To the Editor: In response to Leeder,1 there is no community in this world that can provide free, at the point of contact, healthcare for all its citizens to the current limits of modern medical technology. This problem will in fact become greater as the technology increases and becomes more expensive.

Within the available healthcare resources, there is some medical treatment that is essential and there is some that is quality-of-life treatment; where the two merge depends on one’s point of view.

If you choose to play sport and injure your knee, the question of who should pay for the treatment arises. If you smoke or have any other lifestyle risk factors, how much should be funded by you, and how much by others? And, within a healthcare system where there is patient contribution, does this contribution empower and encourage individuals to adopt a healthy lifestyle?

In essence, I believe the debate in healthcare should be about accessibility of limited resources. Who draws the line, how is the line drawn, and at what level is it drawn?

Pouring money into the public health sector may well parallel the analogy of adding another lane to the motorway. We must be careful to share the responsibility of healthcare between the individual and the healthcare providers in an inclusive and not exclusive manner.

To the Editor: Leeder rightly points out that increased funding of the healthcare system does not necessarily result in improved equity within the health system or better health outcomes for the population.1 This challenges us to develop ways of systematically examining how current healthcare practices either increase or decrease equity. The following two Australian initiatives illustrate how we might work to achieve equity in health — that is, provide opportunities for all Australians to achieve their full health potential.2

Clinical practice guidelines (CPGs) are one mechanism frequently used to facilitate improvements in the quality of clinical practice and healthcare. However, the evidence on which CPGs are based often excludes, or does not consider, the needs of relatively disadvantaged populations.3-5 Recognising this gap, the Health Advisory Committee of Australia’s National Health and Medical Research Council published a handbook for developers of guidelines about ways to access, review and collate evidence of the effect of socioeconomic position on health, and apply that evidence when developing CPGs.5,6

At the policy level, Health Impact Assessment (HIA) is gaining increasing recognition as a tool for assessing the potential effects of a policy or program on health. Health Impact Assessment that systematically addresses equity may also offer a way of incorporating equity concerns into the decision-making process. However, HIA is a comparatively new field, and decision makers are not usually trained in assessing the impact of policy decisions on equity. Through the Public Health Education and Research Program, the Australian Government has commissioned the development of an HIA framework to assist decision makers in systematically identifying potential health equity impacts of policies. This equity-focused HIA framework is currently being tested (through case studies in Australia and New Zealand) to assess whether and where it adds value to the decision-making processes.

These two examples illustrate practical ways in which decisions by practitioners and policy makers can routinely incorporate equity issues in the Australian healthcare system. Ongoing investment and commitment is required to evaluate whether such initiatives make a real difference in achieving equity in health.