This paper focuses on the wellsprings of health equity in social policy, pointers of inequity, and how two national contexts and approaches to education effect better health outcomes. In particular, the paper investigates the most important manifestation of health inequity for Australian Aborigines. There being no such racially-oppressed minority in the Philippines, progress toward Millennium Development Goals becomes the framework.
The two countries subject of this paper are by no means woefully poor. Australia counts among the members of the Organization for Economic Cooperation and Development (OECD), the select club of nations that are wealthier than the rest. A Southeast Asian neighbour, the Philippines, remains among the middle-income countries but certainly leagues above the abject poverty endemic to South Asia and most of Africa.
Universal health as social good is critical to modern government policy. It is also mandated by international treaty. The World Health Organisation (WHO, 2010) has opined that, beyond hiring enough health care staff and dispersing the requisite facilities, bringing about universal health demands action on the social, political, economic and even spiritual contexts that aggravate health and contribute to the continued prevalence or spread of disease. Hence the policy statement that:
The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. (WHO, 2010, para. 1)
Concerned about health inequity, WHO set up the Commission on Social Determinants of Health. The Final Report, issued in 2008, called for action on two broad categories of social determinants that relevant to this analysis. The first is a call for “improving living conditions” – A call to action around compulsory primary and secondary education, affordable housing, potable water, general sanitation, nutrition, wholesome physical activity, full employment, fair labour practices, cradle-to-grave social protection, and universal health care. The second comprises a challenge to more equitable distribution of power, resources and funds – including such matters as allotting a fixed percentage of GDP for development aid to poorer nations, gender equity, accounting for the economic value of housework, progressive taxation and for health equity itself to be a perennial marker of good governance (CSDH, 2008).
Under the auspices of the United Nations Development Programme (2010), in addition, all 192 members of the UN have bound themselves to attain eight development goals by 2015. Three of these have to do with health indicators as signals of a better quality of life: a) Goal 4 mandates reducing child mortality by two-thirds; b) Goal 5 aims to roll back maternal mortality ratio by 75% from 1990 baselines; and, c) Goal 6 aspires to halt the spread of HIV/AIDS in all vulnerable populations, grant universal access to treatment for this syndrome, and reverse the still-rising prevalence of malaria (amongst children) and tuberculosis (for the general population).
And yet, for all the good intentions of government, citizens are free to act or not, notably in respect of adhering to disease-prevention lifestyles or cooperating with government in such health service initiatives for disease eradication as immunisation. Attitudes about maintaining health may be slack, the distance to primary health care facilities too great, money to fill prescriptions scarce, attitudes of primary care personnel intimidating, and concern about apparently-trivial symptoms misplaced. There are any number of social determinants round national health service outcomes that result in inequities. For the purposes of this paper, one investigates unequal access under the Australian Department of Health and Ageing and draws comparisons with a developing nation in Southeast Asia, the Philippines.
As with much else in political systems and governance, both nations owe their basic health service structure to former colonizers: the UK for Australia and the USA for the Philippines. In the case of Australia, (Berridge, 2008) makes one realise how historical precedent in the UK continues to shape the discourse on health service and universal access even in contemporary times. The author considers the emphasis of the UK’s National Health Service on free service since inception in 1948 and labour unionist Nye Bevan’s “serenity” of health care at need the very bedrock of universal health care (Milburn, 2002). In this century, the discourse in the UK has also been shaped by promoting healthier lifestyles as a new cornerstone of NHS policy (Blair, 2006). As well, succeeding Ministers of Health argued to revive the mutualism tradition of Bevan and the Tories to make comprehensive health care a reality by permitting the establishment of primary and even tertiary care facilities owned by foundations, local communities, religious and mutual organisations (Blears, 2003; Reid, 2003).
In the Australian context, the Department of Health and Ageing (2010c) articulates its vision as “Better health and active ageing for all Australians”. Owing to the sheer size and low population density of the continent, one of the most obvious health service gaps is evident in poor coverage of those residing in rural areas. For this sector, DHA furnish funds to attract general practise physicians via Rural Health Workforce Australia (RHWA, the national coordinating body) and directly to the Rural Workforce Agencies. Communities where at least five percent of population reside in rural and remote areas qualify for this subsidy, associated training and other incentives (Department of Health and Ageing, 2010b). A second inequity comprises those who increase their health risks, perhaps unknowingly, by dependence on, or abuse of, alcohol, marijuana and addictive, psychoactive drugs (Australian Institute of Health and Welfare, 2010). Yet a third, qualitative inequity is the waiting time patients must endure for elective procedures in a needs-based universal health system. Since public health services can never deploy enough resources to attend immediately to non-acute and non-emergency patients, DHA have seen fit to encourage, and partner with, the private sector (Department of Health and Ageing, 2010c).
DHA address other health coverage gaps, crucially in the area of preventive medicine. In common with other nations boasting advanced health care systems, for instance, there is an ongoing campaign to induce more women in elevated-risk age cohorts (50+ years) to submit voluntarily for breast cancer screening, i.e. mammography. Sharing as it does the egalitarian philosophy of the UK NHS – particularly in respect of comprehensive health care – the present-day Department of Health and Aged Care (DHAC) must also see to diversity since the department gained responsibility for Aborigines and Torres Strait Islanders around 1997. There are many troubling inequities where the Indigenous population is concerned, a glaring one being that life expectancy has remained about where it was since 1900, when health authorities first began to keep reliable records. In contrast, life expectancy increased at least 50 percent for the mainstream White population, from 52 to 74 years for men and 55 to 81 years for females. With the benefit of hindsight. DHA can admit that the culprit was racism (Department of Health and Ageing, 2010a).
Conceding that “Better health…for all…” is a difficult enterprise, there are extant health gaps and inequities in Australia. At last count (Australian Bureau of Statistics, 2009), 15% of the population 15 years or older rated their health “fair” or “poor”, unchanged from the 2004–05 National Health Survey. No less than three-fourths of Australians claimed to suffer from at least one chronic disorder. Smoking incidence has shrunk but the proportion of those overweight or obese was higher than ever, likely owing much to the fact that the propensity for exercise was static. As well, “risk-level” alcohol consumption was unchanged.
The nadir of inequity for health and other social services has to be the Indigenous population. Though making up just 2.4% of the population (455,000 people, Australian Bureau of Statistics, 2007), Aborigines and Torres Strait Islanders deserve to be treated more humanely.
The Philippines is a democratic, Western-oriented republic in the South China Sea, between Borneo and Taiwan/Republic of China. This archipelago of some 7,107 islands has a total population of 92 million (more than four times that of Australia) and per-capita income based on parity purchasing power of just $3,520 per annum (less than one-tenth that of Australia: $38,910). The country ranks in the middle globally, so far as the Gini ratio (equality of income distribution) is concerned. Among the benefits Filipinos gained from 340 years of colonization by Spain and a half-century under the United States are a strong ethical role for the Catholic Church, a superb network of private and public schools up to the postgraduate level, a functional literacy rate of about 84 percent, English as the second language, and a widespread propensity for American movies, music, books, magazines and Web sites. As to the Millennium Development Goals, it appears that the Philippines is slightly below average in the drive to control child mortality, ensuring at least basic antenatal care, access to trained professionals at delivery, and maintaining markers of primary and secondary enrolment but has made swift progress in managing infant mortality and has the puny HIV prevalence well in hand.
The Praxis of Education to Combat Health Inequities
Given the many health service gaps and sources of health inequity, it stands to reason that education can take many forms. On a global scale, education is a crucial centrepiece of health outcomes. It is among three more of the aforementioned Millennium Development Goals considered essential to improved health status for all since Goals 1 through 3 call on governments to a) eradicate extreme poverty and hunger; b) achieve universal primary education, and, c) empower women (primary caregivers for their children), notably by promoting gender equality (UNDP, 2010, paras. 4 to 6).
The Philippines shows that one route for education to redress health inequity is, bearing mothers as caregivers in mind, embarking on multi-media campaigns to motivate attendance for free infant and child immunisation, available at all health centres nationwide. Since the mid-1980s, a succession of cost-free “Expanded Programmes on Immunisation” have been carried out to target such causes of infant and child mortality as vitamin A deficiency, measles, influenza and polio. Annual and seasonal campaigns run on national TV, radio, print, outdoor posters, and door-to-door drives conducted by health centre doctors, nurses and midwives. Within the limit of developing-nation status where poverty remains substantial and fiscal deficits chronic, helping redress health inequity is unequivocally central to governance. So are social marketing campaigns that motivate otherwise poorly educated mothers to take action in the face of complacency and ignorance.
In the Northern Territories, Aboriginal infants from four weeks to one year of age are subject to multiple disadvantages: official neglect, displacement because of the rich uranium deposits in the region, poor parental education, unsanitary and crowded living conditions. On carrying out a meta-analysis, McDonald et al. realised that such inequities were strongly associated with a six-fold prevalence in “hospitalisation for respiratory, diarrhoeal and parasitic diseases” (2008, p. 2) compared to other Australian infants. Interventions such as community education, soap distribution and encouragement to wash hands, among others, helped to halve the incidence of diarrhoea.
Conclusion
The quote from CSDH that initiated this essay has been borne out by an examination of evidence not only from the WHO-sponsored report but equally from third sources such as the Australian DHA and, in respect of a nearby Southeast Asian nation, progress toward the Millennium Development Goals five years hence. Clearly, even the disadvantage of formal education that plagues Indigenous Australians can be redressed by community outreach for proactive testing at primary care, mass media and outdoor advertising campaigns, all in the name of redressing the serious inequity of life expectancy disastrously shorter than the rest of Australia.
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