Definition

Health inequity (also termed health disparity or health inequality) refers to the poorer than average health status of disadvantaged groups in societies relative to other groups Health inequalities can be related to economic, social, and lifestyle factors or can be caused by dysfunctional health systems. Inequities in health and health care can exist both between and within countries and may be associated with specific social or ethnic groups. For example:

• Dutch men with low levels of education live five years less than men with high levels of education.
• A 25-year-old Estonian man with a university degree can expect to live 13 years longer than one with the lowest level of education.
• An average Australia woman can expect to live to be 82 years old, while an Aboriginal and Torres Strait Islander can expect to live to be only 65 years.

Relevance

Health inequities are a global issue with disparities occurring both within and between counties. Inequities are often associated with lower socioeconomic status and racial/ethnic factors. Many countries in Europe for example, have become immigration destinations. Migrants tend to have lower health and socioeconomic statuses which pose considerable challenges in education and health. Financial and structural barriers often contribute to health inequities in a population.

• Financial barriers. Patients who must pay all costs out-of-pocket are more likely to postpone or go without medical care and forgo prescription medicines. This problem is more exaggerated in countries with lower socio-economic groups such as the working poor who are not covered by state-sponsored programs but cannot afford to buy health insurance.
  
  
• Structural barriers. Insufficient infrastructure and shortage of general providers (GPs) in remote areas and deprived inner city zones contribute to inequities. Infrastructure inefficiencies like excessive distance to health facilities, poor transportation, convenience of clinic hours and wait times and timeliness of appointments, all affect a person's chance and willingness to obtain care.
  
  In addition, patients without a GP have greater difficulty obtaining basic care via doctors’ visits and prescription drugs. Continuing trends toward specialization in medicine, where general practice no longer seems attractive, has reduced the number of GPs.
  Top
  
  
  
• Legal barriers. Legal issues such as length of residency often thwart access to medical care by low-income immigrant minorities in countries where residency is a barrier to public health care.
  
  
• Cultural barriers. Language differences often restrict access to medical care for individuals who are not proficient in the country’s primary language. Cultural differences between predominantly white health care providers and minority patients present barriers to shared decision-making between patients and doctors, which can affect quality of care.
  
  
• Health literacy. Patients with a poor understanding of good health may not seek medical attention when needed. Consequently, their ability to obtain, process, and understand basic health information, closely associated with their educational level, directly impacts quality of care.

Context

Ending or reducing health disparities requires repairing dysfunctional health systems and addressing cultural barriers. Cultural barriers can be addressed in a number of ways, including:

• Interpreter services. Professional interpreters (foreign language and speaking/hearing impaired) should be available to work alongside health professionals.
• Training. Health care professionals must be trained to provide culturally sensitive care to minority groups.
• Coordinating with traditional healers. Health care workers should be supportive and able to adjust health care plans according to the patient’s cultural beliefs and traditional health practices.
• Recruitment and retention of minority workers. Increasing minority representation within health care offices and clinics promotes a culturally sensitive environment for patients.
• Culturally competent community outreach. Community health workers should reach out to populations who rarely seek health services. Outreach strategies may be used to promote early detection and treatment and education about good and risky health behaviors.
• Including family and/or community members. Including family members in health decisions increases the likelihood of obtaining consent and adherence to treatments and promotes cultural sensitivity.
• Administrative and organizational accommodations. Reassessing location of healthcare offices, public transportation availability, clinic hours, and the physical environment of the clinic reduces structural barriers to care.

Innovative Options - Select Country Cases

DiversityRX
http://www.diversityrx.org/

DiversityRx is an educational website dedicated to sharing proven methods for overcoming cultural and linguistic barriers to health care as well provides resources and tools for implementation. The site seeks to help health care organizations employ a wide spectrum of strategies for overcoming linguistic and cultural barriers to care, such as the use of bilingual providers, bilingual/bicultural community health workers, interpreters, and translated written materials. The site helps providers determine which strategies work best in particular health care settings. The site is sponsored jointly by the Resources for Cross Cultural Health Care (RCCHC) and Drexel University School of Public Health’s Center for Health Equality.

New Zealand: Health Equity Assessment Tool http://www.pha.org.nz/documents/health-equity-assessment-tool-guide1.pdf

While many solutions have been offered to ease health disparities, the challenge lies in evaluating programmatic success. The New Zealand government has developed the Health Equity Assessment Tool (HEAT) to assess the potential of new interventions and the success of existing programs and services. The tool consists of ten questions:

1. What inequalities exist in relation to the health issue in question?
2. Who is most advantaged and how?
3. How did the inequalities occur? What are the mechanisms by which the inequalities were created, maintained or increased?
4. Where/how will you intervene to tackle this issue?
5. How will the intervention improve Maori health outcomes and reduce health inequalities experienced by Maori?
6. How could this intervention affect health inequalities?
7. Who will benefit most?
8. What might the unintended consequences be?
9. What will you do to make sure the intervention does reduce inequalities?
10. How will you know if inequalities have been reduced?

These questions provide a clear framework for interventions. Since 2008, HEAT has been supported by a User Guide that provides guidance to decision-makers about sources of information and methods for analyzing responses.

New Zealand: Health Equity Assessment ToolFinland: The National Action Plan to Reduce Health Inequities 2008-2011
http://www.stm.fi/Resource.phx/publishing/store/2008/11/pr1227003636140/passthru.pdf

TEROKA (Reducing Socioeconomic Health Inequalities in Finland) is a joint pilot project for reducing socioeconomic disparities in health. In line with the Finnish Health Policy philosophy, the plan seeks to implement the appropriate social policy and community measures to reduce health inequities. The main principles of the action plan are:

• Reinforcing Health in All Policies (HiAP);
• Focusing on 'upstream' and 'downstream' measures;
• Reducing health inequalities by leveling up; and
• Responding to the needs of the most vulnerable as well as taking into account the gradient in health across the societal hierarchy.

The action plan also includes 15 action proposals that focus on welfare policy measures, healthy habits, health and social service system and knowledge base and tools. The plan was launched in 2008 by the Ministry of Social Affairs and Health.

New Zealand: Health Equity Assessment ToolOxfam Australia: Close the Gap – Promoting Awareness
http://www.oxfam.org.au/campaigns/indigenous-health/

Indigenous Australians life expectancy is nearly 20 years shorter than other Australians. Oxfam Australia, an international health advocacy organization, launched the Close the Gap coalition to increase awareness of this disparity and achieve health equality for Aboriginal and Torres Strait Islanders within 25 years. The broad public/private coalition has called on Australian governments to commit to closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation by:

• Increasing annual Indigenous health funding by $460 million to enable equal access to health services
• Increasing Indigenous control and participation in the delivery of health services
• Addressing critical social issues such as housing, education and self-determination which contribute to the Indigenous health crisis