Improving health equity in Australia: practical advice for those ready to act

A personal checklist for the time-poor clinician

In these times of health reform mired in complexity and politics, I found myself recently wondering where physicians with a particular concern about health inequities for rural and remote Australia, especially public health physicians like me dealing daily with their distribution and determinants, might turn for guidance.

Recalling plaudits in a book review in the Journal,1 I retrieved all three editions of the Oxford handbook of public health practice. The first edition in 2001 of the handbook2 was rightly praised for conceptualising public health practice in a fresh and imaginative way. Its second edition appeared in 2006, and was emphatic in admonishing that “people who dislike decisions should not become public health practitioners”.3 The third and current edition implores the reader “to leave the health of the public in a better state than you found it”.4 Each edition has included a chapter on health inequities — those of the first two were written by Anna Donald, the much-revered Australian-born advocate for evidence-based medicine who died before publication of the third edition.5

Framing the practical actions in each edition is the ability to distinguish between the forces beyond the health system that cause inequities and the factors within the health system. Using this distinction, the Box presents a personal checklist for clinicians who are time-poor yet curious, influential yet non-specialist in health inequities and rigorous in their scrutiny of evidence and ready to act when that evidence is sufficient.

Within our sphere of influence, the handbook invites intelligent and effective policies, incentives and regulations to ensure that health professionals and health services are distributed according to need. Another piercingly clear recommendation is to empower underserved groups experiencing unjust outcomes themselves to demand the health services they deserve. This means transparent investment in cost-saving primary health care as a buffer before expensive hospitals which, by default, become the facility of both first and last resort for the underserved when local options are limited by factors beyond individual control.6

Sensitising colleagues in non-health sectors to the relationship between what they do and the detrimental effect on health equity as an agreed outcome for society is argued strongly in each edition of the handbook. As the significantly higher death rates for women living in rural Australia are not explained by their behavioural risk factors,7 a singular policy obsession by governments to promote individualistic clinical preventive services is unlikely to make a difference in the absence of steady and substantive long-term strategies to improve environmental, social and economic conditions for women in the bush. When none of Australia’s 564 local government areas ranked in the lowest decile for socioeconomic advantage are located in either Victoria or the Australian Capital Territory, perhaps the physical location of national institutions developing such policies might be an important modifiable factor.

Action on local inequity needs support. A prototype of system-level standards already exists in the Systems Assessment Tool available as part of every One21seventy audit undertaken by primary health care services seeking to meet the needs of Australia’s most severely disadvantaged group — remote Aboriginal and Torres Strait Islander peoples (http://www.one21seventy.org.au/cqi-information/systems-assessment-tool). Dated 2000, the reference document establishing benchmark ratios for health professionals to community size now needs updating. Whether urban or remote, Primary Health Networks whose boundaries embrace especially disadvantaged populations in low-ranked local government areas need these standards. Armed with contemporary system-level standards to evaluate the quality, composition, interconnection and capacity of primary health care, an evidence-based understanding of local impediments consequent to central policies would follow.

High-impact medical journals could play a pivotal role for time-poor clinicians, publishing trends in key social and economic indicators by region to provide backgrounds for readers who are not expert in public health practice but are eager to join an informed, professional chorus for action on health inequities. As respected channels for credible evidence exchange, such journals might feature annual updates on key health system determinants that we can do something about, including distribution of and support for general practitioners, and the use of pragmatic trackers of health system performance in the critical sector of primary health care (for example, to monitor potentially preventable hospitalisations). Because doctors love to learn, is there a niche for well written primers about macroeconomics, industrial relations reform, social impact investing and community empowerment? Simultaneous publication of companion lay versions might create preconditions beyond medical and policy networks for what the World Bank terms community-based monitoring.8 All of these ideas are entirely compatible with the prescient recommendations for action on health inequities put forward in each edition of the handbook.