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What is being done to reduce disparities?

  • Australia

    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 a target date of 2031 for closing the gap in life expectancy. Its strategy goes beyond health care, seeking to address disparities in other areas such as education and housing. The Prime Minister makes an annual statement to Parliament on progress toward closing the gap.

    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 for the purpose of publishing small-area data showing disparities in access to health services and health outcomes on a geographic and socioeconomic basis.

  • Canada

    By signing the Rio Political Declaration on Social Determinants of Health, Canada committed to reducing inequalities in health. Although no single body is responsible for addressing health disparities, 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; recent federal initiatives include the Aboriginal Diabetes Initiative, the National Aboriginal Youth Suicide Prevention Strategy, and the Maternal Child Health Program. 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 (Canadian Institute for Health Information, 2015d). However, no formal and periodic process exists to measure disparities.

  • China

    There are still severe disparities in accessibility and quality of health care, although China has made significant improvements in the last decade. Income-related disparities in health care access were serious before the reform of the health insurance system more than 10 years ago, as most people did not have any coverage at all. Today, publicly financed insurance coverage 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 mainly due 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 to urban resident basic insurance and the rural newly cooperative medical scheme have increased in recent years.

    Most good hospitals (particularly tertiary hospitals) are located in urban areas, where there are better-qualified health professionals. Village doctors are often under-trained. 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.

  • Denmark

    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 hospitals)
    • 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 is reported to have increased equity.

  • England

    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 action needs to be taken. NHS England publishes an annual report on the actions 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.

  • France

    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 or without any complementary insurance. The reduction of health inequities is a major target of the 2014 National Health Strategy, and 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. 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 are reported by the Ministry of Health.

  • Germany

    Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ between states. Health disparities are implicitly mentioned in the national health targets. A network of 53 health-related institutions (e.g., sickness funds and their associations) promotes the health of the socially deprived. Primary prevention 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 will be further developed and financially supported .

    The Health Monitor (Gesundheitsmonitor) is a national association of nonprofit organizations and sickness funds. To assess access to health care, it regularly conducts studies from the patient perspective, for example, on the level of information, experiences with health care, or evaluation of health system reforms.

  • India

    Significant inequalities with respect to health care access and health outcomes exists between states, rural and urban areas, socioeconomic groups, castes, and genders. For example, the infant mortality rate is 48 per 1,000 live births in rural areas, while it is 29 in urban areas. With respect to access, it is estimated that the urban rich obtain 50 percent more health services than the average Indian citizen. And 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 .

    Recognizing the lack of a comprehensive national health care system as an important factor in health inequalities, the government views universal coverage through the National Health Mission as the main strategy to address the problem, along with a strengthening of the primary health care infrastructure in both rural and urban areas.

    While there is no single agency responsible for ensuring that health inequalities are reduced, a number of new initiatives have been launched on behalf of low socioeconomic groups and other vulnerable populations. For example, with respect to maternal care, the Janani Suraksha Yojana, which provides mothers with cash incentives for institutional delivery, transportation in case of emergency, and additional incentives for accredited social health activists. Another initiative is expanding the use of information and communication technology in an attempt to increase rural Indians’ access to health services.

    Broadly, there is growing recognition about the need to address the growing burden of noncommunicable diseases, which are responsible for two-thirds of the total morbidity burden and just over half of deaths. Starting in 2013–14, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Strokes is being implemented in 35 states and union territories. It must be emphasized, however, that the effort against these diseases is still in its initial stages.

  • Israel

    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 low-income persons and other vulnerable populations. Most prominently, mental health care and dental care for children has been added to the national health insurance (NHI) benefits package, thereby reducing the substantial financial barriers that existed when these services were provided privately.
    • Enhancing the availability of services and professionals in peripheral regions, by increasing the supply of beds and advanced equipment in the periphery and providing financial incentives for physicians to work in the periphery.
    • Addressing the unique needs of cultural and linguistic minorities, through 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.
    • Intersectoral efforts to address the social determinants of health and promote healthy lifestyles.
    • Creation, analysis, and public dissemination of information about health care disparities, including periodic reporting of variations in health and health care access.
  • Italy

    Interregional inequity is a long-standing concern. The less affluent south trails the north in number of beds and availability of advanced medical equipment, has more private facilities, and less-developed community care services. Data show a rise in interregional mobility in the 1990s, with movement particularly from southern to central and northern regions and an increasing gap between the north and south.

    Income-related disparities in self-reported health status are significant, though similar to those in the Netherlands, Germany, and other European countries (Van Doorslaer and Koolman, 2004).

    The National Health Plan for 2006–2008 cites overcoming large regional discrepancies in care quality as key objective for reform. Directing EU resources toward health services in eight regions in the south was a first step in 2007 in reducing this persistent variation. Regions receive a proportion of funding from an equalization fund (the National Solidarity Fund), 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.

  • Japan

    Reducing health disparities between population groups has been a general goal since 2012. The two explicit targets are a reduction of disparities in healthy life expectancies between prefectures and an increase in the number of local government entities that make efforts to solve health disparity issues. There is another plan to reduce disparities among prefectures in cancer treatment delivery, with each prefecture setting treatment targets. Health variations between regions are regularly reported by government. Health variations between socioeconomic groups and variations in health care access are occasionally measured and reported by researchers, some of them funded by the Ministry of Health, Labor and Welfare.

  • The Netherlands

    Health disparities are considerable in the Netherlands, with up to seven years of difference in life expectancy between the highest and lowest socioeconomic groups. Smoking is still a leading cause of untimely 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, health access variations are measured and published in the Dutch Health Care Performance Reports.

  • New Zealand

    Disparities in health are a central concern in New Zealand, as Maori and people of Pacific Island origin have shorter life expectancies than other New Zealanders (by seven and six years, respectively), and reducing disparities is a policy priority. Maori and Pacific people are also known to experience greater difficulty in gaining access to health services, and data describing disparities are 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 to serve Maori or Pacific populations.

    The post-2008 government has focused on specific initiatives such as Whanau Ora, a policy designed to integrate health and social services for disadvantaged Maori. The aim has been to develop coordinated, multiagency approaches to service provision and foster joint responsibility for outcomes.

  • Norway

    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, kindergarten and education; 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 diets; and specific initiatives for populations at risk.

    There is increasing focus on immigrants’ health and underutilization of health care. Research on pregnancy has been informative, as there are significantly more complications for newborns and mothers among immigrants than among Norwegians (Ahlberg and Vangen 2005). The need for adequate information to be provided in immigrants’ native languages has been emphasized.

    Health outcomes vary geographically, 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.

  • Singapore

    Community Health Assist Scheme: The Community Health Assist Scheme subsidizes treatment for lower- and middle-income Singaporeans at private primary care sites. 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.

    Revised Central Provident Fund contribution rates: 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, with another increase in the employer contribution rate to Medisave slated for January 2015. These increases are intended to encourage low-wage workers to save more for their retirement and medical needs and to have better access to care.

  • Sweden

    The 1982 Health and Medical Services Act emphasizes equal access to services on the basis of 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. Approaches to reducing disparities include programs to support behavioral changes, and the targeting of outpatient services to vulnerable groups in order to prevent diseases at an early stage. To prevent providers from avoiding patients with extensive needs, most county councils allocate funds to primary care providers based on a formula that takes into account both overall illness (based on diagnoses) and registered individuals’ socioeconomic conditions.

  • Switzerland

    There are several reasons why health disparities have not attracted as much political and professional interest at the national level as elsewhere: Health inequalities are not considered to be very significant in comparison to other OECD countries; it is difficult to obtain detailed statistical information about the epidemiology of health outcomes; and health inequalities are seen more as the responsibility of cantons, making them less visible at the national level.

    The Swiss Federal Council’s national Health2020 agenda 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.

  • United States

    There are wide disparities in the accessibility and quality of health care in the U.S. 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, FQHCs 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 ACA contains 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 located in underserved communities. There are also a multitude of public and private initiatives at the local and state levels.