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HEALTH POLICY AND EQUITY

Good health is not guaranteed for all Australians. Policy must address issues of access and appropriate care so no one is left behind.

An evidence-based briefing by the Centre for Social Impact - April 2022

csi.edu.au/briefing-papers

The Centre for Social Impact (CSI) is a national research and education centre built on the foundation of four of Australia’s leading universities: UNSW Sydney, The University of Western Australia, Swinburne University of Technology, and Flinders University.

CSI’s purpose is to catalyse positive social change, to help enable others to achieve social impact. This is achieved through transformational research and education that is rigorous and purpose-driven, and by working with people, communities and organisations to grow their capabilities through research, education, and leadership development. Visit www.csi.edu.au for more information.

ACCESS TO FOOD, HEALTH CARE AND DISABILITY SERVICES ARE FOUNDATIONS TO GOOD HEALTH

Health inequity is the unfair and unequal distribution of healthy living throughout a population. Inequity mainly exists due to factors beyond individual choice and is influenced by the social demographic groups you are part of.

Australians who experience poverty report chronic health conditions at a significantly higher rate compared to the general Australian population.

Chronic health conditions are similarly higher in other socially marginalised groups, such as First Nations people, people from migrant and refugee backgrounds and people with a disability.

Receiving health care during COVID-19

The COVID-19 pandemic has shown that existing health inequities interact with policy concerns around unstable work, disability, aged care and autoimmune disease. Telehealth was a temporary measure that enabled health care during the pandemic and it has been largely successful in providing treatment while reducing the spread of COVID-19.

Before the pandemic, reform was urgently needed to make telehealth available to improve access to care. Barriers to telehealth access still exist for people who do not have enough phone credit, a reliable internet connection, the required phone or computer equipment, computer literacy, or an appropriate space (e.g. due to homelessness or overcrowded housing) to take the appointment.

These barriers to access are not specific to COVID-19 and need to be considered as telehealth has become a permanent option for receiving health care.

Affordability of allied health and specialist services

Even publicly funded health care remains unaffordable for many. Bulk-billing practices are rare, can involve long wait lists and public hospital outpatient services tend to limit access to publicly funded health care.

Fees for private health services are also often higher than Medicare rebates to the patient. This creates a significant barrier to seeking and receiving health care, particularly for people on low incomes.

Under a mental health care plan the rebate for an appointment with a clinical psychologist covers just under half the recommended standard fee. The out-of-pocket expense of $137 represents a significant proportion of income (e.g. 21.4%) for an individual receiving the fortnightly JobSeeker Payment ($642.70), yet they may be 3-4 times more likely to have a diagnosed mental health condition than the Australian general population.

Similarly, the out-of-pocket payments for specialist consultations can be $100-$300 or more, meaning that Australians, particularly those with chronic health conditions, comorbidities, and/or low incomes, often delay or go without appropriate care.

In turn, inadequate health care can result in poorer health outcomes and increased usage of already-strained public hospital services.

Equity in disability

People with disability are more likely to be denied access to mainstream and specialist health services. This is because there is a lack of an inclusive health workforce capacity, a prevalence of negative attitudes towards people with disability, and inaccessible health infrastructure, which creates inequities between people with and without a disability.

A major initiative for people with significant and permanent disability is the National Disability Insurance Service (NDIS). However access to services covered by the NDIS has not been equitable, with lower rates of utilisation occurring for women, First Nations people and people from culturally and linguistically diverse communities.

Food insecurity

At least 5% of Australian individuals and households experience long-term food insecurity due to income stress. This is experienced in as many as 80% of households experiencing acute financial hardship.

Along with the negative health and wellbeing impacts of food insecurity, seeking food assistance can also feel shameful or embarrassing. Although food assistance may meet immediate needs, the nutrition and service quality of the assistance can be suboptimal.

Relying on resourcing services that provide food assistance fails to address the underlying causes of food insecurity. There is currently a lack of coordinated focus both in government and the for-purpose sector on forging sustained pathways out of food insecurity.

POLICY THAT AIMS FOR EQUITY IS ESSENTIAL TO ENSURE A HEALTHY FUTURE FOR ALL AUSTRALIANS

Health policy has the potential to improve health inequities in Australia, but in many cases it has served to worsen them. Governments should develop policy that addresses structural or systemic causes of disadvantage and build upon the success of recent policies that improve accessibility.

Telehealth and COVID-19

The telehealth program shows promise in balancing health equity, providing medical treatment options for people for whom face-to-face treatment was unsafe or otherwise difficult. It also improves access for people with limited mobility, those who live in regional or remote areas, or lack transportation.

The program has been made permanent, and can be further refined to address health equity directly where need is recognised as most urgent. Support and training in digital literacy and inclusion should be continued, particularly for disadvantaged populations, as previously bulk-billed or low-cost health appointments now have added costs to the consumer (e.g. phone credit, devices).

Affordability of allied health and specialist services

Medicare benefits for allied health services and specialist medical practitioners need to be reviewed so that out-of-pocket expenses for care are affordable and low-cost for people with chronic conditions and/or on low-incomes.

Barriers to seeking and receiving appropriate care should be addressed through policy. Processing Medicare claims should be changed so that all patients only pay the gap. For many, paying the full service fee and waiting to receive the rebate is not possible. Increased wait times show the demand for bulk billing services and public care indicates that current funding and infrastructure is insufficient.

Regional and remote communities need additional, targeted support for mental health support including help-seeking and awareness, especially for young people. In regional areas, treatment and support beyond clinical care is a priority, as these initiatives can be locally supported, and may reduce the reliance on clinical care which may be difficult to access.

Alternative models of care, including the mental health care workforce, should be tested and evaluated for their impact on positive health equity outcomes.

Equity in disability

Equity in health service access and workforce capacity to provide disability services needs to be addressed through greater investment in health infrastructure and workforce skills, particularly with a focus on training and care that demonstrates respect for people with disability as experts of their own experience.

Within government, NDIS structures and procedures should be addressed to help link the work of central government agencies with local level non-government services.

For the NDIS to work best, it is essential that care services and availability best represent the needs of all NDIS participants regardless of financial or cultural backgrounds, gender and sexuality.

To address unequal NDIS service utilisation by women, the NDIA should develop and implement an NDIS gender strategy in partnership with women’s disability organisations. This intervention can improve health equity within the NDIS and demonstrates a commitment to addressing women’s health.

Food insecurity

Food relief policies and programs should ensure that access to food relief services can be done with dignity, offering choice and high nutritional value.

Interconnected or wrap around services also need to address the root causes of food insecurity – particularly the cost of living, and financial or employment instability.

WHAT CHALLENGES REMAIN?

Health inequities cannot be solved unless broader societal inequities are also addressed.

Health equity is related to other systems such as digital exclusion, disability inclusion and food access, and other structural factors that link to health equity include financial capability, cultural background and time resources.

Rather than requiring individuals to solve their lack of health care, governments should work to ensure that these systemic barriers are reduced or removed altogether, and that policy and system responses address the fact that those most in need (or in very high distress) may be less likely to find support that meets their needs.

With strong policy making, positive social gains are possible. Governments must move beyond the redesign of individual policies, to instead shape the government structures and processes that support the full implementation of these policies.

RECOMMENDED NEXT STEPS

The health care system needs to be inclusively designed to ensure those with the greatest need have access to health care and the foundations of health equity.

This can mean policy systems which aim to provide appropriate accessible care for marginalised groups including people from culturally and linguistically diverse backgrounds, First Nations, women, and people with a disability. Major reforms, like the NDIS, have provided the opportunity to redesign the way that health policy works to address inequities.

Monitoring and evaluating is key, in order to demonstrate the effectiveness of policy on seemingly intractable social problems. These evaluations need to ensure questions of equity are considered from the outset.

The COVID-19 pandemic has demonstrated that the health care system can change rapidly to allow telehealth services to reduce the risk of infection when accessing care.

Bold policy reform offers the opportunity for doing things differently. Existing inequities are socially created, partly because of policies that have excluded marginalised groups.

The policy response to the COVID-19 pandemic provides an example that rapid and decisive policy making can be achieved.

CSI RESOURCES/REPORTS

• Administering inequality? The National Disability Insurance Scheme and Administrative Burdens on Individuals
• CSI Homelessness Deep Dive
• Insights into Hardship and Disadvantage in Perth, Western Australia: The 100 Families WA Baseline Report
• Towards ‘Zero Hunger’: Improving Food Relief Services in Australia

AUTHORS

Eleanor Malbon, Graham Brown, Svetlana Bogomolova, Zoe Callis, Gemma Carey, Paul Flatau, Ian Goodwin-Smith, Celia Green, Lisette Kaleveld, Michael Kyron, Leanne Lester, Jane Lloyd, Catherine Mackenzie, Tahna Pettman, Erin Wilson.