Explain how health inequalities may be understood as inequalities that require structural level explanations.
Inequalities in health are deplored in modern democratic nations and equal opportunities are extolled in principle, if not in practice. The legacy of racism and economic inequality can be rooted in history and is still permeating in the status quo. Inequalities in health status, disease occurrence and mortality are shaped by accumulated wealth, material circumstances, environmental quality, nutrition and a wide range of personal behaviours, genetic inheritance and health services (Bhopal, 2006).
Within multiethnic societies, European-origin White populations are characterized by being richer, more powerful and enjoying better material circumstances, environment quality, and health services than non-White ethnic-minority populations. Ethnic-health inequalities in such societies are inevitable (Bhopal, 2006).
Social organizations of major interest in inequality in health care are the indigenous groups. The term indigenous is usually used to mean a population belonging naturally to a place in the sense of long-term ancestral origins (e.g., Aborigines). It might also mean the majority population (e.g., in the UK- as an alternative to the word White). These indigenous populations have poor health and many were decimated and demoralized (Bhopal, 2006).
An indigenous group in New Zealand is composed of Maoris. Maoris comprise 10%-15% of the country’s total population. This percentage is relatively small as compared to the majority of the population of in the country which of European descent (80%). In spite of being considered to be more highly politically and socially organized, empowered and in control relative to other indigenous groups, the Maoris’ health status is described as comparatively poor (Bhopal, 2006). As the matter of fact, ethnic health disparities appear to be more pronounced in New Zealand than in other countries such as the United States (Bramley et al., 2005).
As compared to the majority of population in New Zealand, the inequalities were massive between Maoris and their European counterparts. Life expectancy in Maori men was 8.9 less than that of non-Maori males whereas Maori females had a life expectancy of 7.4 years less than non-Maori females (Harris et al., 2006). The differences in life expectancy in different ethnic groups are usually inequitable, because they mainly result from other social injustices (Bhopal, 2006). Further, infant mortality rate was higher in Maoris than the New Zealand European rate. Also, age-adjusted mortality rates were generally higher for Maoris than those of European backgrounds. For modifiable risk factors, Maoris exhibited the highest smoking prevalence; 48.6% of Maori adults were smokers, twice the smoking prevalence of the majority of the population (Harris et al., 2006).
Interestingly, the aforementioned disparities in health indicators between Maoris and their European counterparts in New Zealand are also evident between American Indians/Alaska Natives and the majority of the population in the United States (Harris et al., 2006).
The inequality on health care access and health indicators between the indigenous groups and the majority of the population can be explicated and correlated to differences in structural determinants of health (viz., socioeconomic status, living condition, employment status) between the indigenous group and the majority of the population. Both Maori and Pacific New Zealanders are more likely to live in deprived communities, with over 50% of each ethnicity living in areas in the most deprived three NZDep2001 deciles (Harris et al., 2006).
In addition to the differences on the structural determinants of health, racism is also seen as one of the potent factors that can further the disparity. Others believe that racism is the heart of ethnic and racial disparities in health and health care (Bhopal, 2006). Several studies have noted an association between self-reported experience of racial discrimination and poor health outcomes for a range of ethnic groups in various countries (House & Williams, 2001; Karlsen, 2005; Karlsen & Nazroo, 2004; Karlsen & Nazroo, 2002; Krieger, 2000; Whitbeck, 2002; Williams et al., 2003; Williams et al., 2000). Further, Harris et al. (2006) reported that racism contributes to socioeconomic deprivation, and together these play a major role in causing health disparities. In addition, more and more research suggests that racism has major health consequences in both the individual and community levels (Jones, 2001; Krieger, 2003; Nazroo, 2003; Williams, 1997). These consequences include low self-rated health status, low self-rated mental health, low self-rated risk for cardiovascular disease and low self-rated level of physical functioning (Harris et al., 2006).
Why attention to diversity at the level of policy and health care may assist us in addressing the structural determinants of health?
Equity is the core principle underpinning equality of health care. It is based on fairness and justice (Bhopal, 2006). Addressing the issue of inequity in health care between indigenous groups and majority of the population can be done by addressing disparities and acknowledging the diversity in structural determinants of health of the general population.
Disparities in ethnicity, socioeconomic status and access to health care services are the determinants in the differences in the health indicators of indigenous groups and the majority of the population. Albeit these determinants are likely to be less amenable to local alteration, other modifiable health factors (i.e., smoking rates, housing conditions and physical activity) may be modified using community development and public health paradigms to affect local lifestyles and public health policies (Hefford et al., 2005). Thus, health policies aimed towards the improvement of the structural determinants of health and modifiable health factors are significant in addressing the issue on disparities in health indicators between the minority and the majority of the population.
In New Zealand, one of the strategies to address socioeconomic disparity and access to health care services is to enable all New Zealanders to access low cost primary health care. The New Zealand government has decided to phase in the change by introducing universal access to low cost services in areas with most needy population first relevant to the principles of the Alma Ata Declaration and Health For All 2000 program. These populations are defined as including Maori, Pacific people, residents of the most deprived areas (NZDep deciles 9/10). For this strategy, the government allocates 53% additional funding for strategies to reduce disparities- low cost general practice services, services to improve access project funding and health promotion (Hefford, 2005).
Allocating additional funds for health care for the general population may not fully address the issue on inequities in health care between the indigenous group and the majority of the population. A risk with the emphasis on universal entitlement for health care is that new funding may be used to extend subsidies to more (generally less needy) individuals rather than to raise the subsidy levels for most highly deprived populations (i.e., Maori, Pacific New Zealanders) (Hefford, 2005).
Inequities occur because the minority of more deprived individuals in a practice or without a majority deprived population do not receive additional access funding and do not enjoy low cost access unless they quality under the previous policy rules. As of October 2003, 200,000 vulnerable individuals (Maori, Pacific, or deprivation deciles 9 and 10) were enrolled in interim Primary Healthcare Organizations (PHOs) and did not receive access to low cost care (Hefford et al., 2005). Thus, the accessibility to the improved policies on health care and health care services of the indigenous groups is also significant to address the issue on health care inequity.
Another issue on disparity in health care is the allocative efficiency issue. Health care programs and services are mostly availed by the high income individuals who happen to be enrolled in the said programs. Since many of these individuals can already afford to access health care and are not in a priority group for additional funding, the amount spent on providing them with low cost access is unlikely to result in major health gains, or to reduce health disparities. This is an allocative efficiency issue; the funding being used to subsidize these low priority groups could have been allocated to extend subsidies for high priority groups (i.e., indigenous groups) (Hefford et al., 2005). This issue could be addressed by reintroducing differential fees-based upon income.
Albeit there are many factors to be considered to reduce, if not to eliminate, in healthcare between the indigenous groups and the majority, Hefford et al. (2005) enumerated the following potential mechanisms that may be instituted to reduce these disparities:
- Reduce the cost barriers to needed care;
- Finance projects aimed at, for example, housing lifestyle change, risk reduction, and community health initiatives;
- General focus on population health, increase use and scope of nurses and allied health practitioners;
- Funding should be targeted to those from high need groups who are more likely to have medical complications;
- Implement specific services targeting deprived groups (i.e., Maori and Pacific);
- Involve minority groups in decision making that may increase appropriateness and attractiveness of care for disadvantaged groups; and,
- Reward those who are providing effective services to high need individuals.
Disparity in health care between the minority and the majority of the population remains to be a social struggle which entails appropriate allocation of health care resources and services to be fully addressed. Nevertheless, this resource allocation requires careful policy-making and implementation processes taking into account the principle of equity and allocative efficiency and with the end in mind that the minority (i.e., indigenous groups) will be greatly benefited and empowered by reforms in health care policies and not to be undermined and be taken advantaged by them.
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