance rebate.” Retrieved 6/4/17, from https://www.ato.gov.au/individuals/medicare-levy/private-health-insurance-rebate/.

Adler, N. E. and J. M. Ostrove (1999). “Socioeconomic status and health: what we know and what we don’t.” Annals of the New York Academy of Sciences 896(1): 3-15.

AIHW (2016). Elective surgery waiting times 2015–16: Australian hospital statistics, AIHW.

Armstrong, B. K., et al. (2007). “Challenges in health and health care for Australia.” Medical Journal of Australia 187(9): 485.

Braveman, P. and S. Gruskin (2003). “Defining equity in health.” Journal of epidemiology and community health 57(4): 254-258.

Doyal, L. (2000). “Gender equity in health: debates and dilemmas.” Social Science & Medicine 51(6): 931-939.

Dunlop, S., et al. (2000). “Socio-economic status and the utilisation of physicians’ services: results from the Canadian National Population Health Survey.” Social Science & Medicine 51(1): 123-133.

Frieden, T. R. (2013). “Government’s role in protecting health and safety.” New England Journal of Medicine 368(20): 1857-1859.

Hiscock, R., et al. (2012). “Socioeconomic status and smoking: a review.” Annals of the New York Academy of Sciences 1248(1): 107-123.

Humphreys, J. and J. Wakerman (2008). “Primary health care in rural and remote Australia: achieving equity of access and outcomes through national reform: a discussion paper.” Canberra: National Health and Hospitals Reform Commission.

Korda, R. J., et al. (2007). “Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality.” international Journal of Epidemiology 36(1): 157-165.

La Rosa-Salas, V. and S. Tricas-Sauras (2007). “Equity in health care.” Cuadernos de bioetica: revista oficial de la Asociacion Espanola de Bioetica y Etica Medica 19(66): 355-368.

Larson, A., et al. (2007). “It’s enough to make you sick: the impact of racism on the health of Aboriginal Australians.” Australian and New Zealand journal of public health 31(4): 322-329.

Leeder, S. R. (2003). “Achieving equity in the Australian healthcare system.” Medical Journal of Australia 179(9): 475-479.

Marmot, M. (2011). “Social determinants and the health of Indigenous Australians.” Med J Aust 194(10): 512-513.

Mossialos, E., et al. (2016). “2015 International Profiles of Health Care Systems.” The Commonwealth Fund.

Phillips, B., et al. (2014). “A review of life expectancy and infant mortality estimations for Australian Aboriginal people.” BMC Public Health 14(1): 1.

Rice, N. and P. C. Smith (2001). “Ethics and geographical equity in health care.” Journal of Medical Ethics 27(4): 256-261.

Stabile, M. and S. Thomson (2014). “The changing role of government in financing health care: an international perspective.” Journal of Economic Literature 52(2): 480-518.

Struber, J. C. (2004). “Recruiting and retaining allied health professionals in rural Australia: why is it so difficult?” Internet Journal of Allied Health Sciences and Practice 2(2): 2.

Vos, T., et al. (2009). “Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap.” international Journal of Epidemiology 38(2): 470-477.

WHO (1996). Equity in health and health care: a WHO/SIDA Initiative WHO. Switzerland, WHO.

Witt, C. M., et al. (2017). “Defining Health in a Comprehensive Context: A New Definition of Integrative Health.” American journal of preventive medicine.

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