articles

First published: Wednesday, August 24, 2011

In their final report in 2008, the Commission on Social Determinants of Health (CSDH) called ‘on the World Health Organisation and all governments to lead global action on the social determinants of health with the aim of achieving health equity.’ (CSDH 2008)
The report of the Commission had three main recommendations.
1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money, and resources
3. Measure and understand the problem and assess impact of action

It also emphasised that health and illness follow a social gradient and that it is not just about addressing the most disadvantaged.

This essay discusses the situation in Australia in relation to the first two recommendations. It assumes a knowledge of the well documented inequities in health outcome and status in this country

Improving the daily living conditions involves an emphasis on early childhood development, fair employment and decent work, having a universal social welfare system, and universal health care. In Australia a comprehensive framework for early childhood education and care is being implemented. Recent policies are intended to improve employment, especially amongst the disadvantaged. Our social welfare system is well targeted but there is evidence it is far from generous compared to other rich countries, despite the fact that child poverty levels in Australia are higher than the mean for 20 rich countries (Unicef 2010).

The Commission regards the provision of universal health care as an essential part of improving daily living conditions and health care as ‘a common good rather than a market commodity’. We have a universal health system which guarantees entitlement but not access. There are significant financial, geographical, physical, and cultural barriers to access across Australia. A survey of 7000 Australians by the Australian Bureau of Statistics (ABS) found that 6.4 % delayed or did not see a general practitioner (GP) in a year because of cost, 10% delayed or did not see a specialist because of cost, and 9% delayed or did not obtain a prescribed drug because of cost (ABS 2009). Rather than looking at the general population, the Commonwealth Fund survey from 2005 was performed on sick Australians, those who had recently been hospitalized, had surgery, or reported health problems. In this group who are the very ones whose access should be facilitated by a health system, 34% described access problems due to cost. Thus, 22% didn’t fill a prescription, 18% did not see the doctor when sick, and 22% did not get recommended test or follow-up (Schoen 2005).

Geographical barriers to access continue despite many targeted programs to improve distribution of the workforce. Using the Australian Standard Geographical Classification (ASGC), the Productivity Commission found that population to practitioner ratios in very remote areas for GPs, dentists, and physiotherapists are about 20% that found in major cities but importantly there is a steady gradient of decreasing availability as one moves from major cities, through inner regional, outer regional to remote and very remote (Productivity Commission 2005).

Whilst there are many factors contributing to the unequal distribution of the medical workforce, most of these factors are largely or completely out of control of government. The method of funding however is determined by government. It has chosen to persist with fee for service plus copayment as its main funding mechanism. This inevitably contributes to the medical workforce distributing itself in areas where copayments can be afforded, and where lifestyle choices of the workforce are optimised. Although many programs have been devised to counteract this poor distribution of workforce, the success of such programs will always be limited as they are working in direct conflict with the major funding structure.

The main funding of health care outside public hospitals in Australia is through fee for service plus copayment. This applies to most GP services and specialist services, private hospital services, and increasingly now to psychologists, nurse practitioners, physiotherapists and other allied health professionals. Thus health professionals paid in this way are free to provide publicly subsidised services wherever the market will support them and at whatever level of copayment the market will support. Financial and geographical barriers to access are inevitable. This structure reflects a view of health care as a market commodity rather than a common good. Rather than addressing this structure, the government is expanding it to more groups and entrenching inequity. This basic funding structure is ripe for change.

The distribution of power, money, and resources is seen by the Commission as a key structural driver of conditions of daily life.

We know from Wilkinson that income inequality correlates with health and well being status (Wilkinson 2010). We also know that on most comparative measures of disposable income over the period 1994 to 2008, there has been increasing inequity in Australia (ABS 2008). But the approach of the Government to the inequitable distribution of power, money and resources is limited although well directed in parts. Thus, improving employment, long term plans for improved housing affordability and availability, etc will all help to address these inequity issues. Changes resulting from the recent budget are very directly aimed at redistributing income but are minor and will directly affect only a small number of people. Income inequality will only be marginally affected and then mainly for those who can be employed.

The Commission states that to tackle this issue requires

‘ a strong public sector that is committed, capable, and adequately financed’ (CSDH 2008).

Such a requirement is not evident in our health system. The Minister for Health noted recently that there was a 9 year high in uptake of private health insurance and welcomed the continued growth (Roxon 2011). This growth occurs because of the perception by the public that the public system, particularly the hospital system is increasingly inadequate. What about a strong public sector for primary health care? Primary health care is largely publicly funded but predominantly runs on a small private business model. Between 2003-4 and 2007-8 there was over 20% increase in Emergency Department presentations, with no change in the make-up of the triage categories. 13% were non urgent and 46% semi-urgent (Australian Institute of Health and Welfare 2010). The increase in Emergency Department presentations for problems which could be addressed in general practice would suggest that our publicly subsidised private primary health care system is failing as patients default to the Emergency Departments. The way general practice is both structured and functions is changing. There has been a 51% decrease in home visits from 1997 to 2007 (Joyce and Piterman 2008), and a 37% decline in the proportion of GPs working in practices that provide their own after-hours services (Britt 2010), contributing to the use of Emergency Departments. In addition, there is an increasing need for a more robust business model as the number of solo practices decrease and the number of large practices of more than 10 GPs increases (Britt 2010). Corporate entities have become increasingly involved in these larger practices and some are publicly listed companies whose bottom line is profit (Friedman 1970). Primary Health Care Ltd is one such company which rose to prominence in the early 2000s as a profitable bulk billing GP chain at a time when bulk billing rates were falling across the country. In 2009 this company abandoned bulk billing in many of its clinics (Invest Smart 2011). By that time it had diversified into radi
ology and pathology. The decision to abandon bulk billing and impose a barrier to access was financial, but clearly not directly related to the level of the rebate as the rest of the country’s GPs had taken the bulk billing rate up almost to the historic high of 80% (Medicare Australia 2010). Such corporate entities are not part of a strong public sector but are publicly funded private entities. This trend to increasing corporate involvement which is mirrored in radiology, pathology, and private hospitals, is not indicative of a Government presiding over a strong public sector.

More broadly there exist inequalities in access to education, housing, and employment opportunities (Argy 2006). Education funding structures are controlled largely by government. Despite some moves to address the complicated causes of inequitable access to educational resources, the basic funding structure in primary and secondary education continues to support inequitable access. Thus, the Federal Government continues to fund the richest schools in the nation with money which could be being spent on the most disadvantaged schools. These and other factors contribute to inequities in health outcomes

There are a variety of ways in which these different inequities are addressed in Australia. Charitable organisations frequently help the most disadvantaged, for housing, employment, education or access to health care. Another form of charity is exemplified by the doctor or other health professional who chooses not to charge a copayment (bulk bill) or another type of professional who goes way beyond the expectations of their position to help the disadvantaged. The third form of charity comes from government. It is the system of safety nets introduced to address the gross inequities in access to health, quality education, housing, food security, and all of the other social determinants. Such safety nets are required because the societal structures result in inequities. Many of these structures are largely or entirely due to government policy eg, a copayment is required for pharmaceutical but 22% sick Australians don’t fill a prescription because of cost (that’s even with a safety net).

Governments frequently correctly identify disadvantaged groups and introduce programs or projects specifically targeted to such groups. Such an approach is entirely appropriate when combined with addressing the structural drivers of such inequity. This approach aims for equity. When targeted programs are not combined with addressing the structural problems however, the approach is aiming only to reduce gross inequity. In such situations, one could consider programs as yet another form of charity, picking up the pieces resulting from structures of the government’s own making.

The approach to the vexed question of the health of indigenous Australians has demonstrated an understanding of the broad range of factors contributing to health inequity. Recent funding for mental health with targeted funding initiatives across different areas including housing, education, and employment, is a recognition of the range of social determinants, and the mechanism of funding does begin to address the structural problems of funding through fee for service (National Mental Health Reform 2011). The inclusion in the functions for Medicare Locals of a population health approach is also encouraging (Department of Health and Aging 2010), but to date there is no evidence of the recognition of the structural barriers to equitable funding and access with which Medicare Locals will have to contend to fulfil its multiple functions. Whilst these initiatives are encouraging the general approach to health care and health reform has been to ignore the structural drivers of inequity whilst addressing some areas of gross inequity.

The Federal Government has appointed the Australian Social Inclusion Board (ASIB) which states its task as:
It is the main advisory body to the government on ways to achieve better outcomes for the most disadvantaged in our community and to improve the social inclusion in society as a whole (ASIB 2008)
It is puzzling that the task of the Board does not seek to achieve better outcomes (health or other) for all, given the very clear gradient of health outcomes documented previously. This gradient means that for example those in the 2nd highest quintile for health outcomes are still disadvantaged compared to those in the highest quintile.

There does not seem to be sufficient recognition that there are fundamental structural barriers to equity in our society, particularly in the health and education systems and in income distribution. There also appears to be a lack of recognition of the social gradient, which therefore supports the concept of targeting the most disadvantaged and ignoring those structural barriers.

Instead, the approach to health inequities appears to be largely focused on targeted programs, safety nets, and other forms of charity. The other concern about a reliance on charity is that it deflects those interested in equity from pursuing that idea through the much harder to achieve structural reform. Those who spend all their time in charity work including well targeted programs, feel they are doing the right thing. They are. But whilst they may believe strongly in equity, they have no time left for the pursuit of the big changes required. Politicians who start off with ideals of equity must turn into practical people, doing what is possible. Thus, even the well intentioned target gross inequity and feel they are doing well, and then they ignore or have no time and energy to address the structures which are amenable to change. The changes required to tackle the root causes of the inequity are major, but what is being done is minor if not minimal. For other politicians, targeting gross inequity is perfect as they don’t actually believe in equity, and much prefer the idea of charity, which fits well with their belief in a class based tiered society.

There is recognition amongst our politicians that to achieve health equity one needs to address both the health system and many factors outside the health system. There is a failure of recognition however that heath inequity follows a social gradient, and structural change is required to address this issue. A targeted approach to the most affected groups ignores this gradient and ignores the structural causes of the inequities. Indeed, one could view the approach of relying just on targeting as another form of charity, striving to reduce gross inequity but ignoring the goal of equity.

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