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 COAG agreed to set a target for closing the gap in life expectancy by 2031. This is a government and nongovernment effort, with the nongovernment component supported through the Australian Human Rights Commission.
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 in the gap of 0.8 years for males and 0.1 years for females.31
Disparities between major urban centers and rural and remote regions, and across socioeconomic groups, are also major challenges. The federal government provides financial 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.
Democratic progress in Brazil has enabled the development of national policies to ensure human rights and universal access for vulnerable groups.26 The National Human Rights Plan defends civil rights, protects social groups that have suffered historical inequities, and guarantees social rights in the context of economic inequalities.
Health policies have been implemented to improve equity and reduce disparities for black Brazilians; Romany and descendants of escaped slaves (quilombolas); lesbian, gay, bisexual, and transgender groups; the homeless; and people living in rural areas and riverine communities. Initiatives have included adding gender reassignment surgery to SUS coverage; adding information on color and race to SUS ID cards; giving attention to sickle cell anemia, which disproportionately affects black people; exempting gypsies from having to show proof of residence to qualify for SUS care; and recognizing the role of healers and midwives in health care.
In the Ministry of Health, the Special Secretariat for Indigenous Health was created to coordinate and manage policies and programs related to the health of indigenous people. Priorities include observing traditional health practices and carrying out sanitation actions to ensure indigenous health. The Brazilian indigenous population encompasses nearly 820,000 people in close to 5,400 villages (12.6% of Brazilian territory).
The expansion of primary care has led to large improvements in access and in health outcomes.27 Primary care services have been developed locally to reduce disparities and address differential patterns of burden and need. Local solutions include mobile clinics for the homeless, floating health units in river communities, and indigenous health teams.
The Public Health Agency of Canada includes health disparities reporting in its mandate, and the Canadian Institute for Health Information also reports on disparities in health care and health outcomes, with a focus on lower-income Canadians.38 No formal or periodic process exists to measure disparities; however, several P/T governments have departments and agencies devoted to addressing population health and health inequities.
Health disparities between indigenous and nonindigenous Canadians are a concern for government at both the federal and the P/T level. The 2018 federal budget offers new funding of CAD 5 billion (USD 3.9 billion) for indigenous people, building on previous investments totaling CAD 11.8 billion (USD 9.3 billion). The money is earmarked for education, the environment (for example, water quality), and health and social services.39
In 2015, the Truth and Reconciliation Commission, which was established to collect stories regarding the events and effects of the Indian Residential School legacy, released a series of calls to action, including several addressing health disparities that affect indigenous communities.40
In Ontario, a 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 First Nations youth.41
There are still severe disparities in the 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 (see above). As a result, income-related disparities have been reduced substantially. However, there is no oversight agency to monitor or report on health disparities and there are no targeted programs to reduce disparities for specific groups.
Remaining disparities in access are due mainly to variation in insurance benefit packages that are determined locally, urban and rural factors, and income inequality. Urban Employee Basic Medical Insurance offers lower cost-sharing than Urban-Rural Resident Basic Medical Insurance. Central and local government subsidies to Urban-Rural Resident Basic Medical Insurance have increased in recent years.
Most good hospitals (particularly tertiary hospitals) with better-qualified health professionals are in urban areas. Village doctors are often undertrained. To help bridge the urban–rural health care gap, 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 Statistical Yearbook shows that substantial disparities remain.
Equity is a value in the Danish health care system, as in other Nordic welfare systems. This is evident in the key principle of equal and easy access in the Danish health law and, more broadly, as an underlying argument for universal, tax-financed health systems that provide coverage to all citizens largely free of charge. Equity is also a key focus for regional and municipal organizers of health and social care services. Nevertheless, some social and geographical differences in health remain.
One of the key mechanisms for ensuring geographical equity in health care is a scheme for systematic redistribution of tax revenues from affluent to less affluent municipalities based on sociodemographic parameters. Equity aims are also supported by various efforts to standardize treatment quality through pathway programs and mandatory publication of relevant indicators for comparison across geographical units. Finally, the implementation of nationwide free choice of hospitals and maximum waiting times for hospital diagnosis and treatment also pressures the regions to deliver fast and equitable access.
The Danish Health Agency regularly publishes reports on variations in health and health care access based on survey data, subdivided according to age, gender, education, employment, and geography (region).20 The reports have prompted the formulation of municipal-level action plans and initiatives, including:
- 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, such as through increased municipal cofinancing of hospitals, which creates 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
- Various projects and special funding opportunities, for example, those focusing on the health of socially disadvantaged groups such as the immigrants and ethnic minorities.
The Secretary of State, Public Health England, NHS England, and 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.36
NHS strategies include:
- ensuring that local CCG areas receive adequate resources to tackle inequalities
- measuring progress toward reducing disparities
- financially incentivizing reductions in inequalities in certain areas, such as early cancer diagnosis and mental health
- sharing best practices for achieving targeted goals, such as care for homeless people
- using risk stratification tools to identify people at risk of ill health.
Public Health England also has been tasked with reducing health inequalities and has published extensive guidance for local authorities.37 The agency also publishes data on progress in a health equity “dashboard.”38 Budgets for public health are held by local government authorities, which are required to host health and well-being boards to improve coordination of local services and reduce health disparities. Using local taxes and grants from central government, local government also funds social services for children and adults, the latter subject to means testing.
Reducing disparities in regard to social determinants of health and access to care is a national priority. There is a 6.3-year gap in life expectancy between males in the highest social category and those in the lowest,16,17 and poorer self-reported health among those with state-sponsored insurance and no VHI.
The 2004 Public Health Act set targets for reducing geographic and financial inequities in access to services and inequities in preventive care related to obesity, cancer screening, and immunization. Toward these goals, disparities are being addressed through physician contracts. For example, financial incentives encourage physicians to practice in underserved areas. Furthermore, physician contracts under SHI prohibit physicians from denying care to beneficiaries of state-sponsored health insurance and put a cap on balance billing.
There are published national statistics on nutrition, physical activity, and tobacco use, analyzed by social class and type of employment.18 Differences in access to care are measured by participation in systematic screening programs and differences in health outcomes.
In March 2018, the Minister of Health presented the national plan to reduce health inequities with a EUR 400 million (USD 506 million) investment over five years and 25 measures that concern all age groups.19
Compared to percentages in other European countries, the share of population reporting an unmet need for medical care is very low (0.3%), ranging between 0.8 percent in the lowest income quintile and 0.1 percent in the highest income quintile in 2017.13 This suggests good access with few disparities.
The Health Monitor (Gesundheitsmonitor) was a national initiative of not-for-profit organizations and sickness funds. To assess the performance of the health care system, it regularly conducted studies from the patient perspective—for example, on the availability of information, experiences with health care, and the 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.
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, including sickness funds and their associations, promotes the health of the socially deprived.14 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 in nurseries, schools, and other setting.15
Significant health, social, and income inequities exist across India, many of them a result of the country’s diversity, rapid economic growth, and historically limited wealth redistribution.56 There is evidence of high unmet need in access to public health services, especially among women in rural and tribal regions, who lack access to reproductive health services, neonatal care, and family planning services.57
No centralized system exists for monitoring and evaluating health indicators and health status.
In addition to targeting vulnerable populations under the National Health Protection Scheme, there have been a number of initiatives over the years to help poor households afford care and to promote treatment-seeking behaviors. Examples include:
- The Janani Suraksha Yojana, launched in 2005, is a centrally sponsored scheme to reduce maternal and neonatal mortality by promoting institutional delivery among poor pregnant women. It is one of the largest conditional cash transfer programs in the world.58
- The Health Minister’s Cancer Patient Fund provides financial assistance to patients suffering from cancer.59
- Rashtriya Arogya Nidhi offers financial assistance to patients living below the poverty line who are suffering from life-threatening diseases.
- The Health Minister’s Discretionary Grant provides financial assistance to patients with significant hospital bills.
- Mission Indradhanush provides universal immunization for all children under age 2 and pregnant women.
The Ministry of Health is leading a major national effort to reduce disparities, in cooperation with the NHI health plans and hospitals.22 Key initiatives include:
- Reducing financial barriers to care, particularly for those with low incomes and other vulnerable populations. Most prominently, mental health and dental care for children and the elderly have been added to the NHI benefit package.23
- Enhancing the availability of services and professionals in remote regions by increasing the supply of beds and technologically advanced equipment in those regions.
- Addressing the unique needs of minorities through the adoption of cultural responsiveness requirements for all providers, the establishment of a national translation call center, and targeted interventions for the Bedouin and other high-risk groups.
- Implementing intersectoral efforts to address the social determinants of health and promote healthy lifestyles.
Italy has no national agency tasked with monitoring disparities; in most cases, the monitoring of inequalities is a responsibility of each region.
Interregional inequity is a long-standing concern to both regional and national policymakers. The less-affluent south trails the north in the number of beds and in the 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.12
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 occasionally publish reports with analysis of health care variation.
Reducing health disparities between population groups has been a goal of Japan’s national health promotion strategy since 2012. The strategy sets two objectives: the reduction of disparities in healthy life expectancies between prefectures and an increase in the number of local governments organizing activities to reduce health disparities.29
Health disparities between regions are regularly reported by the national government; disparities between socioeconomic groups and in health care access have been occasionally measured and reported by researchers.
Every four years, variations in health accessibility are measured and published in the Dutch Health Care Performance Reports by the National Institute for Public Health and the Environment, focusing on socioeconomic differences such as ethnicity and education. Geographic or regional variation is not measured consistently.34
Socioeconomic 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. Although health disparities are monitored by the National Institute for Public Health and the Environment (part of the Ministry of Health), the government does not have specific policies to overcome them. In 2013, the government decided to cover weight loss advice and smoking cessation programs in the statutory benefit package.35
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. Data describing disparities are routinely collected and publicly reported at both the national and the district level.9 A full range of data are collected and reported, including socioeconomic status, ethnicity, and proximity to services.
The post-2008 government has focused on specific initiatives such as “Whānau 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 government now requires district health boards to report on Māori health plans in their statutory reporting, and to consult with Māori on their annual plans.
The Patient and User Rights Act ensures that all inhabitants have equal access to quality health care.
A national 2013–2017 strategy, Equality and Equity in Health Care – Good Health for All, targeted social determinants of health. The emphasis has now shifted to individual health-related behaviors, rather than social determinants of health.16
The NIPH publishes data on social inequality and health. Information on disparities in outcomes and access to care is available through registries, and has been studied at the national and the regional level. Income disparities seem to be larger than educational disparities.17 The largest differences in life expectancy (nine years) are found among districts in Oslo.
Recent demographic studies of mortality differences between immigrant and Norwegian populations reveal no disadvantage for immigrants. Disparities between the indigenous people of northern Europe, the Sami, and Norwegian populations are studied through the SAMINOR population-based study.18 So far, there is little evidence for health disparities between the two.
In public hospitals, care is provided based on patients’ clinical condition, rather than on their subsidy status. When nonsubsidized drugs or treatments are deemed clinically required and cannot be replaced by subsidized alternatives, needy patients receive assistance (such as through MediFund) in accessing these drugs or treatments.
Singapore has also adopted a system of differentiated charges, based on a patient’s and his or her family’s ability to pay. Means-testing is used, but even higher-income patients receive subsidies when they access subsidized services (although they pay more than lower-income patients). For example, higher-income patients who choose to stay in subsidized C-class hospital wards will receive up to a 65 percent subsidy while lower-income patients in these wards receive up to an 80 percent subsidy. Nearly all government-funded services, from acute to long-term care, have differentiated charges, except for polyclinic services and accident and emergency services.
The government has also introduced schemes to assist specific cohorts of Singaporeans:
- The Pioneer Generation package, honoring older residents50 who contributed to Singapore’s nation-building but are unlikely to have accumulated sufficient money in their MediSave accounts to support retirement health needs, as MediSave was introduced late in their working lives. Pioneers receive additional outpatient care subsidies, annual MediSave top-ups (up to $800), and MediShield Life premium subsidies (up to 60%).51
- The Merdeka Generation package, which recognizes Singaporeans who laid the groundwork for an independent Singapore.52 The benefits include MediSave top-ups of $200 per year for five years beginning in 2018. Merdeka Generation seniors also receive additional subsidies for outpatient care at certain clinics, as well as an additional subsidy of 5 percent for their annual MediShield Life premiums that increases to 10 percent at age 75.53
Sweden ranks in the top three among 11 high-income countries on measures related to health care equity.14 The Health and Medical Services Act emphasizes equal access to services according to need and a vision of equal health for all, and the level of unmet need is very low in Sweden.15 Disparities in access and health outcomes are measured primarily with regard to gender, income, and education by the National Board of Health and Welfare and the Public Health Agency.
Disparity-reduction approaches include programs to support behavioral changes and outpatient preventive programs targeting vulnerable groups. To prevent primary care providers from avoiding patients who have extensive needs, most regions allocate funds based on a formula that accounts for both overall illness (based on adjusted clinical groups) and registered individuals’ socioeconomic conditions (measured through the Care Need Index).
Another health care disparity issue relates to unwarranted regional variation in wait times and access to different services. One way in which such inequalities are addressed is through evidence-based clinical guidelines and performance indicators set by the government, sometimes accompanied by targeted grants. Moreover, in 2005 (regulated in the Health and Medical Services Act since 2010 and the Patients Act since 2015), Sweden introduced a wait-time guarantee—the 0–7–90–90 rule—to improve and ensure equal access to services across the country:
- 0: zero delay, or instant contact with the health system for advice
- 7: seeing a general practitioner within seven days
- 90: seeing a specialist within 90 days
- 90: waiting no more than 90 days to receive treatment after being diagnosed.
The Swiss Federal Council’s national Health2020 strategy explicitly calls for improving health opportunities for the most vulnerable population groups, such as children, people with low incomes or poor educational backgrounds, the elderly, and immigrants.22 The aim is to facilitate easier access to necessary health care services.
Toward this purpose, the Federal Office of Public Health supports various initiatives to strengthen the health literacy of disadvantaged people and the competence of health professionals. From 2012 to 2017, these efforts focused mainly on the migrant population; today, the programs are broader in scope.
Starting in 2018, the National Strategy for the Prevention of Non-communicable Diseases and the National Strategy on Addiction and Mental Health have focused on health equity.23 In addition, health and health access variations (by region and socioeconomic characteristics) are measured and reported publicly by the Swiss Health Survey every five years.24
More than 3 million economically disadvantaged Taiwanese (12.8% of the population) have full access to NHI services, owing to the NHIA’s various financial and access-assistance measures, including premium subsidies and copayment and coinsurance reductions or exemptions (see “Safety nets” in table above). 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. In recent years, the government has lowered the income threshold to allow more people to become eligible for these premium subsidies.
Several federal agencies are tasked with monitoring and reducing disparities. The Agency for Healthcare Research and Quality publishes an annual national report highlighting disparities in health care quality by race/ethnicity, age, and sex. According to the latest report, disparities related to income and race persist but grew smaller between 2000 and 2016.35 African Americans, American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders received worse care than whites according to about 40 percent of quality measures. Hispanics and Asian Americans received worse care per 35 percent and 28 percent of measures, respectively. Disparities for poor and uninsured populations are also persisting in major priority areas for quality.
Certain federal offices have specific responsibilities related to reducing disparities:
The Office of Minority Health is tasked with developing policies and programs to eliminate disparities among racial and ethnic minority groups.
The Health Resources and Services Administration is tasked with providing grants to states, local governments, and community-based organizations for care and treatments for low-income, uninsured, or other vulnerable populations, including specific programs targeting individuals with HIV/AIDS, mothers and children (through the Maternal and Child Health Bureau), and rural or remote populations.36 The agency also houses the Office of Health Equity, which works to reduce health disparities.
The Indian Health Service serves 2.6 million American Indians and Alaska Natives who belong to more than 500 federally recognized tribes in 37 states. The service is fully funded through the federal government.
The ACA created a legal requirement for nonprofit hospitals, which are exempt from paying certain taxes because of their charitable status, to conduct community health needs assessments together with community stakeholders to identify and address unmet health needs in their communities. This requirement is enforced through the Internal Revenue Service, and reporting must be made available to the public.37