The most prominent disparities in health outcomes are between the Aboriginal and Torres Strait Islander population and the rest of Australia’s population; these are widely acknowledged as unacceptable. In 2008, the Council of Australian Governments (COAG) agreed to set a target of closing the gap in life expectancy by 2031. Progress toward this target is not on track, with the gap currently at 10.6 years for males and 9.5 for females. From 2005–2007 to 2010–2012 there was a very small reduction of 0.8 years for males and 0.1 years for females.
Disparities between major urban centers and rural and remote regions, and across socioeconomic groups, are also major challenges. The federal government provides incentives to encourage GPs and other health workers to work in rural and remote areas, where it can be very difficult to attract a sufficient number of practitioners. This challenge is also addressed, to an extent, through the use of telemedicine. Since 1999, the Australian government has funded the Public Health Information Development Unit (http://www.phidu.torrens.edu.au/) to publish small-area data showing disparities in access to health services and in health outcomes on a geographic and socioeconomic basis.
The Public Health Agency of Canada includes in its mandate reporting on health disparities, and the Canadian Institute for Health Information also reports on disparities in health care and health outcomes, with a focus on lower-income Canadians. No formal and periodic process exists to measure disparities; however, several provincial or territorial governments have departments and agencies devoted to addressing population health and health inequities.
Aboriginal health is a concern for federal as well as provincial and territorial governments. The 2016 federal budget included CAD8.4 billion (USD6.7 billion) over a five-year period earmarked for services for indigenous people, including education, environment (e.g., water quality), and health and social services. In Ontario, a new strategy to improve the health of indigenous people was launched in 2016, with emphasis on investments in primary care, cultural competency training for health care providers, access to fresh fruit and vegetables, and mental health services for youth for First Nations. In 2008, the Truth and Reconciliation Commission was established to collect stories regarding the events and effects of the Indian Residential School legacy. In 2015, the commission ended its mandate, releasing a series of calls to action including several to address health disparities affecting Aboriginal communities.
The Swiss Federal Council’s national Health2020 strategy includes the explicit objective of improving the health opportunities of the most vulnerable population groups, such as children and the young, those on low incomes or with a poor educational background, the elderly, and immigrants. The aim is to prevent vulnerable population groups from being unable to make appropriate use of necessary health care services. Health and health access variations are measured and reported publicly by the Swiss Health Survey every five years.
There are still severe disparities in accessibility and quality of health care, although China has made significant improvements in this regard in the past decade. Income-related disparities in health care access were especially serious before the reform of the health insurance system more than 10 years ago, as most people did not have any coverage at all. Health coverage through publicly financed insurance is now nearly universal, and there are safety nets for the poor. As a result, income-related disparities have been reduced substantially.
Remaining disparities in access are due mainly to variation in insurance benefit packages, urban and rural factors, and income inequality. Urban employment-based basic insurance offers broader benefit packages than the other two insurance schemes. To improve benefit packages and reduce disparities, central and local governments intend to consolidate insurance schemes, an effort that has already been piloted in selected areas, such as Dongying City in Shandong Province and Jinhua City in Zhejiang Province. In addition, central and local government subsidies of urban resident basic insurance and the rural newly cooperative medical scheme have increased in recent years.
Most good hospitals (particularly tertiary hospitals) are in urban areas, where there are better-qualified health professionals. Village doctors are often undertrained. To help bridge the urban–rural health care divide, the central government and local governments sponsor training for rural doctors in urban hospitals and require new medical graduates to work as residents in rural health facilities. Nevertheless, the China Health and Family Planning Statistical Yearbooks show that substantial disparities remain.
Regular reports are published on variations in health and health care access. These have prompted the formulation of action plans, with initiatives including:
- higher taxes on tobacco
- targeted interventions to promote smoking cessation
- prohibition of the sale of strong alcohol to young people
- establishment of anti-alcohol policies in all educational institutions
- further encouragement of municipal disease prevention activities (e.g., through increased municipal cofinancing of hospitals, thus creating economic incentives for municipalities to keep citizens healthy and out of the hospital)
- improved psychiatric care
- a mapping of health profiles in all municipalities, to be used as a tool for targeting municipal disease-prevention and health-promotion activities
The introduction of pathway descriptions (see above) is reported to have increased equity.
Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ among states. Health disparities are implicitly mentioned in the national health targets. A network of more than 120 health-related institutions (e.g., sickness funds and their associations) promotes the health of the socially deprived. Primary preventive care is mandatory by law for sickness funds; detailed regulations are delegated to the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds support 22,000 health-related programs, e.g., in nurseries and schools. With the Act to Strengthen Health Promotion and Prevention, these programs have recently been further developed and financially supported.
The Health Monitor (Gesundheitsmonitor) was a national association of nonprofit organizations and sickness funds. To assess the accessibility of health care, it regularly conducted studies from the patient perspective—for example, on the availability of information, experiences with health care, and progress of health system reforms. The Health Monitor, which last conducted a study in 2016, ceased to exist after 15 years. A comparable survey on health access has not been provided.
There is a 6.3-year gap in life expectancy between males in the highest and males in the lowest social categories and poorer self-reported health among those with state-sponsored insurance and no complementary insurance. The 2004 Public Health Act set targets for reducing inequities in access to care related to geographic availability of services (so far, only nurses have agreed to limit new practices in overserved areas), financial barriers (out-of-pocket payments will be limited by state-sponsored complementary insurance), and inequities in prevention related to obesity, screening, and immunization. In 2009, launching its Second Cancer Plan, France placed inequalities at the heart of its public health policy. In 2012, the French president reaffirmed this priority with the Third Cancer Plan and later the 2015 Touraine law. A contractual agreement allows for the use of incentives for physicians practicing in underserved areas, the extension of third-party payment, and enforced limitations on denial of care.
National surveys showing regional variations in health and access to health care are reported by the health ministry.
The Secretary of State, National Health Service (NHS) England, and Clinical Commissioning Groups (CCGs) have a legal duty to “have regard” for the need to reduce health disparities, although the applicable legislation does not specify what actions need to be taken. NHS England publishes an annual report on the actions taken and progress being made in reducing disparities in access and outcomes, by gender, disability, age, socioeconomic status, and ethnicity. Strategies include ensuring that local areas receive adequate resources to tackle inequalities and that the outcomes for at-risk groups are routinely monitored.
Significant inequalities with respect to health care access and outcomes exist between India’s states, rural and urban areas, socioeconomic groups, castes, and genders. For example, children in rural areas are about 1.6 times more likely to die before their first birthday and 1.9 times more likely to die before their fifth birthday than those in urban areas. From 1991 to 2013, neonatal mortality declined by 53 percent in urban areas, compared with 44 percent in rural areas. There are also significant interstate differences in health outcomes. The social determinants of health play a significant role in health equity, with income, education, caste, and social group determining to a significant extent the distribution of health outcomes. With respect to access, it is estimated that the urban rich obtain 50 percent more health services than the average Indian citizen. Also, the number of government hospital beds per population in urban areas is more than twice the number in rural areas, and urban areas have four times more health workers per population. There is also evidence that public spending does not always translate into benefits for those most needing them.
Recognizing the lack of a comprehensive national health care system as an important factor in shaping health inequalities, the Ministry of Health and Family Welfare strengthened its flagship program, the National Health Mission. Through the program, 900,000 accredited social health activists work at the community level to promote immunization, disease control, effective breastfeeding, and healthy nutrition. Other initiatives seek to reduce maternal mortality—for example, by incentivizing women, including through cash payments, to deliver their babies in government health facilities. Recent evidence indicates that these policies have reduced disparities in maternal care.
The Ministry of Health (MoH) is leading a major national effort to reduce disparities, in cooperation with the health plans and hospitals. Key initiatives include:
- Reducing financial barriers to care, particularly for those with low incomes and other vulnerable populations. Most prominently, mental health care and dental care for children have been added to the NHI benefit package, thereby reducing the substantial financial barriers that existed when these services were provided privately.15
- Enhancing the availability of services and professionals in peripheral regions by increasing the supply of beds and advanced equipment in those regions and providing financial incentives for physicians to work there. In addition, in 2010, a new risk adjustment related to place of residence in the peripheral regions was added to the capitation formula.
- Addressing the unique needs of cultural and linguistic minorities through the adoption of cultural responsiveness requirements for all providers, establishment of a national translation call center, and targeted interventions for the Bedouin and other high-risk groups.
- Designating particular professionals within the hospitals and the health plans to be the leaders in their institutions for promoting equity and cultural responsiveness, along with government-sponsored training programs for them and for additional professionals.
- Promoting greater poverty awareness at all levels of the health system.
- Implementing intersectoral efforts to address the social determinants of health and promote healthy lifestyles.
- Compiling, analyzing, and publicly disseminating information about health care disparities, including periodic reporting of variations in health and health care access and instituting an annual conference showcasing initiatives to reduce disparities.
Interregional inequity is a long-standing concern. The less affluent south trails the north in the number of beds and availability of advanced medical equipment, has proportionally fewer public versus private facilities, and has less-developed community care services; this gap in availability is increasing. Income-related disparities in self-reported health status are significant, though similar to those in the Netherlands, Germany, and other European countries. The regions receive a proportion of funding from an equalization fund (Fondo Perequativo Nazionale), which aims to reduce inequalities. Aggregate funding for the regions is set by the Ministry of the Economy and Finance, and the resource allocation mechanism is based on capitation adjusted for demographic characteristics and use of health services by age and sex.
There is no systematic public reporting of health and health access variation, although several public and private institutions publish reports with analysis of health care variation (e.g., ISTAT, Ministry of Health, Catholic University of Rome).
Reducing health disparities between population groups has been a goal of the national health promotion strategy since 2012. The strategy sets two objectives: the reduction of disparities in healthy life expectancies between prefectures and the increase in the number of local governments organizing activities to reduce health disparities. Health disparities between regions are regularly reported by government; disparities between socioeconomic groups and in health care access are occasionally measured and reported by researchers.
Health disparities are considerable in the Netherlands, with up to seven years’ difference in life expectancy between the highest and lowest socioeconomic groups. Smoking is still a leading cause of death. The current government does not have a specific policy to overcome health disparities. In 2013, government decided to include diet advice and smoking cessation programs in the statutory benefits package. Every four years, variations in health accessibility are measured and published in the Dutch Health Care Performance Reports.
Eliminating socioeconomic inequalities in health is a priority of the Directorate for Health. A national strategy for addressing inequalities in health and health care includes various ways of increasing knowledge and awareness. There have been some initiatives for children, including vaccination programs and kindergarten- and school-based programs; initiatives for people with disabilities to be included in the workplace; price and tax policies; initiatives for care integration; general information campaigns regarding smoking cessation, alcohol, and diet; and specific programs for populations considered at risk.
There is increasing focus on immigrants’ health and their underutilization of health care. Research on pregnancy among immigrants has been informative, as there are significantly more complications for newborns and mothers among immigrants than among native Norwegians. There has been a resulting emphasis on the need for adequate information to be provided in immigrants’ native languages.
Health outcomes vary by geography, not only because of differences in the prevalence of diseases but also as a result of variations in the availability and quality of health care. Recruitment of health personnel, notably doctors and specialized nurses, is more difficult in rural areas.
Health disparities are a concern in New Zealand. Maori and Pacific Island people have shorter life expectancies than other New Zealanders (by seven and five years, respectively) and experience greater difficulty in gaining access to health services. Reducing disparities is a policy priority, with data describing disparities routinely collected and publicly reported.
Through much of the 2000s, a multisector policy approach saw investments in housing, education, and health, as district health boards (DHBs) and primary health organizations were required to develop strategies for reducing disparities. Many primary health organizations (PHOs) were created especially for Maori or Pacific populations.
The post-2008 government has focused on specific initiatives such as “Wh?nau Ora,” a policy designed to integrate health and social services. The aim has been to develop coordinated, multiagency approaches to service provision and to foster joint responsibility for outcomes.
The Community Health Assist Scheme provides subsidies to Singaporeans from lower- to middle-income households to obtain treatment at private primary care providers. The subsidies cover acute conditions, 15 chronic conditions, and a range of dental procedures. Subsidies are also available for recommended screenings for obesity, diabetes, hypertension, lipid disorders, colorectal cancer, and cervical cancer.
The Central Provident Fund is the umbrella account under which Singaporeans save for retirement, housing costs, and medical care (through the “3Ms”). There have been periodic increases in both employee and employer matching contribution rates in recent years, including an increase in the Medisave employer contribution rate in 2015. Increases are intended to encourage low-wage workers to save more for their retirement and medical needs and to have better access to care, in addition to the government’s additional contributions to Medisave accounts; the latter are also provided to the elderly.
The 1982 Health and Medical Services Act emphasizes equal access to services according to need and a vision of equal health for all. International comparisons indicate that health disparities are relatively low in Sweden. The National Board of Health and Welfare and the Public Health Agency compile and disseminate comparative information about indicators on public health. Disparity-reduction approaches include programs to support behavioral changes and programs targeting outpatient preventive services to vulnerable groups. To prevent primary care providers from avoiding patients who have extensive needs, most county councils allocate funds based on a formula that takes into account both overall illness (based on diagnosis) and registered individuals’ socioeconomic conditions.
Taiwan guarantees a right to health care. Everyone receives the same level of care based on the national uniform benefit package, regardless of ability to pay. More than 3 million economically disadvantaged Taiwanese (12.8% of the population) have full access to National Health Insurance (NHI) services, owing to the National Health Insurance Administration’s (NHIA) various financial and access assistance measures, including premium subsidies and copayment reductions or exemptions (discussed earlier). In recent years, the government has lowered the income threshold to allow more people to become eligible for these subsidies.
The NHIA also makes interest-free loans and installment plans available to those who cannot pay their premiums on time because they are temporarily unemployed or between jobs.
Other programs to ensure access to care and financial protection, such as integrated delivery system (IDS) plans, are discussed elsewhere in this profile.
There are wide disparities in the accessibility and quality of health care in the United States. Since 2003, the annual National Healthcare Disparities Report, released by the Agency for Healthcare Research and Quality, has documented disparities among racial, ethnic, income, and other demographic groups and highlighted priority areas requiring action. Federally qualified health centers (FQHCs), which are eligible for certain types of public reimbursement, provide comprehensive primary and preventive care regardless of their patients’ ability to pay. Initially created to provide health care to underserved and vulnerable populations, these centers largely provide safety-net services to the uninsured. Medicaid and the Children’s Health Insurance Program (CHIP) provide public health insurance coverage for certain low-income populations. In addition, the Affordable Care Act (ACA) has a number of provisions aimed at reducing disparities: subsidies to enable low-income Americans to purchase insurance through the exchanges; efforts to achieve parity for mental health care and substance abuse services; and additional funding to community health centers in underserved communities. There are also a multitude of public and private initiatives at the local and state levels.