Editorial Issue 4 2011
Rethinking health inequities at a time of reform: a lost opportunity?

Current health reform in Australia represents a unique opportunity to see health inequity addressed as a headline feature of the organisation of our health care system and the delivery of primary health care. This special edition of the Australian Journal of Primary Health explores this opportunity in detail.

In 2008, the then Rudd Government announced the development of Australia’s first ever National Primary Health Care (NPHC) Strategy (Commonwealth Department of Health and Aged Care 2010). The strategy development was accompanied by the establishment of a National Health and Hospitals Reform Commission (NHHRC) (2009), taskforces and key advisory groups. The NHHRC delivered their final report in 2009 with 123 recommendations. This was followed by an extensive consultation over 2009 and 2010 about the recommendations to develop the National Preventative Health Strategy (National Preventative Health Task Force 2009) and develop the building blocks for the NPHC Strategy. All of the key health reform and task force documents contain strongly worded statements of commitment to addressing and reducing health inequity in Australia as a high priority.

Nevertheless, there is some evidence that in moving from aspiration to implementation, this commitment to reducing inequity has been somewhat attenuated. The government’s response to the NHHRC (Commonwealth of Australia 2010) released last year, overall, had much less focus on equity, while nevertheless stating that:

• ‘all Australians should have equitable access to high quality health care, including those living in regional and remote areas; and

• Australia’s health system should promote social inclusion and reduce disadvantage, especially for Indigenous Australians.’

Similarly, the Council of Australian Governments (COAG) National Partnership Agreement on Preventive Health (Council of Australian Governments 2009), which provides the framework for the National Preventive Agency and new preventive health spending, makes no reference to inequity, despite making some effort to focus on disadvantaged Australians, particularly Indigenous communities. The national health reform agreement (Council of Australian Governments 2011) emerging from COAG in February this year also makes no specific mention of health equity. Medicare Locals and Super Clinics are to play a role in promoting ‘access for all’ without any reference to reducing inequity.

A scan of the Gillard Government’s report National health reform delivering outcomes for Australians (Commonwealth of Australia 2011) shows some progress in improving access for patients receiving hospital care and after-hours general practice care, but very little attention has been directed specifically to how health inequities will be tackled as a system issue beyond improving access to some services in mental health and aged care. The focus on national standards does not include any mention of cultivating a professional culture attuned and oriented towards responses to health inequities.

What can we make of this loss of focus on reducing inequity? Some answers can be found in the papers published together in this special edition. Political will notwithstanding, part of the problem is the complexity of the field. Health inequity is indeed a ‘wicked’ problem. Consensus is lacking on many important issues about how to understand and conceptualise the problem of health inequity as well as how best to take action.

Several the papers take an equity lens to the very policy documents supporting health reform. Baum and Fisher (2011) critique the preventive strategy documents. Taking as a starting point the World Health Organization Commission on Social Determinants of Health, their analysis suggests that the policy is narrowly focussed on individual lifestyle choice, failing to address the social context of such ‘choices’ or to acknowledge the wider inequitably distributed resources that shape health. The authors compare this with the Close the Gap strategy, which does embed a broader social determinants approach.

Focusing on particularly disadvantaged groups is often seen as an urgent priority. Wood et al. (2011) provide the only paper in this edition focussed on Aboriginal communities. They describe the process of organisational change in a non-government organisation (NGO) as it embeds a focus on Aboriginal health within its work. Yet while a ‘target group’ approach can be easier to sell and show short-term benefit, this runs the risk of omitting important groups (as discussed by Rosenstreich et al. (2011)) while potentially distracting attention from the underlying causes of the social gradient itself. The work of Henderson and Kendall (2011) illustrates this latter point well. The paper describes a local initiative where community navigators aimed to improve access to care for several disadvantaged culturally and linguistically diverse communities. The navigators met challenges around the need to work with clients on non-health issues of social disadvantage as well as the difficulty of addressing embedded inequities generated within the system. The contribution by Rose et al. (2011) highlights again the underlying psychosocial needs that must be confronted even within an exemplary local initiative aimed at improving access to care for a disadvantaged low-income housing estate community.

There is a natural tendency of health providers and services to focus largely on equity of access to care. This is seen as important, measurable and feasible to address. Access to care is one of the most well studied aspects of health inequity. Conceptually, there is a strong understanding of the distinctions between equity and equality, between differences in health status that are to be expected versus those that are unfair and unjust, and between horizontal and vertical equity. Yet these definitions still fail to grasp important aspects of equity of access to care. The paper by Ward et al. (2011) illustrates the need to report routinely on access to services (in this case bowel cancer screening) as well as exploring potential inequities of access in care through linked qualitative work. Relationships with care providers that empower and engage are an important characteristic of health care that is ‘accessed’. Rossiter et al. (2011) focussed on this in a ‘partnership’ model of care and service provision for vulnerable and disadvantaged families.

Health providers working in disadvantaged communities know that while access (availability, affordability and acceptability) is important, what is much harder is taking action and advocating on the social determinants of health in these disadvantaged communities. This is well described by Freeman et al. (2011), who talked to providers working in exemplary comprehensive primary health care services, each serving disadvantaged communities, about how they understand and address inequity in their work. The need to work at multiple levels is also seen in the work of Larkins et al. (2011). While access to care is a key underlying concern, they describe their part in an international network of universities aimed at improving the broader social accountability of medical students’ education.

In the end, a focus on target groups and access reminds us of the very real challenges of addressing underlying social inequity through health care. Young and McGrath (2011) explore the interface between notions of social justice and the implementation of health reform. Keleher (2011) points out the challenges awaiting Medicare Locals in attempting to embed social determinants approaches within their population health planning work.

Finally, the paper by Banham et al. (2011) repays careful reading, highlighting the importance of bringing an open debate about values to the table in making progress in reducing inequity. The paper presents a simulated example of using an ‘equity effectiveness framework’ for evaluating and considering the potential for health service interventions to produce equitable health outcomes. While complex in its detail, one critical issue to emerge from the paper is that uniform distribution of resources across disadvantaged areas will not only worsen health inequities but will appear rational to economic managers as the incremental cost per unit benefit of targeted investment in disadvantaged areas is higher than in advantaged areas. Positively redressing inequities requires using the summary data they illustrate to allow weighting when distributing resources to move proactively towards health equity. This requires making explicit the valuing of equity over efficiency, in a process of participatory decision making.

The importance of values in shaping a coherent and sustained response and commitment to reducing inequity is touched on in many of the papers, often implicitly. Health inequity is a complex technical problem, with no easy or simple solution. However, we must not allow this technical complexity and lack of clear guidance on action to consign health inequity to the ‘elephant in the room’. Health inequity is a moral and ethical problem that is a concern for professionals, policy makers and theorists. While our call for contributions to this special issue asked for papers related to practice, policy and theory, we note that there is a continued absence of papers on the latter aspect of health inequity. Where there is mention on the importance of values and theories of social justice to inform this debate, it remains implicit.

It is clear that achieving health equity will require a balance between addressing the social determinants of health, the delivery of health care by professionals and ensuring the system can respond to the issue. The signs are that the opportunity presented by current reform is being lost. Both political will and a national program of sustained, integrated research are needed if progress is to be made. Political will can set the framework by requiring the health sector to openly report on and be accountable for reducing inequities. This will in turn provide the push for a focussed program of health inequity research that is strongly theoretically based as well as being practically relevant to areas of health reform. Collectively, we also need to explicitly articulate the important moral and ethical frameworks underpinning a national push to reduce health inequity. Without all these elements, health inequity will continue to slide off the agenda in moving from the aspirations of reform to the practicalities of implementation.

John Furler and Victoria Palmer

Department of General Practice
The University of Melbourne