MJA Vol 179 3 November 2003 475HEALTHCAREThe Medical Journal of Australia ISSN: 0025-729X 3November 2003 179 9 475-478©The...
476 MJA Vol 179 3 November 2003HEALTHCAREof Indigenous people by multiplying the allocation forIndigenous populations by 2...
MJA Vol 179 3 November 2003 477HEALTHCAREbecause of the huge additional expenditure from privatesources which drags govern...
478 MJA Vol 179 3 November 2003HEALTHCAREaccess to equal care for equal need, and may never fully doso. A previous federal...
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Achieving Equity in the Australian Health Care System


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  1. 1. MJA Vol 179 3 November 2003 475HEALTHCAREThe Medical Journal of Australia ISSN: 0025-729X 3November 2003 179 9 475-478©The Medical Journal of Australia 2003 www.mja.com.auHealthcareIN 1988, I ATTENDED A WORKSHOP of healthcare servicemanagers sponsored by the King’s Fund of London. Partic-ipants included such managers and the odd academic fromthe United Kingdom, the United States, Canada, Australiaand New Zealand. We were discussing resource allocation,and frustration mounted during the first 2 days. Ideologi-cally, participants had divided into two teams — the US andthe Rest.On the third day, the leader of the US team said, “Thedifference between us is that you guys believe in equity andwe don’t. In the US, people are less interested in makingsure everyone gets care than that those who can get it getgreat care. They accept not getting care now if they can seethe opportunity to improve their position and succeed, sothat, when they get the money, they will be able to buy greatcare the minute they want it. It is all about opportunity.People in the US want opportunity, not equity. That’s whatthey think is fair.”It was important that the US delegate said what he did. Itcleared the air. It reminded us that not all societies, and notall people within a society, share a common view of what isfair. In the US, fairness means that you will be encouragedto seek personal success without having to worry muchabout anyone else.In the UK, Canada, New Zealand and Australia, there is ageneral interest in the well-being of others. I doubt thatRobert Putnam could have written his book Bowling alone1about Australia. Putnam’s book mourns the loss of socialcapital, a resource that grows from community trust andparticipation. Putnam especially laments its replacementwith a fierce individualism.The meaning of equityEquity conveys a sense of fairness, but sharpens fairness byadding equality and fellow-feeling. Equity it is not the sameas equality, which simply implies similarity of status, capac-ity, or opportunity. Indigenous Australians, whose lifeexpectancy is shorter than that of non-Indigenous Austral-ians, represent the pre-eminent example of an inequalitythat is also an inequity.Equity is an ethical value. US health and human rightsacademics Braverman and Gruskin defined equity as itapplies to health:“. . . An ethical concept grounded in the principle of distrib-utive justice . . . Equity in health reflects a concern to reduceunequal opportunities to be healthy [which are] associatedwith membership in less privileged social groups, such aspoor people; disenfranchised racial, ethnic or religiousgroups; women and rural residents.. . . Pursuing equity in health means eliminating health dis-parities that are associated with underlying social disadvan-tage or marginalisation. Equity. . . focuses [our] attention onsocially disadvantaged, marginalised or disenfranchisedgroups within and [among] countries, but not limited to thepoor.”2This definition emphasises that individuals’ need forhealthcare services is based on both their medical conditionand their social situation.Of course, the problem of inequity in health is not dueonly to the healthcare system. According to Matthews, thepoor health of Indigenous Australians is linked inextricablyto social, cultural and educational as well as more classicallymedical causes.3She reminds us that, when addressing thehealth needs of the less socially privileged, we must do muchmore than just provide equitable access to healthcare.Australia’s health economists have also written and spo-ken frequently about equity in healthcare, but none hasdone so more consistently, clearly and passionately thanGavin Mooney. He accepts that there are many definitionsof equity, but the one that he endorses is “equal access toequal care for equal need”.4That is fine for people on the same income and living inthe same suburb. Nevertheless, as do Braverman andGruskin, Mooney extends this definition by recognising theadditional needs of underprivileged people. These peoplemay need more access to more care for the same healthproblem than those with more money, better social supportand better opportunities. Ring and Brown5and Deeble6observe that current healthcare service funding for Indige-nous Australians does not match their severe and specialneeds. The extent of the positive discrimination we make infavour of such people will reflect how caring our society is.In New South Wales, the resource allocation formula thatguides the distribution of funding among geographicalregions includes a loading that recognises the greater needsAchieving equity in the Australian healthcare system*Stephen R Leeder*The final in the MJA’s series of keynote addresses presented at theAustralian Health Care Summit 2003.Stephen Leeder was Director of the Divsion ofPublic Health and Community Medicine atWestmead Hospital and Professor of PublicHealth and Community Medicine (1985–1997)at the University of Sydney and Dean ofMedicine 1987–2002. He was the foundationchair of the Board of Censors of the AustralasianFaculty of Public Health Medicine 1990–1994,and has served two terms as National Presidentof the Public Health Association of Australia. Hechaired the Health Advisory Committee of theNational Health and Medical Research Council, 1997–1999.The Earth Institute at Columbia University, New York,NY, USA.Stephen R Leeder, PhD, FRACP, Visiting Senior Research Scientist, andProfessor of Public Health, and Director, Australian Health Policy Institute,University of Sydney.Reprints will not be available from the author. Correspondence: ProfessorStephen R Leeder, The Earth Institute at Columbia University, 215 West125th Street, Suite 3F, New York, NY 10027, USA. sl2249@columbia.eduHEALTHCARE
  2. 2. 476 MJA Vol 179 3 November 2003HEALTHCAREof Indigenous people by multiplying the allocation forIndigenous populations by 2.5.7This is a good start, but weneed to do more.When equity is at work, sick individuals who seek helphave their needs met. There is no compulsion or competi-tion. No one is told, “Your need is too great; we can’t affordto treat you — unless you can pay for it yourself.” Patients inneed of a heart transplant or expensive long-term therapyfor HIV have the same degree of access — equitable access— to medication and care as patients with hypertension ormild asthma. Nor are sick people told, “Because you are oldor poor or receive a pension, the government will pay foryour healthcare, but will pay the doctor only half or three-quarters of what he or she would receive from treating ayounger, rich person.”So the care provided under this definition is impartial.Who you are or how much money you have does notdetermine your care. Equitable care does not depend onyour fame, fortune, or your ability to pay.The principle of universality, on which Medicare has beenbuilt, takes seriously the reality that sickness and accidentshappen chaotically to any of us, and that a humane andcaring society wishes all its citizens to have the same accessto the same standard of care, according to need, andunrelated to their financial status. This principle shouldapply to all public expenditure on healthcare in this country.At present, many Australians do not have equitable accessto good quality healthcare. The reasons for this are asfollows:■ Some general practitioners have closed their books,healthcare services are scarce in poorer areas, and, in ruraltowns, “up-front” payments for consultations are increasingwhile bulk-billing is in decline.8Indeed, there were recentreports of some patients having received more speedyattention because they were willing to pay a surcharge(Professor J Richardson, Director, Health Economics Unit,Monash University, personal communication). All thesethings tear us away from equitable primary healthcare.■ Public hospital infrastructure is growing old and needsreplacement.■ Access to high technology is patchy. Richardson (seepersonal communication, above) has shown that investiga-tion and treatment of heart disease is three times morecommon among privately insured patients.■ Access to timely surgery is uneven, with private patientsgetting it quickly and public patients often waiting for a longtime.■ Access to dentistry and ancillary healthcare services isinequitable — better access to high-quality services isoffered to those who are privately insured and/or wealthy.9Public funding for healthcare and equityI want to examine two aspects of the relationship betweenpublic funding for healthcare and equity.■ The first follows from the observation that rich countriesapply more public funding to healthcare (as a percentage ofGDP) than do underdeveloped countries.10Investment inhealthcare is a sign of a country’s economic strength, and areflection of its democratic values. Government investmentin healthcare is both ethically desirable and economicallyrational.This has some clear implications. To honour equity, as anation, we must set aside enough resources to buy appropri-ate, quality services and safe treatments, and make theseaccessible to our citizens based on their need.If the level of remuneration to doctors and other healthprofessionals is lower than is economically or socially appro-priate, or if the funds do not allow procurement of the mostappropriate treatments, problems follow. Deeble estimatedthat the consumer-price-index-adjusted Medicare rebate fora standard general practitioner consultation (Item 23) hasdeclined by $6 since 1984.6The recent fall in bulk-billing bygeneral practitioners has led to reform proposals from theCommonwealth Government and the Opposition. Whilethese proposals are different, both would cost an extra $300million per annum, and neither would apply the fundsequitably.General practice is by no means the most expensive itemin the healthcare system. As well as supporting generalpractice, we must ensure that our public hospitals areadequately funded. It is disappointing that the federalbudget surplus has been used to fund a tiny personal tax cutwhen $2.4 billion, or thereabouts, would greatly help inraising our public hospital infrastructure to acceptablestandards.Canadian social commentator John Ralston Saul hassuggested that governments which are committed to corpo-ratism, rationalism and cost cutting as means to achievegreater efficiency can make beliefs such as “publicly-fundedhealthcare services cannot cope” come true. The failure ofpublicly funded healthcare services is an inevitable conse-quence of insufficient investment or disinvestment. Indeed,the Romanow Commission, set up to review CanadianMedicare, recommended an increase in its funding.11I am convinced that, as a nation, we need to spend morepublic money on healthcare services, and that much of thestrain on Australian healthcare in recent years is the result ofunderfunding. Furthermore, there is room to improve theeffective, safe and efficient use of the allocated money, thusassuring its support for equitable access.■ The second aspect of the relationship between publicfunding of healthcare and equity that I want to discuss is theobservation that high levels of government funding forhealthcare do not guarantee equity. A strong investment bygovernment in healthcare may be necessary, but is notsufficient, to achieve equity. Big private-sector contributionsbias the government contribution in favour of the rich. Thisis the case in India12and the US, and is increasingly the casein Australia.About 14% of GDP goes on healthcare funding in the US,compared with about 9% in Australia. The difference is theresult of healthcare spending in the private sector, not thepublic sector. The public sector accounts for 44% of UShealthcare spending,13and the proportions of GDP spenton public-sector healthcare are similar in the US andAustralia. However, US public-sector healthcare expendi-ture is distributed preferentially to middle-class Americans
  3. 3. MJA Vol 179 3 November 2003 477HEALTHCAREbecause of the huge additional expenditure from privatesources which drags government funding in its train.In Australia, the private health insurance rebate actuallyincreased overall government spending on healthcare.14However, the rebate tends to distribute government expend-iture preferentially to those with private health insurance —that is, the wealthier members of the community.Moving forwardTo place equity on the agenda in the public funding ofhealthcare for Australia, we need two things:■ Greater clarity as to what Medicare and other publicmoney for healthcare actually fund (clearly, where thenature or means of funding is inadequate or inefficient, weshould develop new funding mechanisms); and■ A way to determine funding priorities that has equity asits centrepiece.On the first of these, we should consider a few fundingadditions and redistributions.First, we should extend the principles of the Pharmaceuti-cal Benefits Scheme and the Commonwealth Medical (pre-viously Medicare) Benefits Schedule to cover other essentialservices in our healthcare system. We currently supportdental and allied health professional services with publicmoney, but preferentially for those with private insurance.We pay for a third of private health insurance premiumsfrom public funds. From the 1998 Australian Bureau ofStatistics Health Insurance Survey and AXA/NationalMutual data for NSW, Spencer estimated that each year wegive some $300 million of public funds for dental care ofthose with private insurance.9I believe that we shouldsubsidise basic dental services for all Australians, as dentalhealth is not a luxury.Private health insurance rebates for physiotherapy, podia-try and other support services also channel public-sectorfunds to those who are privately insured. This runs counterto the principle of Medicare. If we consider dental andancillary services justifiable areas of public expenditure forthose with private health insurance, then we should assesswhat public funds provide to all other citizens in respect ofthese services. We should focus on equity in what we do anddo not fund.Second, the disparity in the payments that general practi-tioners receive from bulk-billed versus non-bulk-billedpatients needs to be redressed. The Commonwealth Gov-ernment is about to increase this disparity through its“Fairer Medicare” proposals.15This is unacceptable. Iunderstand the complexity of the issues, and the need toincrease remuneration for general practitioners, but thepresent proposal widens the gap between those who arebulk-billed and those who are not. We must be able to comeup with something better.Third, the Australian Health Care Agreements shouldtake account of chronic disease management. For example,we could make more use of casemix methods in fundingchronic disease management, although the AR-DRGs (Aus-tralian refined diagnosis-related groups) would have to beexpanded to encompass continuing care and reflect thegrowing burden of chronic disease. The care of the chroni-cally ill is an aspect of Medicare arrangements that requiressubstantial revision, including a full exploration of capita-tion rather than fee-for-service funding.Funding of healthcare provided by all professionals, notjust doctors, is critically important for people with multiplechronic health problems. Models of care for chronic illnessurge team approaches with good leadership and manage-ment. Extended and coordinated care is difficult to achieveif we only pay doctors at bulk-billing rates, or, indeed, if wecontinue to rely on a fee-for-service basis.Fourth, we need a coordinated plan to improve publichospital infrastructure in Australia. We need substantialadditional capital funds, as well as ongoing funding. In themeantime, public hospital waiting lists, which dispropor-tionately apply to those without private health insurance,constitute a real problem of equity.How do we move forward? Our healthcare services changeincrementally, and from time to time we need to review andconsolidate them. Yet it is easy to overlook the importanceto us of equity in such reviews.This requires that we establish a process of determiningwhat we should pay for through Medicare. For this reason, Ipropose the formation of a National Council for Equity inHealthcare, accountable to the Australian Parliament, witha mission to make the healthcare system more equitable. Itsterms of reference would concentrate on the extent to whichthe resources available for healthcare are used equitably.As part of its charter, the Council for Equity in HealthCare should support community debate leading to thedevelopment of a national healthcare charter containingprinciples for a more equitable healthcare system. Thedebate would provide an opportunity for citizens, patientsand carers to state their expectations clearly, and mightproduce some surprising results. When Gavin Mooneyrecently asked a citizens’ jury in Perth to set priorities, itvoted for equity and public health. When asked to setpriorities within equity, Aboriginal health came first in thejury’s agenda, ahead of rural and remote health and agedcare.16,17The proposed Council for Equity in Health Care couldalso review the contribution of the taxation system tohealthcare. This is especially timely now that the GST is inplace. The Australian economy is in good shape and it couldsustain an increase in public spending on healthcare andhealth.Although some say that there would be strong resistanceamong voters, a small progressive increase in the Medicarelevy, to be used for the provision of more equitable health-care, may well be acceptable. Opinion polls conducted bythe major political parties have found that such an increasewould be acceptable to most people in the way I havedescribed.18There are barriers to the achievement of equity that arenot financial, and these deserve the careful attention of theproposed Council for Equity in Health Care. In remoteAboriginal communities, the absence of basic services com-promises the universality of Medicare, and equity suffers.19People who live a long way from a city do not have equal
  4. 4. 478 MJA Vol 179 3 November 2003HEALTHCAREaccess to equal care for equal need, and may never fully doso. A previous federal Health Minister, Dr MichaelWooldridge, was correct when he said that Medicare wasnot the instrument to address the special needs of ruralAustralia. The Australian Institute of Health and Welfarehas documented that Australians in large cities are bulk-billed for general practice services much more frequentlythan those living in remote areas.8One description ofMedicare is that it is a metropolitan system.20On the positive side, the Commonwealth Government hasbeen energetic in seeking to improve healthcare services inrural areas. It has funded programs for medical studenteducation and registrar training, and provided enhancedfunding for services. These efforts are laudable, as are thelevels of dedication of many healthcare professionals whohave worked hard under less than ideal circumstances. Thegovernment is also working to open up access to Medicareand the Pharmaceutical Benefits Scheme for many rural andremote Indigenous Australian communities, and this iscommendable.There are also cultural and language barriers to equity inhealthcare that can limit access to quality care. If there arenot enough interpreters available in public hospitals, thosewho do not speak English fluently are disadvantaged. Thecultural norms of the medical profession may easily preventdoctors from treating working-class patients in appropriateways. Apart from underfunding, lack of cultural security is amajor block to improving Aboriginal health.20The proposedNational Council for Equity in Health Care should includethese issues in its remit.With increasing affluence, we can choose to invest more asa nation in the healthcare of our citizens. We can do muchmore to improve the degree of equity in healthcare inAustralia. This is the course of a humane, caring nation witha belief in the value of civil society. We can apply businessprinciples with benefit to many parts of healthcare. There isalso a strong case for investing more in innovation and theevaluation of healthcare, and more in improving its qualityand safety.At its core, though, healthcare is about sharing and caring— sharing the load of illness and caring about ensuringaccess to the privilege of hope that humane medical careoffers. We need political leadership, both lay and medical,that will seek to strengthen, not weaken, worthwhileachievements, and build on what this country has achievedover recent decades in providing equitable healthcare for allAustralians.AcknowledgementsI am grateful for critical comments from Michael Frommer, Alix Magney, Warren Talbot,George Rubin, John Dwyer, Miles Little, Gavin Mooney, Kathy Esson and Mick Reid.References1. Putnam R. Bowling alone: the collapse and revival of American community. NewYork: Simon and Schuster, 2000.2. Braverman P, Gruskin S. Poverty, equity, human rights, and health. Bulletin WorldHealth Organ 2003; 81: 539-545.3. Matthews C. Caught in a vicious cycle. Australian Medicine 2003; 15(12): 16.4. Mooney G. Economics, medicine and health care. 3rd ed. London: Prentice Hall,2003.5. Ring I, Brown N. Indigenous health: chronically inadequate responses todamning statistics. Med J Aust 2002; 177: 629-631.6. Deeble JS. Medicare’s maturity: shaping the future from the past. Med J Aust2000; 173: 44-47.7. New South Wales Health Department Implementation of the economic statementfor health. Sydney: NSW Health Department Structural and Funding PolicyBranch, Policy Development Division, 1996.8. Mooney G. Access and service delivery issues. In: Productivity Commission andMelbourne Institute of Applied Economic and Social Research. Health PolicyRound Table Conference Proceedings, 2002. Canberra: AusInfo, 2002.9. Spencer AJ. What options do we have for organising, providing and fundingbetter public dental care? Sydney: Australian Health Policy Institute, 2001.10. The 10/90 Report on health research 2001–2002, Geneva: Global Forum forHealth Research, 2002: 5.11. Building on values: the Final Report of the Commission of the Future of HealthCare in Canada. November 2002. Available at: www.hc-sc.gc.ca/english/care/romanow/hcc0086.html (accessed Aug 2003).12. Mahal A, Yazbech AS, Peters DH, Ramana DNV. The poor and health service usein India, 2001. World Bank. Health, Nutrition and Population Discussion Paper.Available at: www.fiscalconf.org/papers/mahal.pdf (accessed Sep 2003).13. OECD Health Data 2001. Available at: www1.oecd.org/media/publish/pb01-24a.pdf (accessed Oct 2003).14. Australian Institute of Health and Welfare. Australia’s health 2002. Canberra:AIHW, 2002: 263.15. Australian Government Department of Health and Ageing. A fairer Medicare.Better access, more affordable. Available at: http://www.health.gov.au/fair-ermedicare/ (accessed Sep 2003).16. Medical Council. Health and economics — bridging the abyss. Perth: HealthDepartment of Western Australia, 2000.17. Medical Council. What’s fair in health care? Perth: Health Department of WesternAustralia, 2001.18. Australian Broadcasting Corporation. Tax hike “okay” if services improve.Available at: abc.net.au/news/newsitems/s918065.htm (accessed Sep 2003).19. Australia’s health 2002: the eighth biennial report of the Australian Institute ofHealth and Welfare. Canberra: AusInfo, 2002.20. Houston S. Aboriginal cultural security. Perth: Health Department of WesternAustralia, 2001.(Received 5 Sep 2003, accepted 24 Sep 2003) ❏