Addressing Health Equity - Prague workshop report
Addressing Health Equity was a workshop held at the recent world conference held in Prague, in June 2013.
This workshop sought to explore how a better understanding of the health inequities present in a population can enable the general practitioners to adopt strategies that could improve health outcomes in the delivery of primary health care; it explored the development of a health equity curriculum and opened the discussion of the future and potential impact of health equity training among general practitioners.
As part of the workshop, it was proposed to seek interest in establishing a WONCA special interest group on health equity. There is an indissoluble link between health equity and social justice and our success to make a difference for our patients relies on all frontline doctors and health professionals to advocate for greater socioeconomic equity and the health rewards that would follow.
The workshop was divided into four sections:
1. Welcoming note by Prof Michael Kidd
2. Scope of health equity; and challenges and problems pushing the agenda forward by Prof Iona Heath
3. Brief overview of current initiatives and best practices dealing with health equity in family medicine/ primary care setting by Dr Efrat Shadmi
4. Discussion: regional priorities and challenges in achieving health equity
5. Drafting a proposed curriculum/other business
Here follows a summary of the discussion.
1. Please list three health inequity situations specific to your country that you are aware of (especially if it is related to primary care or your work) and describe how these may impact on health. (From each participants)
Uneven distribution of social determinants of health could systematically affect the distribution of poor health outcomes, such as different life expectancies, and risk behaviours, such as alcohol, domestic violence, smoking, among population of low social economic status (SES). Some common social determinants of health which affect general low SES population include income differences; poor housing; poverty; unemployment; education; access to healthcare services, social support and isolation.
There is a wide income gap between the rich and the poor- it affects people’s affordability to healthcare services. In Pakistan, only 30-35% of health care is covered by the public sector. The rest of the patients would go to private practitioners, faith healers, alternate medicine specialists and even quacks. In Brazil, 45% cover is available through public sector; while in Holland, co-payment for secondary care becomes financial barrier to some patients. National cuts in allocation of funding have affected people in socially deprived areas more. Misallocation of resources by central funding body is observed since there is no needs assessments matched with funding.
Income gap could also affect education hence literacy of people. Literacy is only 59% in Pakistan; while in Brazil, literacy is good but not properly exercised.
For countries with urban or rural division, urban areas usually enjoy better healthcare access, whereas healthcare services are extremely limited in rural areas. Pakistan immunization is not possible in remote Pakhtoon areas whereas in Romania, there is a lack of General practitioners in remote areas or rural areas.
For indigenous group or aborigines, cultural differences and expectations could affect their access to healthcare services. Health related policy might be recognised by these groups as cultural Imperialism that serves the purpose of maintaining the cultural hegemony.
Migration is recognised as social determinant of health which might affect migrants’ access to healthcare services due to language barriers or unfamiliarity of healthcare systems, which makes their navigation through the healthcare system difficult. One of the examples given was the UK homeless migrant groups.
2. From all of the problems above or mentioned in the presentation, what are the key barriers and facilitators in meeting the health equity agenda (with examples from your own country).
Barriers on the supply side
Health workforce shortage is observed in rural area or primary care which makes health services unavailable to people living in rural area or of low SES. Furthermore, some government doctors might engage in private practice and reduce the already limited manpower. Efficiency and effectiveness of services will be affected by the lack of coordination and communications between primary and secondary care.
For developing countries, there will be lop-sided priorities; for example, AIDS programs are supported by foreign funding but no attention is paid on safe water supply, immunization and sanitation in Pakistan.
Poorer people/ minorities/ communities with low political equity have little effect on politically driven health policy. Furthermore, there might be a lack of political will, money, and/or knowledge in tackling the problem. Other barriers include the prevalence of corruption feeling that the problem is too big/ difficult even to get started.
Barriers on Demand side
The SES status of patients could affect their utilisation of health services. For those who have no jobs or on low wage, they could not afford health care; for those who have low education, they would have low health literacy. Poverty could have impact on psychology which resulted in low worthiness and expectations. Cultural Norms could also affect people value, perceptions and trust on health services utilisation.
Facilitators
Income gap narrowing and strong democracy over a consistent period can facilitate the health equity agenda. Also policymakers should talk “truth to power”, which they should use medical data by UK lobby groups to support provisions of housing, education, social services and employment, and engage the community. Resources should be focused at departmental level. QUIDS measurements assessed on GP practice IT systems monthly.
General Practitioners could provide patient advocacy locally through media. Health professionals could also empower patients through patient participation groups. Culture of responsibility for health inequities should be borne by the community but not rested on individuals.
Telemedicine for remote areas could be provided to rural area where there is a lack of doctors. Free and comprehensive primary health care could be provided to people in need.
Training on health equity must be provided to the health professionals.
3. How can we as primary are team overcome these barriers with one specific attention to be given to: 1. Health access; 2. Vulnerable groups; and 3. Education and training of health professionals?
Health access
Primary health care should be accessible through family doctors (one doctor for sizable population) like the NHS model.
Practice meetings should be conducted to identify local issues/ problems and it should involve policymakers, general practitioners and nurses. Being aware of what is available locally and getting ideas from other countries may be useful.
Education for patients and public
Signposting for how to navigate healthcare system should be provided to the public and the patients. Community awareness should be promoted in settings that reach out to different groups, such as mosque. Training should be provided to the leaders of vulnerable groups.
Vulnerable groups
Women, minorities, children and people with low social standing should be attended to more comprehensive training of health professionals.
For migrants, ethnic minorities or indigenous groups, signs in different languages should be installed and education about cultural awareness should be provided to staff including general practitioners, or nurses.
Education and training of health professionals
Training in inequity should be provided to medical students as well as general practitioners to improve health equity through primary care. Medical students and doctors should be trained to conduct face-to-face discussions with patients in services to increase understanding. There should be increased exposure with general practitioners for medical students.
More general practitioners should be trained to ensure there are service providers in rural areas.
Dr William Wong