Inequalities 2005

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Inequalities - 2005
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Some thoughts

• a scenario - (data)
• viewed from different mountain tops -
  (analysis)
• within the culture, values and norms of that
  place (ideology)
• become truisms (evidence)

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Statistics many views
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Interpretations

• Headline More Maori are failing in schools
• Maori are 50 less likely compared to non-Maori
  to leave school with a qualification
• Non-Maori are 50 more likely to leave school
  with a qualification
• 50 of Maori are failing the systems
• Or the system is failing 50 of Maori compared to
  20 of non-Maori
• The system shows non-Maori privilege?
• THINK ABOUT THE GAZE and multiple interpretations

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Why bother?Equity and the layers

• A link with justice and fairness
• An egalitarian society
• Good for all
• Cost effective?
• A link to the Treaty

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Equity

• Equity of access
• Into the system
• Equity of process
• Through the system
• Equity of outcome
• Out of the system
• The definition used is critical

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Which population groups

• Maori
• Pacific Peoples
• Low SES
• Refugees and new immigrants
• Mental health patients
• Asian peoples

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The Cause

• Socioeconomic determinants
• Structure of society
• Biological effects
• Cultural effects
• Racism and privilege
• The inverse care law
• Other

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Root and Surface Causes
Williams 1997 AEP 7322-333
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Equity

• Equity of access
• Into the system
• Equity of process
• Through the system
• Equity of outcome
• Out of the system
• The definition used is critical

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Inequalities

• Difference in status social or economic
  disparity between people or groups
• Lack of equal treatment unequal opportunity or
  treatment based on social or economic disparity
• State of being unequal the condition or an
  instance of not being equal

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Who

• Maori
• Pacific Peoples
• Low SES
• Refugees
• The homeless
• Mental health patients

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The Cause

• Socio-economic determinants
• Structure of society
• Biological effects
• Cultural effects
• Racism and privilege
• The inverse care law
• Other
• Multiple confounders but.

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Ethnic disparities - three levels

• Differences in access to the resources of society
• Differential access to health care
• Differences in quality of care received

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Distribution Gap
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Ethnic disparities - three levels

• Differential access to health determinants or
  exposures - differences in disease incidence
• Differential access to health care
• Differences in quality of care received
• Jones, 2001

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Ischaemic Heart DiseaseMortality 1996-99 and
Interventions 1990-99 Male standardised rates
per 100,000
Ajwani et al 2003 Tukuitonga
Bindman 2002
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Ethnic disparities - three levels

• Differential access to health determinants or
  exposures - differences in disease incidence
• Differential access to health care
• Differences in quality of care received
• Jones, 2001

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Differential quality of care

• lower satisfaction with care
• preventive asthma medication less likely
• antidepressants less likely
• fewer caesarean sections even when main
  confounders controlled for
• fewer cardiovascular interventions
• diabetes - equity in quality can be improved
  through monitoring, feedback and protocols but
  still need to address inadequate coverage/access

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How do we move forward in health?

• Think gaze and systems
• Governance
• Adjust methodology
• Equal explanatory power
• Multiple approaches
• Novel approaches
• Culturally appropriate approaches
• Examples later
• Criteria for success

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How do we move forward in health?

• Needs based funding is race based funding
• Ethnicity data the right to be counted
• Raise awareness
• Policy development
• Intersectoral links

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Moving forward

• Reorientation of health services
• Attempt to measure unmet need
• Extend reach of services into community
• Go to those in need
• Community development and empowerment
• Community involvement and governance
• Community responsiveness

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Moving forward

• Reorienting health services
• Performance indicators and times
• Ethnicity data collection and accuracy
• Monitoring of referral pathways
• Integration of the public health, primary and
  secondary care
• By Maori for Maori services
• By Pacific for Pacific services

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Moving forward

• Work on the SE determinants of health
• Macro policy change
• Redistribution of resources and wealth
• Improved standard of living for all
• Employment and housing
• Examples of intersectoral collaboration
• Healthy Housing
• Social Services
• Walking buses

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Examples of Maori research moving forward

• Changing mainstream paradigms
• The STOMP trial
• The PROMPT evaluation
• The Polypill trial
• Indigenous research collaboratives

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When is

• Enough is Enough
• Maybe when there is a 10 year gap in life
  expectancy?

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Indigenous health disparities. A comparison
between New Zealand, Australia, Canada and the
United States.
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Overview of presentation

• Project outline and aims
• Methodology
• Results
• Discussion points and policy analysis
• Conclusions

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Project outline

• Disparities in health status for indigenous
  peoples have been documented in New Zealand,
  Australia, Canada and the United States
• A paucity of information exists comparing
  indigenous non-indigenous health status across
  countries
• A reduction in indigenous health disparities has
  become a common theme for health policy makers

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Aims

• To describe and compare the health status of the
  indigenous population of New Zealand, Australia,
  Canada and the United States, with the
  non-indigenous population, over a range of health
  indicators
• To review the quality of indigenous health data
• To review the policy response to indigenous
  health disparities

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Methodology

• Selection of a wide range of health indicators
• Collection and analysis of comparative health
  indicator data, including crude mortality data
• Review of the policy response to disparities with
  the aid of international experts

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Results the life expectancy gap

• New Zealand
• Males 7.3 years
• Females 7.9 years
• Australia
• Males 20.6 years
• Females 19.1 years

• Canada
• Males 7.4 years
• Females 5.2 years
• United States
• Males 6.7 years
• Females 5.3 years

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Results - smoking
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Results - diabetes
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Results measles, mumps and rubella immunisation
coverage
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Results renal transplant
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Maori/non-Maori mortality risk ratio versus
Australian Indigenous/non-Indigenous risk ratio
 
   
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Maori/non-Maori mortality risk ratio versus
AIAN/ White risk ratio
   
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Results health data quality

• Lack of ethnicity data collection
• Mortality datasets
• Treatment datasets
• Prevalence surveys
• Primary care
• Inaccuracy of numerator counts
• Inaccuracy of denominator counts

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Policy - New Zealand

• Historical context the Treaty
• Crown response based on three principles
• Partnership
• Participation
• Protection
• Cultural competency by all and mainstream
  engagement
• Funding 14.7 of total health expenditure for
  15.4 of the population

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Policy - New Zealand

• By Maori for Maori health service development
• Increase workforce training and capacity
• Governance and ownership mechanisms
• New funding mechanisms
• Ethnicity adjuster
• Population based approach
• Legislative action

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Policy - Australia

• Historical context - Terra Nullius
• Mabo - 1992 restores legal doctrine of native
  title into Australian law
• Native Title Act -1993, enabling Indigenous
  people throughout Australia to claim traditional
  rights to unalienated land

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Policy - Australia

• Ownership - six different portfolios since 1968.
  Office of Aboriginal and Torres Strait Islander
  Health since 1995
• Funding - 2.2 of total health spending for 2 of
  the population
• Cultural competency and indigenous capacity
  slowly increasing
• Problems - double burden, low SES, access and
  small indigenous workforce

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Policy - United States

• Historical context - nations within a nation
• Via laws and treaties - federal responsibility
  for health founded
• 558 federally recognized tribes
• Since 1970s movement toward self determination
  in health
• Transfer of autonomy to tribes
• Heterogeneity

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Policy - United States

• Indian Health Service
• Receive all care from
• Receive from to operate own care
• Under funding of services - 50 increase needed
  to meet average federal health plan
• Public health - community models of care delivery
• Problems - double burden of disease, small
  indigenous workforce and urbanization

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Policy - Canada

• Historical context -assimilation and treaties
• Royal Commission on Aboriginal Peoples
• Period of restitution
• Monitoring and co-ordination of policy -First
  Nation and Inuit Health Branch of Health Canada
• Health funding 60 higher per capita

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Policy - Canada

• Priorities
• Transfer of autonomy and control of health
  programs and resources to local communities
• Partnership in delivery of care
• Support action on inequalities as identified by
  local communities
• Institute of Aboriginal Peoples' Health - has a
  focus on capacity, research and collaboration

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Discussion

• Disparities exist across many indicators
• Largest in Australia and New Zealand
• Some disparities are not universal
• Disparities may not be intractable

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Discussion

• Indigenous health data quality poor
• Common themes regarding poor health data quality
• New Zealand has the highest levels of indigenous
  health information available
• Improvement is needed in data collection

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Discussion

• Health sector response to indigenous disparities
  differ across countries
• Multiple factors influence
• Historical context important
• All share a history of colonization, land loss,
  marginalization and low SES

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Discussion

• Common themes
• Double burden of disease
• Movement toward self autonomy in health affairs
• Chronic under-funding, given health need
• Increasing cultural awareness
• Lack of critical mass in health workforce and
  research capacity

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Summary

• Indigenous peoples suffer from large health
  disparities
• The quality of indigenous health data available
  is poor
• Different approaches have been taken to reduce
  disparities, though common themes exist

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Acknowledgements

• The Commonwealth Fund
• Dr. Mark Chassin and Prof. Rod Jackson
• Dr. Fadwa Al-Yamen (Australia)
• Adam Probert (Canada)
• Prof. Spero Manson (United States)
• Co-authors, collaborators and friends at Mount
  Sinai