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Social Inequalities: do they matter to healthcare managers? Print E-mail
The Quarterly 2011


This article was written by Dr Susan Keam, derived from material presented by Professor Sian Griffiths on 5 September 2010 at RACMA/HKCCM 2010.

"Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them from becoming ill or treat illness with it occurs. Within countries, the evidence shows that in general the lower an individual's socioeconomic position the worse their health. This is a global phenomenon."
Margaret Chan ("Closing the gap in a generation”, WHO Commission on Social Determinants of Health")

Social Determinants of Health

Equity in health is about ensuring that poorer and vulnerable people in our communities have the opportunity and fair chance to reach the maximum health that they can achieve. How we provide medical services can play an important role along with the other factors highlighted in the well known diagram from Dahlgren and Whitehead (1991).i Socioeconomic, educational, cultural and environmental factors all interact, and are important for maintaining good health. This is something that needs to be remembered by hospital based staff; for example, when they discharge patients to the community, poor housing can be the cause of a patient soon ending up in hospital again.



Figure 1: The social determinants of health
(Source: Dahlgren and Whitehead, 1991)

Many of us are familiar both with the WHO report "Closing the Gap in a Generationii as well as with Sir Michael Marmot's "Strategic Review of Health Inequalities in England, Post 2010 - Fair Society, Healthy Lives" iii, which provided an evidence-based strategy for achieving better equity in health through specific policies and interventions to address the social determinants of health.

That social conditions have a direct relationship with health is not new. The sanitary reformers of the nineteenth century were well aware of the importance of work, housing and living conditions. Countries such as the UK have actively pursued policies to reduce inequalities, based on facts such as mortality due to circulatory diseases correlating strongly with the extent of social deprivation - both are higher in the north of England than in the southern counties. Likewise, in London, each tube stop east of Westminster represents nearly one year of life expectancy lost (see figure 2), reflecting levels of social deprivation of local populations.


Figure 2 Life expectancy in different geographic and socioeconomic areas of London
(Source: London Health Observatory using Office for National Statistics Data)

Ethnic and cultural factors are also important. For example, in the UK, there is an increased risk of diabetes in the Black Caribbean and South Asian populations compared with the Chinese and general UK population, while the risk of Cardiovascular Disease is higher in the general and Irish populations than in the Chinese population.

Similar ethnic differences in disease prevalence are also seen in the US, where diabetes is more prevalent in the poorer Black and Hispanic/Latino populations than in the wealthier White or Asian populations. In Australia, WHO data show that Aboriginals have higher infant mortality and more drug abuse and alcoholism than the rest of the population, are three times more likely to contract diabetes and twice as likely to suffer heart disease between the ages of 35 and 44. Aboriginal health conditions have been likened to those of the developing world.iv

While some of the risk of illness in these examples may be genetic, some are definitely environmental (the socioeconomic conditions in which people are living, government policies, and the way that we deliver health services), and it's important that in public health we understand the combination factors of gene-environment interaction and the differential health needs. According to the Inverse Care Law, the availability of good medical or social care tends to vary inversely with the need of the population served. Julian Tudor Hart (1971)v showed this in a Welsh village setting, and it's also seen internationally. Figures from the World Bank show that in 2005, the lowest income quintile population received less benefit than the highest income quintile in 15 of 21 countries surveyed, while in 2 countries they received the same benefits and in 4 they received greater benefits. So, inequalities are an international, global phenomenon, and there are things the healthcare system can do, and things that we as public health and medical management leaders can do.

The Role of Healthcare Systems in Health

Healthcare systems not only cure disease, but also promote health. A healthcare system can have different roles regarding the social determinants of health, depending on the level (macro, meso or micro) they operate at. For instance, at the macro level the role of a healthcare system is through public policy and equitable resource allocation processes, at the meso level (the community) it is through performance of the decentralized policy, and at the micro level it is through factors related to the organisation of the health care system (physical, financial, psycho-social, cultural and administrative access) as well as factors related to the health care provider (skills, knowledge, approach to the patient). vi

Macro Level

Political commitment is needed to implement policy to reduce inequity. For example, in the United Kingdom this is reflected in a national programme to tackle inequalities: "Healthy Places, Healthy Lives".vii In Australia, the Office of Aboriginal Health, Government of Western Australia has an emphasis on cultural respect and cultural health, and this is reflected in the WA Health Aboriginal Cultural Respect - Implementation Framework.viii In China, there is a policy of redistribution of health resources from urban to rural settings in the New Rural Cooperative Medical Care System.

Having commitment to equitable resource allocation is very important. A study we conducted here in Hong Kong found that having secondary or below education and a lower income was associated with a poorer experience by patients during general outpatient clinic use in Hong Kong.ix This is also a common finding in other parts of the world. These results voice a need for redistribution of resources to achieve equity, possibly through means of subsidy.

Meso Level

Policy involvement at meso level relates to the role in the community, with emphasis on civic engagement and the role of healthcare institutions. We need a change in the way we think about hospitals. They are not just places people go when they are sick, but they also have a role in the community. Ideally we need to keep people out of hospital and in the community, but hospitals are important institutions within communities not least because they provide employment to the local population. Health promoting approaches by hospitals will therefore impact on the health of their local communities.

Here in Hong Kong, our smoking cessation service is an example of community engagement by healthcare institutions. Smoke Cessation Services include a Quit Line, Smoke Cessation community clinics and Smoke Cessation Information.x

The programme is an example of advocacy, of engagement of primary care for smoking cessation and of hospitals as exemplars of no smoking environments. There is a partnership at a community level between all Smoke Cessation Services providers - the Department of Health, the Hospital Authority, NGOs, the University and private practitioners and private hospitals.

Micro Level

At the micro level, policy involvement relates to the micro-organisation of health systems and their organisations. One of the biggest issues we as managers need to think about is access for the disadvantaged. From a health system organisation perspective we need to increase physical, financial, psycho-social, cultural and administrative access to the disadvantaged. We also need to look at the attitudes and awareness of providers, with a need for education about inequities and their impact on health and empowerment of staff to address remedial factors.

Of interest, a survey in Hong Kong found that people with chronic non-communicable diseases did not currently have a family doctor and were mainly of lower socioeconomic status than those with a family doctor. They also had a perception that a family doctor was something of a 'luxury item' for the wealthy and not within the financial reach of the bulk of the population in Hong Kong xi.Thus there is a need to make primary care acceptable, accessible, and affordable to all, especially those in need.

The WHO agenda for primary health care has improving health equity as one of its core values, and as one of the four platforms for reform. xii Primary healthcare is the building block of healthcare systems, and hospitals need to engage with primary care physicians to find out what services are important to them. Primary healthcare reforms are necessary to refocus health systems towards Health for All. The rationale for the benefits of focusing on primary care for health include greater access to needed services, better quality of care, a greater focus on prevention, early management of health problems, the cumulative effect of the main primary care delivery characteristics, and the role of primary care in reducing unnecessary and potentially harmful specialist care.

From the WHO Western Pacific Region perspective of "Now More Than Ever", the four goals of a health system are xiii:

  1. Health - both the absolute level across the entire population and equity across socioeconomic groups
  2. Social and financial risk protection in health
  3. Responsiveness and people-centeredness
  4. Efficiency

And the key issues that comprise the six building blocks to achieve this are:

  1. Leadership and governance
  2. Health care financing (incentivising equity)
  3. Health workforce
  4. Medical products and technologies
  5. Information and research
  6. Service delivery - integrated service delivery packages at multiple levels adapted to socioeconomic reality, patient safety and infrastructure

A UK example of where policy implementation has successfully focused on reducing inequalities is The Coronary Heart Disease National Service Framework (CHD NSF).xiv The NSF set goals and targets for primary care physicians and hospital clinicians, and together they have worked to achieve the improvements in circulatory deaths. Inequalities in the death rate from heart disease, stroke and related disease among the under-75s has narrowed throughout the NSF years. Measuring the difference between the worst fifth of areas in the country for health and deprivation (the spearhead primary care trusts [PCTs]) and the national average has shown that the absolute gap has reduced by 35.9% between 1996 and 2007 (see figure 3). Despite some factors getting worse (risks associated with obesity, diabetes and less physical activity), the overall outcome was achieved by significant reductions in other risk factors (e.g. smoking, cholesterol levels, population blood pressure, and social deprivation) and better management of cardiovascular diseases (e.g. acute MI, heart failure).

As medical managers, our role is not just about health promotion , it's also about what clinicians and managers as leaders in hospitals do - if we are not looking at outcomes and how risk factors and treatments fit together to achieve them, we are not going to see successes such as those achieved by the NSF. It shows that by addressing the inequalities gap, especially in the non-communicable diseases where we know inequalities exist, we can make a positive difference.


Figure 3 Impact of The Coronary Heart Disease National Service Framework on reducing the gap in circulatory
death rates between the average and worst of areas for health and deprivation in the United Kingdom
(Source: CHD NSF)

So, what can medical managers contribute to reducing social inequality? We can look at the areas highlighted by the WHO report and think about:

  • Our leadership role in intersectoral action
  • Our engagement with the population and civic society on how healthcare is provided, promoting patient-centred care
  • Ensuring services provide universal coverage
  • Distributing resources according to need through financial and organisational policies
  • Monitoring and evaluating services for their impact on inequity, and
  • Strengthening community based primary care.

Professor Sian Griffiths
Professor of Public Health
Director, School of Public Health and Primary Care
The Chinese University of Hong Kong

iDahlgren G. & Whitehead M. (1991). Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies (Report).
iiCommission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health organization.
iiiMarmot M. (2010, February 11). Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010 (Marmot Review).
ivDart J. Australia's disturbing health disparities set Aboriginals apart. (2008, April). Bulletin of the World Health Organization, 86(4), 245-47.
vTudor HJ. (1971). The inverse case law. The Lancet, 1(7696), 405-12.
viCommission on Social Determinants of Health. (2007, April). A Conceptual Framework for Action on the Social Determinants of Health. Geneva: World Health Organization.
viiNational Health Service (NHS). (2011). Healthy Places, Healthy Lives.
viiiGovernment of Western Australia. Office of Aboriginal Health, Department of Health. (2005). WA Health Aboriginal Cultural Respect - Implementation Framework.
ixWong S.Y.S, Kung K., Griffiths S., Carthy T., Wong M.C., Lo S.V., Chung V.C., Goggins W.B., & Starfield B. (2010, July 6). Comparison of primary care experiences among adults in general outpatient clinics and private general practice clinics in Hong Kong. BMC Public Health, 10:39.
xTobacco Control Office. Department of Health. The Government of the Hong Kong Special Administrative Region of the People's Republic of China.
xiMercer S.W., Siu J.Y., Hillier S.M., Lam C.L.K., Lo Y.Y.C., Lam T.P., Griffiths S. (2010, June 4) A Qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong. BMC Family Practice, 11(1):46.
xiiWorld Health Organization. (2008). Primary Health Care: Now More Than Ever. (The World Health Report 2008). Geneva:WHO.
xiiiWHO Western Pacific Region. (2010). Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care. Geneva: World Health Organization.
xivUK Department of Health. (2000, March 6). Coronary heart disease: national service framework for coronary heart disease - modern standards and service models. (Guidance document). United Kingdom.

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