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Concepts of Inequality

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Introduction
In this essay I will define the concepts of inequality, accessibility and community participation in health care. I will also discuss these concepts and explain their origins in relation to the Ottawa Charter and the Declaration of Alma Ata. Furthermore I will provide examples of how these concepts are being addressed in New Zealand health policy.

Inequality in Health
Discussion and Definition of the Concept Within New Zealand significant inequalities in health exist. The reasons for these inequalities are linked with socioeconomic status, ethnicity, gender and the geographical area in which people live. There is also statistical evidence which highlights the fact that Maori, Pacific Islanders and people from lower socioeconomic backgrounds are dying at a younger age and generally have poorer health than other New Zealanders (Ministry of Health [MOH], 2002).

The Reducing Inequalities in Health report (MOH, 2002) states that the primary causes of health inequality in New Zealand are directly related to the distribution of and access to resources such as income, education, employment and housing. The report also states that another major influence on this inequality in health is the difference in how and when people access health care services and how that care may differ between those receiving the services. This is also said to have a significant impact both on peoples’ health status and mortality rates. Primary health care services will focus on better health for a population, and actively work to reduce health inequalities between different groups.

The Treaty of Waitangi is a key document of Maori health which states that the Crown has an obligation to ensure Maori have a health status which is at least equal to that of non-Maori (WAVE, 2001). Unfortunately this is not currently the case. The mortality rate caused by potentially preventable health

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conditions such as SIDS, respiratory conditions, and infectious diseases for Maori children under the age of 14 is 83 percent higher than that of NonMaori (WAVE, 2001). This drastic difference brings to light the extreme inequality between Maori and the rest of New Zealand’s population. Although no single factor is to blame many Maori live in circumstances associated with an increased risk of poor health such as sub-standard over-crowded housing which can increase the likelihood of infectious diseases, respiratory problems and possibly even violence and sexual abuse. These circumstances must be addressed for improvement in Maori health to take place.

Historical Origins from Seminal Documents The Declaration of Alma Ata signed in 1978 is one of the most influential founding documents concerning primary health care, it identified the immediate and ongoing need to ‘protect and promote the health of all the people of the world’ (WHO, 2006). The Alma Ata set the world a goal, it declared that by the year 2000 all people should reach an adequate level of health which would allow them to live productive lives. This was to be achieved by collaboration, using the resources of the world to their full capacity and ensuring that primary health care was given the resources necessary to reach this objective. This goal, although seemingly farfetched, was a tool to navigate and direct governments toward health for all and the reduction of inequalities in health.

Examples from New Zealand Health Policy The current New Zealand health strategy has a strong focus on reducing the health inequalities facing New Zealanders today (King, 2004).The primary health care strategy (Ministry of Health, 2001) states that over the next ten years primary health care services will focus on better health for the population, and actively work to reduce health inequalities between different groups. There are 13 population health objectives which have been identified and these are the current focus of the Ministry of Health and of District Health

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Boards. Primary health care is seen as one of the five areas crucial to achieving the health care priorities and reducing inequalities that exist in the health of New Zealanders (King, 2004).

The first step in the health care strategy was the establishment of Primary Healthcare Organizations (PHOs). These PHOs were designed not only to reduce the cost of visiting the doctor to the individual, but also to contribute to the New Zealand Healthcare Strategy’s objectives of reducing the instances and the effect of cardiovascular disease, diabetes and to improve mental, oral and child health (King, 2004). The Ministry of Health recognizes that to achieve its health goals there must be collaboration not only within the health sector but with others such as the housing, education and social development sectors (ibid). This partnership between sectors is necessary to improve education, health literacy and living standards in addition to promoting the actions required to make these important changes possible.

Accessibility
Discussion and Definition of the Concept According to McMurray, (2007) the concept of accessibility in relation to primary health care is defined as the equal opportunity to access healthcare for all people, regardless of where they may live, their sex, race, religion or socioeconomic status. Within society there are those who are less able to access health care when the need arises. This may be due to any number of social, economic and environmental factors (ibid).

Social and economic factors which may hinder or prevent people from accessing health services are; low literacy skills, a general lack of health knowledge, financial status and also language and cultural differences. Environmental factors such as the lack of transport to and from facilities, phone access and physical distance to health amenities may cause a portion of people to be unable to access the healthcare necessary. This is true for many

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people living in remote or rural areas in New Zealand, as the health facilities are generally situated in more urban areas and often away from where they are needed most.

Historical Origins from Seminal Documents As stated in the Declaration of Alma Ata primary health care is essential in achieving health for all and must be made accessible to everyone (WHO, 2006). Health services in the past have often existed in areas in which they were rarely used. In many cases they have been imposed on developing countries or communities who were unlikely to use them (World Health, 1998). In 1973 the World Health Organization’s Director General, Marcolino Candua, called for action that would directly focus on asking the consumer what their priorities were so as to form health services which the people would be willing and able to access (World Health, 1998). The deficit in the accessibility of health services in New Zealand is of great concern. If people are unwilling or unable to access health services they are likely to suffer from health deficiencies. For this issue to be remedied the reasons for people not accessing health services must be identified and addressed accordingly.

Examples from New Zealand Health Policy King (2004) in the document on Implementing the New Zealand Health Strategy stated that the formation of Primary Health Organizations (PHOs) in July, 2002 assisted in tackling the financial difficulty a large portion of the population had in accessing primary healthcare services. Individual PHOs have also initiated strategies to combat other issues of accessibility. Dunedin’s Mornington PHO identified one of the major access issues in their area as transport to and from medical centers, this was overcome to an extent by the implementation of a pick-up and drop-off service for those who were finding it difficult to make it to their medical appointments. Also many PHOs around the country identified and addressed the matter of a language barrier by employing the services of interpreters to ensure migrants and refugees are able

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to access primary health care services (ibid). These accomplishments, along with many others, are specific to the needs each of community. Although the issue of access is still a significant problem, if communities and healthcare providers are able to work together the barriers restricting access will continue to be recognized and remedied.

Community Participation
Discussion and Definition of the Concept The concept of community participation is a vital principal of primary health care and of health promotion. It promotes empowerment of the people who form the community to take control and actively define what they consider to be their health priorities (McMurray, 2007). For community participation to be an option the people of the community must first be aware that they have opportunity to become involved. With this knowledge individual members of the community can then decide whether or not they wish to participate (McMurray).

Health Promotion is an approach for improving the health of the population by supplying individuals and communities with the tools to make informed decisions about their well-being (WHO, 1986). Health Promotion looks beyond simply treating illness and injury, it looks at all determinants which effect health, the social, physical, economic and political factors. There is a strong focus on intersectorial collaboration, calling for policy makers across all sectors to consider the implications of how their policies may either directly or indirectly affect health (WHO, 1986). With the empowerment of communities to participate in making the decisions which will impact them, policy makers have no choice but to listen to the needs and concerns of the people.

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Historical Origins from Seminal Documents The Declaration of Alma Ata established that people have a right and obligation to take part in the planning and execution of the health care of their community (WHO, 2006). The Ottawa Charter for Health Promotion built upon this concept with a focus of enabling people to gain increased control over their health (World Health Organization [WHO], 1986). For this to happen health services must move toward a partnership which involves the community as it clear that this is imperative in the pursuit for health. People from all backgrounds must be involved in health planning and implementation so that health promotion strategies can be adapted to fit the needs of the people in each community (WHO, 1986). This is an essential component if our aim is to achieve equity in health.

Examples from New Zealand Health Policy The new vision of the Primary Health Care Strategy, to be achieved over the next five to ten years, is to include people of the community in the governing of their local primary health care services. The aim of involving communities in the governing of these services is to ultimately improve the health of the community and keep people well. This will also help to determine what the needs of the community are and make the services increasingly accessible (Ministry of Health, 2001). This focus will see the communities themselves defining where funding is best spent and the actions and services needed to achieve health for their population. Making Primary Health Organizations accountable not only to the Ministry of Health and the District Health Boards, but also to the public for the standards they aim to achieve will help to build trust. This is an important step in removing barriers which exist between the community and health care providers.

Conclusion
In conclusion, I believe that with such solid and powerful documents as the Alma Ata and the Ottawa Charter behind us, New Zealand is on the right path

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to resolving the health issues of inequality and accessibility on a local level. Although there is still a significant gap between the haves and the have not’s, with increasing community participation and the formation and implementation of PHOs we are slowly moving toward that ultimate goal of health for all.

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References

King, A. (2004). Implementing the New Zealand Health Strategy. Retrieved April 11, 2007, from http://www.moh.govt.nz/moh.nsf/0/2145C3597FBDDE80CC256F63000
HTU

D12DA/$File/implementingthenzhs2004.pdf
UTH

McMurray, A. (2007). Community Health & Wellness: a socio-ecological approach (3rd ed.). Sydney: Elsevier.

Ministry of Health. (2002). Reducing Inequalities in Health retrieved March 20, 2007, from http://www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c2566a40079ae6f
HTU

/523077dddeed012dcc256c550003938b/$FILE/ReducIneqal.pdf
UTH

Ministry of Health. (2001). The Primary Health Care Strategy Retrieved March 21, 2007, from http://www.moh.govt.nz/moh.nsf/0/7BAFAD2531E04D92CC2569E600
HTU

013D04/$File/PHCStrat.pdf
UTH

WAVE (Working to Add Value through E-information). (2001). From Strategy to Reality – The Wave Project. Retrieved April 20, 2007, from http://www.moh.govt.nz/moh.nsf/0/F34F8959738E992CCC256AF4001
HTU

77998/$File/TheWAVEreport.pdf
UTH

T

World Health. (1998). Back to basics: The shift to primary health care.
T

Retrieved April 11, 2007, from Health Module database.

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World Health Organisation. (2006). Declaration of Alma-Ata, 1978. Retrieved March 20, 2007, from http://www.euro.who.int/AboutWHO/Policy/20010827_1
HTU UTH

World Health Organisation. (1986). Ottawa Charter for Health Promotion. Retrieved March 20, 2007, from http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
HTU UTH

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