Title: Inequalities 2005
1Inequalities - 2005
2 Some thoughts
- a scenario - (data)
- viewed from different mountain tops -
(analysis) - within the culture, values and norms of that
place (ideology) - become truisms (evidence)
3Statistics many views
4Interpretations
- 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
5Why bother?Equity and the layers
- A link with justice and fairness
- An egalitarian society
- Good for all
- Cost effective?
- A link to the Treaty
6Equity
- Equity of access
- Into the system
- Equity of process
- Through the system
- Equity of outcome
- Out of the system
- The definition used is critical
7Which population groups
- Maori
- Pacific Peoples
- Low SES
- Refugees and new immigrants
- Mental health patients
- Asian peoples
8The Cause
- Socioeconomic determinants
- Structure of society
- Biological effects
- Cultural effects
- Racism and privilege
- The inverse care law
- Other
9Root and Surface Causes
Williams 1997 AEP 7322-333
10Equity
- Equity of access
- Into the system
- Equity of process
- Through the system
- Equity of outcome
- Out of the system
- The definition used is critical
11Inequalities
- 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
12Who
- Maori
- Pacific Peoples
- Low SES
- Refugees
- The homeless
- Mental health patients
13The Cause
- Socio-economic determinants
- Structure of society
- Biological effects
- Cultural effects
- Racism and privilege
- The inverse care law
- Other
- Multiple confounders but.
14(No Transcript)
15Ethnic disparities - three levels
- Differences in access to the resources of society
- Differential access to health care
- Differences in quality of care received
16Distribution Gap
17Ethnic 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
18Ischaemic Heart DiseaseMortality 1996-99 and
Interventions 1990-99 Male standardised rates
per 100,000
Ajwani et al 2003 Tukuitonga
Bindman 2002
19Ethnic 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
20Differential 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
21How 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
22How 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
23Moving 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
24Moving 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
25Moving 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
26Examples of Maori research moving forward
- Changing mainstream paradigms
- The STOMP trial
- The PROMPT evaluation
- The Polypill trial
- Indigenous research collaboratives
27When is
- Enough is Enough
- Maybe when there is a 10 year gap in life
expectancy?
28Indigenous health disparities. A comparison
between New Zealand, Australia, Canada and the
United States.
29Overview of presentation
- Project outline and aims
- Methodology
- Results
- Discussion points and policy analysis
- Conclusions
30Project 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
31Aims
- 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
32Methodology
- 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
33Results 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
34Results - smoking
35Results - diabetes
36Results measles, mumps and rubella immunisation
coverage
37Results renal transplant
38Maori/non-Maori mortality risk ratio versus
Australian Indigenous/non-Indigenous risk ratio
Â
 Â
39Maori/non-Maori mortality risk ratio versus
AIAN/ White risk ratio
 Â
40Results health data quality
- Lack of ethnicity data collection
- Mortality datasets
- Treatment datasets
- Prevalence surveys
- Primary care
- Inaccuracy of numerator counts
- Inaccuracy of denominator counts
41(No Transcript)
42Policy - 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
43Policy - 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
44(No Transcript)
45Policy - 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
46Policy - 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
47(No Transcript)
48Policy - 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
49Policy - 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
50(No Transcript)
51Policy - 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
52Policy - 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
53Discussion
- Disparities exist across many indicators
- Largest in Australia and New Zealand
- Some disparities are not universal
- Disparities may not be intractable
54Discussion
- 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
55Discussion
- 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
56Discussion
- 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
57Summary
- 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
58Acknowledgements
- 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