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I'm interested in this topic because I want to find out more about how people get and afford healthcare in the world.

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The pandemic and other ongoing crises are hindering progress in achieving SDG3, exacerbating existing health inequalities and threatening progress towards universal health coverage. As a result, 68 million children are known to be un- or under-vaccinated as of 2022 from TB and malaria increased. This has been particularly challenging in low- and middle-income countries, where health systems were already under-resourced before the pandemic. The pandemic has also highlighted the need for stronger global health security systems to prevent and respond to future pandemics. Overcoming these setbacks and dealing with longstanding shortcomings in health-care provision requires an urgent strengthening of health systems.

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Goal 3 | Department of Economic and Social Affairs

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Ensure healthy lives and promote well-being for all at all ages

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I think it would be really interesting to deep dive into how to prevent or help refugees and people in need of safety. I'm also interested in researching human trafficking and solutions to bring it to an end.

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Goal 16 | Department of Economic and Social Affairs

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Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

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Goal 3: Ensure healthy lives and promote well-being for all at all ages — SDG Indicators

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Goal 3: Ensure healthy lives and promote well-being for all at all ages - Sustainable Development Goal Indicators

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"Overall, 16.9% of Americans report at least 1 financial barrier"

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In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a…

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"Fifty-one percent of working-age Americans struggle to afford their health care and about one of three (32%) are saddled with medical debt, according to findings from a Commonwealth Fund survey released today."

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.commonwealthfund.org/sites/default/files/2023-10/Collins_2023_AffordabilitySurveyTopline_PR_10-26-2023_v2.pdf

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"How many countries have free healthcare? All but 43 countries in the world have free healthcare or access to universal healthcare for at least 90% of their citizens according to Hudson's Global Residence Index. However, Brazil is the only country in the world that offers free healthcare for all its citizens."

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An overview of countries that offer free healthcare

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As a global organization, it is essential to be fully equipped with all the necessary information on countries that offer free healthcare.This article highlights comprehensive information on countries that offer free healthcare and benefits that apply to visitors and foreigners.

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"Even before the pandemic, half a billion people were being pushed (or pushed still further) into extreme poverty because of payments they made for health care."

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More than half a billion people pushed or pushed further into extreme poverty due to health care costs

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New evidence compiled by the World Health Organization and the World Bank shows that the COVID-19 pandemic is likely to halt two decades of global progress towards Universal Health Coverage.

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"Universal access to health and universal health coverage imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services does not expose users to financial difficulties, especially groups in conditions of vulnerability."

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Universal access to health and universal health coverage imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services does not expose users to financial difficulties, especially groups in conditions of vulnerability.

Universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and promote a society-wide commitment to fostering health and well-being. The right to health is the core value of universal health coverage, to be promoted and protected without distinction of age, ethnic group, race, sex, gender, sexual orientation, language, religion, political or other opinions, national or social origin, economic position, birth, or any other status.

On average, about one-third of people in countries of the Americas (29.3%) reported forgoing needed care due to multiple access barriers.

Of those who reported forgoing needed care, 17.2% attributed their decision to organizational issues (i.e. long waiting times, inappropriate hours of operation, cumbersome administrative requirements).

Financial barriers were reported in 15.1% of cases, inadequate availability of resources (i.e. health personnel, medicines, and inputs) was cited in 8.4% of episodes and geographic barriers in 5.4% of cases.

Importantly, 8.0% attributed their decision to acceptability issues (i.e. language barriers, lack of trust in health personnel, or being mistreated by personnel, preference for traditional and indigenous medicine).

People in the poorest wealth quintile were more likely to experience barriers related to acceptability issues, financial and geographic access, and availability of resources.

* Source: Leveraging household survey data to measure barriers to health services access in the Americas

Despite the advances made the Region remains one of the most inequitable in the world. The process of reducing health inequities is made more complex by the new epidemiological and demographic patterns that require different and innovative responses from health systems and services; and that problems of exclusion and lack of access to quality services persist for large sectors of the population in the Region, especially those groups in conditions of greatest vulnerability. Recognizing that there are many ways to achieve universal access to health and universal health coverage and that each country will need to establish its own action plan, taking into account its social, economic, political, legal, historical, and cultural context, as well as its priorities and current and future health challenges, the proposed strategic lines are intended for use by the Member States

1. Expanding equitable access to comprehensive, quality, people- and community-centered health services.

2. Strengthening stewardship and governance.

3. Increasing and improving financing, with equity and efficiency, and advancing toward the elimination of direct payments that constitute a barrier to access at the point of service.

4. Strengthening multisectoral coordination to address the social determinants of health that ensure the sustainability of universal coverage.

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Universal access to health and universal health coverage imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate and timely, quality health services determined at the national level according to needs, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services does not expose users to financial difficulties, especially groups in conditions of vulnerability.

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AFRICA

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Abstract

Introduction

Healthcare systems in Africa suffer from neglect and underfunding, leading to severe challenges across the six World Health Organization (WHO) pillars of healthcare delivery. We conducted this study to identify the principal challenges in the health sector in Africa and their solutions for evidence-based decisions, policy development and program prioritization.

Methods

The study was conducted as part of a recent African Epidemiological Association Meeting in Maputo, Mozambique with participants drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Participants were divided into 10 groups, consisting of 7 to 10 persons each. Brainstorming approaches were used in a structured, modified nominal group process exercise to identify key challenges and strategies to mitigate healthcare service challenges in Africa. Identified challenges and solutions were prioritised by ranking 1-5, with 1 most important and 5 being least important.

Results

The first three challenges identified were inadequate human resources (34.29%), inadequate budgetary allocation to health (30%) and poor leadership and management (8.45%). The leading solutions suggested included training and capacity building for health workers (29.69%), increase budgetary allocation to health (20.31%) and advocacy for political support and commitment (12.31%).

Conclusion

The underdeveloped healthcare systems in Africa need radical solutions with innovative thought to break the current impasse in service delivery. For example, public-private initiatives should be sought, where multinational companies extracting resources from Africa might be encouraged to plough some of the profits back into healthcare for the communities providing the workforce for their commercial activities. Most problems and their solutions lie within human resources, budget allocation and management. These should be accorded the highest priority for better health outcomes.

Keywords: Africa, healthcare management, human resources, health systems

Introduction

Globally, countries are faced with health system problems which vary from one to the next. While health service delivery challenges are more often seen in countries with a very high Human Development Index (HDI), human resources challenges attract more attention within those with a low HDI.¹ Healthcare systems in Africa have, over the years, suffered from man-made issues which cut across institutional, human resources, financial, technical and political developments. With this in mind, the World Health Organization (WHO) in 2007 proposed a framework that describes healthcare systems in terms of six core components or "building blocks": i) service delivery; ii) healthcare workforce; iii) healthcare information systems; iv) medicines and technologies; v) financing; and vi) leadership/governance.² The majority of African countries are unable to meet the basic requirement for good healthcare systems. Poor governance and human resource challenges are linked to ineffective integration of services in resource-limited nations.³⁻⁵

Dilapidated healthcare systems have facilitated medical tourism, for example, leading to over 5000 people leaving Nigeria every month for various forms of treatment abroad and about 1.2 billion US dollars lost from the Nigerian economy to medical tourism yearly.⁶ Other healthcare system problems prevalent in Africa include financial barriers to healthcare services with high rates of out-of-pocket expenditure, owing to ineffective national health insurance systems,⁷⁻⁹ and poor service integration.³,⁸ Human resources shortages and "brain drainage" from Africa to Europe, the Middle East and North America compound healthcare outcomes.⁹⁻¹¹ Healthcare sector industrial action (healthcare worker strikes) is frequent in Nigeria, where it has complicated most aspects of the healthcare service delivery¹⁰⁻¹⁴ and consequently prevented optimal healthcare delivery to the Nigerian population.¹⁵

As part of efforts to remedy the lack of financial risk protection mechanisms in Africa, some countries, such as Nigeria, Ghana, Tanzania, Kenya, Rwanda and Ethiopia have started implementing social health insurance schemes.⁷⁻⁹ However, the majority of people still suffer financial barriers as out-of-pocket expenditure is required before medical care can be provided, even in emergency situations and importantly, many insurance programs leave out the poor.¹⁶ The poor therefore bear the highest burden of diseases and experience high levels of financially crippling healthcare expenditure in many sub-Saharan African countries.¹⁶,¹⁷ In countries like Nigeria, non-implementation of relevant policies, programs and agreements between government and the various healthcare workers have frequently led to employee industrial action and periodic refusal to provide healthcare services to the sick.¹⁰,¹¹

Several studies have documented key healthcare system challenges globally with recommended solutions. However, challenges that healthcare systems in Africa face require in-depth exploration to identify, generate and implement contextual solutions that make significant population-level health gains with efficient use of resources.¹⁸ In order to bridge this information gap, the authors used the opportunity of a gathering of key opinion leaders at a recent African Epidemiological Association Annual Meeting in Maputo (with participants drawn from various countries in Africa) to identify perceived unmet needs in African healthcare systems and suggest ways of addressing them. This was done to determine healthcare system challenges which were most worrisome to principal African policy makers and implementers across Africa, as well as to identify major ways these challenges could be effectively addressed.

Methods

The study was conducted as part of the African Epidemiological Association (AfEA) Annual Scientific and General Meeting in Maputo, Mozambique, between April 14 and 17th, 2019.

The conference, with the theme, "Epidemiology for Sustainable Development in Africa" had epidemiology, policy development and community health; data and the science of evidence; disease surveillance and response; environmental epidemiology; epidemiological transition; new tools and horizons in epidemiology; and delivery science and implementation research as subthemes. Participants focused on how to improve epidemiology practice and policies in Africa in particular, and the world at large. Plenary discussions, group work and scientific sessions were used to fully explore the various topics and a communiqué addressing the participants' submissions, fears and solutions were delivered at the end of the conference.

A total of 77 participants, composed of programme implementing partners (n=40), policy-makers (n=5) and health researchers (n=13) were drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Some participants were identified as belonging to multiple categories, either as both implementing partner and researcher (n = 24), researcher and policy-maker (n = 5), implementing partner and policy-maker (n = 1), or implementing partner, researcher and policy-maker (n = 6). The participants were divided into 10 groups with each group consisting of 7-10 persons. A brainstorming approach in a structured-modified nominal group process (NGP) exercise was used.¹⁹,²⁰ This was conducted to identify key challenges facing healthcare services and develop strategies to mitigate the identified healthcare system challenges in Africa. Identified challenges and solutions were prioritised by ranking 1-5, with 1 being the most important and 5 being the least important. Participants included policy-makers, program managers and implementers, faculty of universities, executives of non-governmental organizations, researchers and residents in public health.

The NGP was conducted in two phases designed to maximise participant focus and engagement. During the first phase, each group member identified key challenges facing healthcare services and strategies to mitigate them in the African context. The groups then discussed and elaborated on these issues in the next NGP phase. Each of these sessions included three distinct activities, namely 1) generating key challenges, 2) generating key strategies/solutions, and 3) ranking the challenges and strategies.

We used "brainstorming" first as it is an effective and low-cost method of identifying key challenges and possible solutions to identified challenges.²¹ Individuals and groups identified between 3 and 7 challenges and solutions; generating a total of 275 challenges and 214 potential solutions. A team member was identified to document and present the findings to the meeting organizers.

The principal investigator, a public health physician, recruited 2 research assistants who acted as the facilitators of this study. The facilitators created the 10 groups, shared the study instrument and timed the whole exercise. Approval for the study was obtained from the AfEA Council and Executive and each participant provided consent to participate in the study.

Data Analysis

We delinked data, entered findings into SPSS v23 (IBM Corp, Armonk, NY, USA) and MS Excel Sheet (Microsoft Inc., Redmond, WA, USA), analysed, and reported aggregated results. Four questionnaires were completed in Portuguese. These were translated and analysed by one of the authors who speaks Portuguese. Two of the authors analysed the results and developed themes base on similar entries. Results were further summarized along the line of the WHO health system pillars (building blocks)¹ The most appropriate theme or block for each entry was used based on specialist (A Public health practitioner with post-graduate degree in public health) opinions. Results were presented in tables and charts.

Results

Respondents came from 11 African countries, Cuba and Portugal with close to half of the respondents from Nigeria (44.2%), followed by Mozambique (31.2%), which was the host country for the conference. The majority of the respondents had an MPH or MSc (36.4%); this was followed by those who had a Medical College Fellowship (23.4%) or a PhD (14.3%). Over a half of the respondents were programme officers (54.6%), while about one-fifth of the respondents were academics ( Table 1).

Table 1.

The top four problems of the health sector in African countries identified by individual participants were inadequate human resources (n = 49 respondents, 17.82%), poor resource allocation to health (n = 48, 17.45%), poor maintenance of healthcare system infrastructure (n = 28, 10.18%) and lack of political will (n = 20, 7.27%). The rest includes lack of access to healthcare, weak healthcare systems, high disease burden, healthcare system corruption, poor leadership and administration, non-use of evidence-based intervention, poor quality of healthcare services, lack of good resource management, weak training and education of healthcare workers, weak healthcare management information systems (HMIS), non-prioritization of healthcare activities, and professional rivalry, as shown in Table 2.

Table 2.

According to the groups, the top four challenges were inadequate budgetary allocation (n = 10 groups, 21.7%), inadequate human resources for health (n = 9, 19.6%), ineffective leadership and management (n = 5, 10.9%), poor data quality with poor use of data for audit (n= 4, 8.7%) and lack of political will (n = 4, 8.7%). The rest included limited access to healthcare, inadequate healthcare infrastructure, weak healthcare systems, poor integration of healthcare programmes and professional rivalry.

When these problems were regrouped, based on the six building blocks of the health system proposed by WHO, the leading problems clustered around leadership and governance (26.18%), healthcare workforce (25.45%) and healthcare service delivery (22.91%) ( Figure 1).

Figure 1.

Challenges regrouped according to the six pillars of the health systems.

Participants also individually and collectively identified some solutions to these challenges. The leading solutions suggested to the outlined challenges in the healthcare sector by individuals included training and capacity building of healthcare workers (n=43 respondents, 20.1%), adequate health insurance schemes (n = 20, 9.3%), advocacy and increase political engagement (n = 19, 8.9%), increased budgetary allocation to healthcare (n = 19, 8.9%) and improved healthcare infrastructure (n = 17, 7.9%). Other factors included increase collaboration among stakeholders to address healthcare issues, improved capacity to prevent and control disease, leadership and management training, improved monitoring and evaluation of healthcare services and better remuneration of healthcare workers, as shown in Table 3.

Table 3.

Groups identified investment in capacity building/training of healthcare workers (n = 8 groups, 16.7%), advocacy for political support (n = 7, 14.6%), increased budgetary allocation (n = 6, 12.5%), and adequate health insurance schemes (n = 5, 10.4%). The rest included improved data management and use of data for action, upgrading of healthcare infrastructure, improve leadership and management and active recruitment of healthcare workers.

Further analysis of the suggested solutions based on the six WHO health system building blocks showed that the solutions proffered were majorly changes in leadership and governance (31.8%), healthcare workforce (31.8%) and healthcare financing (21.50%). These were followed by service delivery, healthcare information systems and access to medicines and technologies ( Figure 2).

Figure 2.

Solutions regrouped based on the six building blocks of the health system.

Solutions ranked first by the groups include training and capacity building of health workers (n =19, 29.69%), increased budgetary allocation to health (n =13, 20.31%), and advocacy for political support and commitment (n = 8, 12.50%). The rest is shown in Table 4.

Table 4.

Discussion

Healthcare systems in Africa are mostly in unworkable conditions with very poor health outcomes. There have been several studies that looked at the challenges of the healthcare system in Africa, and our major findings were to a large extent similar to previous studies.¹⁰,¹¹,²² We found that the leading challenges in the healthcare sector as identified by the study participants were inadequate human resource for health, inadequate budgetary allocations to healthcare, and poor leadership and management in healthcare. These three problems accounted for over two-thirds of the perceived problems in the healthcare sector in Africa. When viewed from the perspective of the six WHO pillars of the healthcare system, the leading problems still clustered around leadership and governance, healthcare workforce and health service delivery and financing. Although this categorization may seem to overshadow the individual issues that make up these categories, it enables prioritization of the segments of the healthcare system most affected or requiring urgent attention. These findings are also similar to that of Roncarolo and colleagues, which found that the most frequently reported challenges in the health sector related to human resources (22%), leadership and governance (21%) and health service delivery (24%).¹ The findings therefore suggest that addressing these three key challenges in the healthcare system may solve over two-third of the problems associated with the healthcare system in Africa.

At individual level, our study showed that inadequate human resource is the foremost leading challenge in the health sector in Africa. This is both overt and covert which reflects the complexity of this challenge. It is overt in the sense of inadequate number, mix and distribution resulting from inadequate output from training institutions; brain drain to Europe, America and Asia; and unfavourable governmental policies mitigating employment into the civil services. Covert reasons include poor availability of engaged healthcare workers to deliver services, resulting from healthcare worker strikes, attendance at private practice (rather than public hospitals), internal migration to big cities, and poor attitude to work.²³⁻²⁵ This is in line with the findings of WHO which showed that sub-Saharan Africa (SSA) faces the greatest challenges in shortage of human resource for health. Every component of the healthcare system depends on the people who manage and provide the services. For instance, healthcare provision depends very much on the people who provide the services to clients. Yet over the years, attention and support to the healthcare workforce has not received the priority it deserves.²⁵ Little wonder, African countries are experiencing a disproportionate global disease burden of 24% with the least share of health workforce at only 3%.²⁶ The same study showed that out of 57 countries globally classified as having critical healthcare workforce numbers, 36 of them are in sub-Saharan Africa; although some countries in Europe are beginning to have similar challenges²⁷ These have implications at all level beginning with households especially those who are poor and those who live in rural areas who may have limited access to quality healthcare. This may be due to lack of qualified health personnel in health facilities which may lead to poor health outcomes and ultimately impede achievement of national and global health goals.²⁵

Also, healthcare systems may not be able to respond to public health emergencies such as outbreak of diseases leading to increase mortality and morbidity in these countries. The major solution proffered to this key challenge centered on capacity building of healthcare workers, which may itself address this challenge to some extent. Other issues which influence the retention of healthcare workers also need to be investigated.

Inadequate financing of healthcare in Africa is another major challenge identified. This is in tandem with several other previous studies.¹⁰,¹¹,²⁸

For instance, Musango and colleagues in their studies found that in the majority of African countries, scarcity of funds for healthcare is a chronic problem with even the richest countries finding it increasingly difficult to keep up with rising healthcare costs, especially in the face of the ongoing economic downturn.²⁸ Another study found that in about half of African countries, 40% or more of total healthcare expenditure is made up of out-of-pocket payments (OOPs), which are the most regressive way of funding healthcare. The average total healthcare expenditure (THE) in African countries stood at US$ 135 per capita in 2010, but only a small fraction of the US$ 3 150 spent on healthcare in an average high-income country.²⁹ These poor healthcare financing indices are prevalent in Africa despite several declarations signed by African heads of state, which among others include the Abuja Declaration of 2001 on increasing government funding for health, and the 2012 Tunis Declaration on value for money, sustainability and accountability in the health sector.²⁸

Although we identified low budgetary allocation to the healthcare sector and poverty as the key financial challenges faced by the healthcare systems, these are in contrast to those outlined by Roncarolo and colleagues which included increasing healthcare costs, financial unsustainability and lack of financial autonomy.¹ The difference in findings may have resulted from the differing perspectives of the study participants. The implication of these findings lies in the fact that inadequate financing of healthcare by many governments leaves the burden for healthcare financing on households, usually through OOPs, which have been shown to be catastrophic to households, pushing some households into poverty. However, the main solutions proffered to the problem of inadequate financing of health are increasing budgetary allocation to healthcare and healthcare insurance for all. This solution may in itself be dependent on prevailing economic situations in these countries and other underlying factors which again account for the complexity of this challenge.

The third leading challenge identified in this study is poor leadership and management. This finding is in line with that noted by Dye and Garman, who stated that one of the biggest challenges in the coming decades will be the selection and development of leaders who are trained and prepared for leadership in increasingly complex healthcare systems.³⁰ A study on leadership challenges in healthcare revealed that one of the underlying reasons for poor leadership stem from managers' unfamiliarity with leadership techniques which in many cases is due to managers' disbelief in the effectiveness and necessity of learning these techniques.³¹ Some other authors also documented similar challenges in two previous studies in Nigeria.¹⁰,¹¹ Some of the leadership and management challenges mentioned by respondents include lack of political will, corruption in healthcare systems, poor resource management/inefficiencies and poor integration of healthcare programmes. These factors are similar to those noted in a previous study which outlined issues of poor governmental role in health policy and poor oversight of the whole health system¹ The implications of these are that poor leadership could lead to increased healthcare costs, reduced efficiency and effectiveness, dissatisfaction among staff and ultimately resulting in lower patient satisfaction and poor health outcomes.³¹ Appropriate leadership, on the other hand, can create an organizational culture that is committed to quality, reducing conflicts, improving efficiency and productivity of teams, enhancing staff satisfaction, advancing healthcare system performance, and finally, meeting personal and organizational goals.³² Improved leadership and management have been proferred to address this challenge. There is an urgent need for capacity building on this subject which should be made mandatory beginning from healthcare training institutions and regular refresher course for all healthcare workers and finally should be a requirement for leadership in the healthcare sector.

In summary, the solutions proffered by the respondents which mostly addressed the issues outlined as the major challenges include training and capacity building for health workers, increase budgetary allocation to health, advocacy for political support and commitment, health insurance for all and improved leadership and management. Categorization of these solutions into the six WHO pillars of the healthcare system further showed that the major solutions outlined grouped into leadership and governance, healthcare workforce, and healthcare financing, accounting for over two-third of the suggested solutions. These imply that the solution to the key challenges in the healthcare system lies mainly in these three building blocks. These must be prioritized for action by policy makers and implementers if we desire to see better, healthier and more functional healthcare systems in Africa, translating into better healthcare outcomes and health indices.

Strength And Limitations

The strength of this study is the variety of subjects drawn from across Africa and beyond, who are lettered and well versed in healthcare services and systems in Africa. The study also used self-administered questioner to avoid interviewer bias. The study has not been done anywhere before and thus provides a fresh perspective to the issues of healthcare systems in Africa, and results and recommendations are designed to improve healthcare systems in Africa.

The limitations include the sample size which was small and the fact that majority of the responders are epidemiologists at different career levels. There is therefore the need for a broader study involving not only epidemiologists, but also professionals and healthcare customers from other fields. However, the findings are very important and should both inform policy decisions in health, and development of strategies to improve healthcare outcomes in Africa.³³

Conclusion And Recommendation

Inadequate human resource and healthcare financing and poor leadership and management are the major challenges of healthcare systems in Africa. The major solutions outlined by the participants grouped into leadership and governance, healthcare workforce and healthcare financing. It is important for public health policy makers in Africa to adopt national guidelines for healthcare system development, based on the WHO framework with buy-in from healthcare workers and most importantly from governments across the region. Creative solutions are required and lack of resources may mean that public-private partnerships may need to be adopted with companies using corporate social responsibility schemes to provide a portion of profits to offset health insurance schemes for employees, their families and the communities in which they work. Legislation may be required to encourage large multinationals to participate in such schemes as the price for extracting raw resources from the African continent.

Acknowledgements

This study was made possible by a grant from the Wellcome Trust Institutional Strategic Support Fund (ISSF) to Imperial College London. Thomas Barbera and Simon Taylor-Robinson are grateful to the NIHR Biomedical Facility at Imperial College London for infrastructure support.

Disclosure

The authors report no conflicts of interest in this work.

References

Articles from International Journal of General Medicine are provided here courtesy of Dove Press

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Identifying Key Challenges Facing Healthcare Systems In Africa And Potential Solutions

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Healthcare systems in Africa suffer from neglect and underfunding, leading to severe challenges across the six World Health Organization (WHO) pillars of healthcare delivery. We conducted this study to identify the principal challenges in the health ...

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Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries

Abstract

Background

Evidence suggests that there is a link between inequitable access to healthcare and inequitable distribution of illness. A recent World Health Organization report stated that there is a need for research and policy to address the critical role of health services in reducing inequities and preventing future inequities. The aim of this manuscript is to highlight disparities and differences in terms of the factors that distinguish between poor and good access to healthcare across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.

Methods

A population survey was undertaken in each country. This paper is a secondary analysis of these existing data. Data were collected in each country between 2009 and 2010. Four variables related to difficulties in access to healthcare (distance, appointment, waiting time, and cost) were analysed using binomial logistic regression to identify socio- and demographic predictors of inequity.

Results

Consistent across the findings, poor health and low income were identified as difficulties in access. Country specific indicators were also identified. For Thailand, the poorest level of access appears to be for respondents who work within the household whereas in Taiwan, part-time work is associated with difficulties in access. Within Hong Kong, results suggest that older (above 60) and retired individuals have the poorest access and within Australia, females and married individuals are the worst off.

Conclusion

Recognition of these inequities, from a policy perspective, is essential for health sector policy decision-making. Despite the differences in political and economic climate in the countries under analysis, our findings highlight patterns of inequity which require policy responses. Our data should be used as a means of deciding the most appropriate policy response for each country which includes, rather than excludes, socially marginalised population groups. These findings should be of interest to those involved in health policy, but also in policy more generally because as we have identified, access to health care is influenced by determinants outside of the health system.

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Introduction

Both trans-nationally [ 1- 3] and within particular countries [ 4], it is widely recognised that public health policy and practice needs to focus on addressing the Social Determinants of Health (SDH) in order to increase the health of the most vulnerable and disadvantaged groups [ 5]. The focus on promoting health and preventing illness for the most vulnerable groups in society has been part of the named agenda of public health for decades, and is central to contemporary global agreements such as the Jakarta Declaration [ 6] and the Bangkok Charter for Health Promotion [ 7]. Indeed, Professor Sir Michael Marmot recently referred to health inequities as a "stain on our society" which requires concerted political will and moral imperative to change [ 8].

Equitable access to healthcare services is a major SDH [ 1, 3], with a WHO report stating there is a need for research and policy to address the critical role of "health services in reducing ill health and suffering, redressing inequities, and preventing future inequities" [ 9]. The WHO Commission on the SDH provides evidence on the link between inequitable access to healthcare and the resulting inequitable distribution of illness and make a recommendation for interventions to increase the equity of access to healthcare services [ 10- 12].

There is a large research literature demonstrating that access to, quality of, and outcomes from healthcare are inequitable across a number of clinical areas including screening for a variety of cancers [ 13- 16], surgical interventions [ 17- 19] and primary care prescribing [ 20- 22]. These examples provide evidence for the 'inverse care law' [ 23], whereby the groups with the greatest healthcare need receive the lowest levels of service. This evidence has led to an international call for action to reduce inequities in health and healthcare [ 1, 24, 25].

The incorporation of equity in health provision helps to identify the significant roles of political and social consciousness in developing and sustaining the needs and agendas of all people in a fair and just way [ 26]. For the purposes of this manuscript, a key distinction needs to be made between a relatively large field of research which defines equity in health [ 27- 30] and an emerging field of research which defines equity in healthcare [ 31- 34]. It is hypothesised that improving equity in access to healthcare will lead to improved equity in health outcomes [ 11].

This manuscript presents for the first time, a secondary analysis of cross-country data which identifies populations at risk of poor access to healthcare in six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand. Specifically, this manuscript reports the findings of a population survey undertaken in each country regarding difficulties in access to healthcare: namely, difficulties due to distance, obtaining an appointment, waiting times and costs. The aim of this manuscript is to highlight disparities and differences in terms of the factors that seem to be important to distinguishing between poor and good access to healthcare within each country.

Background

Healthcare is socially determined in that it is influenced by social policies that govern the receipt and utilization of health services, allocation of healthcare resources, the financing of healthcare, and the quality of healthcare services [ 35]. Ensuring that appropriate resources are mobilized to meet the healthcare needs of different groups in different populations is key to healthcare access [ 36]. The notion of 'equity' is inextricably linked to the concept of access to healthcare, because the inclusion of fairness or social justice is one of the key factors necessary for the effective provision of healthcare [ 37].

There is a great deal of research focused on defining equity in access to healthcare [ 36, 38- 40], and its operationalisation [ 41- 44]. The literature on "equity" and "access" to healthcare is abundant, diverse, and complex and the conceptualisation and operationalisation of these two concepts is not consistent [ 44]. Many studies have typically relied on measures of utilization as the basis for analyses of equity of access, although this is methodologically and conceptually problematic because it does not measure need and thus, does not identify problems of inequity. This study diverts the focus away from measuring utilization of health services and instead, measures socio-demographics against healthcare access indicators. We then discuss these findings in relation to healthcare provision within each of these six countries.

We conceptualise access as the level of facilitation or inhibition affecting the ability of individuals to gain entry to and receive care from healthcare services [ 45]. The accessibility of healthcare depends on a multitude of supply- and demand-side factors [ 46]. Supply-side factors include the distribution of facilities, waiting times, and human resources and capital [ 36, 47, 48]. Factors influencing accessibility on the demand-side result from predisposing, enabling, and needs factors [ 49], including socio-demographics, past experiences with healthcare, perceptions regarding health and illness, income levels and scope, and extent of health insurance coverage [ 50]. Our conceptualisation of access was used to guide our investigation which looks specifically at the supply-side factors affecting access (cost, waiting time, appointment, distance) and relevant demand-side factors (socio-demographic and health related predictors).

An equitable health service implies that individuals' utilisation of and access to service depends on their health state alone, and not upon their socio-economic status [ 51]. The research presented herein is based on our argument that this notion should be extended and access should not be based upon age, race, geography, gender, language, culture, and functional capacity. Equity in healthcare should be concerned with the reduction of systematic discrimination and marginalization between different groups and within groups, regardless of whether a group is found to attain a generally high or low level of equitable access. Our use of socio-demographic variables (e.g. sex, age, income) and variables related to the beliefs and expectations about health and illness (e.g. chronic health condition, self-rated health) help to reveal the differing levels and standards of needs, and have been included for analysis in this study.

Methods

The data presented in this manuscript come from a larger survey designed to investigate social quality [ 52] across six Asia-Pacific counties: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand. The survey was developed, and data collected, by academic representatives from each of the universities involved; Australia (Flinders University), Hong Kong (Chinese University Hong Kong), Japan (Chiba University), Korea (Seoul National University), Taiwan (National Taiwan University), Thailand (King Prajadhipok Institute). The survey was then translated into the language of the host country and validated. The survey was then piloted in each language and tested for reliability (see [ 53] for an overview of the validity and reliability testing in Australia). All questions asked were the same, but in a different language. The authors undertook data collection in Australia only and therefore, this paper reports a secondary analysis of a combined dataset representing all countries involved. The merging and cleaning of the dataset was conducted by academics at Seoul National University. Details of method for selected countries represented in this paper are published elsewhere [ 54- 57]. Data were collected in each country between 2009 and 2010.

Four variables related to difficulties in access to healthcare (distance, appointment, waiting time, and cost) were selected and form the basis of this manuscript. The survey question regarding access is provided in Table 1.

Ten independent variables (sex, age, marital status, work status, income, financial situation in the last year, subjective health satisfaction, self-rated health, perception of importance of health, and chronic health condition) were tested against the four dependent variables based on previous studies linking their relevance to equity of access to healthcare [ 47, 58, 59].

Data were analysed using the SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). Binomial logistic regression models were used to investigate associations for all six countries [ 60]. In order to conduct binomial regression, the original four dependent variables were recoded into new variables with two categories of response. 'Very difficult' and 'a little difficult' were recoded as 'difficult'. Responses 'not applicable/never needed to see a doctor' were coded as missing. 'Not difficult at all' was not recoded. Due to differences in data collection methods, and changes to survey questions to make them culturally relevant, a few of the independent variables were not available from some countries thus reducing the number of association tests performed. Goodness-of-fit for all models were checked [ 60, 61].

To ensure that there would be no redundant calculations during the multivariate analyses, co linearity diagnostics (using SPSS) were performed to check for variables that may have similar degrees of variance [ 62]. A tolerance value of ≤ 0.20 and a variance inflation factor of ≥10 were used to indicate a multicollinearity problem [ 63]. Diagnostics were conducted for all 24 models (six countries by four dependent variables).

Some methodological issues were faced when the data from all six countries were checked for consistency. Rice et al. (2010:82) identify that the design of International surveys needs to be mindful of the requirement for the cross-cultural equivalence of instruments [ 64]. In order to address this, we consulted with academics who comprise the Asia-Pacific Scientific Steering Group on Social Quality (PR Ward is a founding member of this group) [ 2]. It was decided among committee members that options provided in the Australian survey were 'very difficult', 'difficult', or 'not difficult at all'. Based on the recommendations of the committee member in Asia, response options were: 'very difficult', 'difficult', 'easy', and 'very easy'. Additionally, it was decided that the wording for one independent variable, subjective health satisfaction, differed between the Australian survey and all other countries' surveys; Australia's item options were 'happy', 'average', and 'unhappy' and all other countries' were 'satisfied', 'neither satisfied nor dissatisfied', and 'unsatisfied'.

Robone et al. (2011) also identify difficulties in using scale variables in cross-country comparisons because there is potential that when faced with the instrument individuals are likely to interpret the meaning of the available response categories in a way that systematically differs across populations or population subgroups [ 65] which compromises the comparability of the data in cross-country analyses. We recognise that by applying country level estimates within the analysis (mixed effects logistic regression models [ 66]), we can draw more insightful conclusions for comparing the data. However, this form of analysis in not in line with the aim of this manuscript which is to report on within country results rather than across country comparisons.

Table 2 summarizes the methods employed for the collection of data within Australia, Japan, South Korea, Hong Kong, Taiwan (Taipei), and Thailand. It outlines the methodological issues which are discussed in more detail as limitations in the conclusion of the paper.

Appropriate approvals were obtained within each country to undertake the individual surveys. The authors were granted ethics approval from Flinders University Social and Behavioural Research Ethics Committee to obtain and use the collected data for secondary analysis (project number 5221).

Results

The reports below are inclusive of only statistics regarding the predictor variables. Table 3 summarizes all of the predictors found to be significant for each of the four dependent variables.

Statistically significant outputs for all binomial regression models for all predictor variables are presented below. Within the following section, any odds ratios of less than one should be interpreted as relating to poor access for the particular group within which we are referring.

Distance

Table 4 provides statistical results from binomial logistic regression models computed for the dependent variable distance.

Monthly/annual income

In Australia, respondents who fell in the highest annual income quartile were 45% more likely that those in the lowest income quartile [OR=0.55, CI=0.30-1.00, p<0.05] and second-lowest income quartile [OR=0.54, CI=0.32-0.91, p<0.05] to state that distance was not a difficulty factor.

In Hong Kong, respondents who fell in the highest annual income quartile were about 75% more likely to state that distance was not a difficulty factor than those from the lowest income quartile [OR=0.27, CI=0.14-0.52, p<0.001].

Subjective health satisfaction

In Australia, respondents who felt indifferent [OR=3.15, CI=1.74-5.69, p<0.001] or happy [OR=3.91, CI=2.28-6.71, p<0.001] about the state of their health were three or four times (respectively) more likely to indicate that distance was not a difficulty factor than those who stated they were very unhappy with their health.

Those who stated average satisfaction with their health in Japan [OR=2.18, CI=1.41-3.37, p<0.001] or said they were satisfied [OR=1.72, CI=1.09-2.72, p<0.05] were approximately twice as likely to state that distance was not difficult than those who indicated they were dissatisfied with their health.

In Thailand, respondents who stated they were satisfied with their health were about 1.9 times more likely [OR=1.85, CI=1.15-2.98, p<0.05] to state that distance was not a difficulty than those who stated they were dissatisfied with their health.

Financial situation

In Australia, respondents who stated they had saved money were about 65% more likely to state that distance was not a difficulty factor than those who stated they had spent savings and borrowed money [OR=0.35, CI=0.19-0.63, p<0.01].

Hong Kong respondents who stated they had saved money in the last year were about 65% more likely to state that distance was not a difficulty factor than those who stated they had spent some savings [OR=0.37, CI=0.20-0.66, p<0.01].

In Taiwan, respondents who stated they had saved money in the last year were about 50% more likely to state that distance was not a difficulty factor than those respondents who stated they had spent some savings [OR=0.51, CI=0.29-0.88, p<0.05] and respondents who stated they had spent savings and borrowed money [OR=0.49, CI=0.26-0.91, p<0.05].

Compared with respondents who stated they had spent some savings in Thailand [OR=0.47, CI=0.27-0.82, p<0.01] and respondents who selected the item 'just got by' [OR=0.49, CI=0.35-0.70, p<0.001], those who stated they had saved money in the last year in Thailand were about 50% more like to respond that distance was not a difficulty factor. Additionally, those who stated they had saved money in the last year were about 60% more likely than those who stated they had spent savings and borrowed money [OR=0.43, CI=0.27-0.67, p<0.001] to state that distance was not a difficulty factor.

Self-rated health (Not applicable to Hong Kong & Taiwan)

In Japan, respondents who rated their health as being very good were approximately 70% more likely to state that distance was not a difficulty factor than respondents who rated their health condition as bad [OR=0.31, CI=0.14-0.68, p<0.01].

Korean respondents who rated their health as very good were about 60% more likely to state 'not difficult' than those who felt that their health condition was 'fair' [OR=0.43, CI=0.28-0.68, p<0.001]. Those who rated their health as being very good were about 75% more likely to state that distance was not a difficulty factor than those who rated their health as being very bad [OR=0.25, CI=0.09-0.71, p<0.01].

In Thailand, those who rated their health as being very good were approximately 50% more likely to state that distance was not a difficulty factor compared with respondents who rated their health condition as good, fair, or bad [OR=0.54, CI=0.35-0.82, p<0.01; OR=0.47, CI=0.30-0.75, p<0.01; and OR=0.44, CI=0.21-0.90, p<0.01, respectively].

Chronic health condition (Not applicable to Hong Kong, Japan & Taiwan)

In Korea respondents who had no chronic health condition were nearly 3.5 times more likely [OR=3.34, CI=1.37-8.18, p<0.01] to state not difficult for distance than those who stated they had a chronic health condition.

Marital status

In Australia, those who stated they had never married were around 70-80% more likely to report distance was not a difficulty factor in seeing a doctor or a specialist on the last occasion they required compared with those who stated they were married [OR=0.26, CI=0.13-0.52, p<0.001], divorced [OR=0.19, CI=0.09-0.45, p<0.001] widowed [OR=0.21, CI=0.08-0.52, p<0.01] or separated [OR=0.22, CI=0.07-0.70, p<0.01].

In Taiwan, those who had never married were about 70% more likely than those who stated they were divorced [OR=0.34, CI=0.17-0.69, p<0.01] to state that it was not difficult in terms of distance to travel on the last occasion they required to see a doctor/specialist.

Work status

In Taiwan, respondents who worked full-time were approximately 50% more likely to state 'not difficult' in terms of distance than those who worked part-time [OR=0.50, CI=0.28-0.88, p<0.05]. Those who were retired/pensioners [OR=2.00, CI=1.06-3.77, p<0.05] were twice as likely as those who worked full-time to state that distance was not a difficulty factor the last time they required to see a doctor or specialist.

In Thailand, respondents who worked full-time were about 55% more likely to state that distance was not a difficulty factor than those who indicated that they worked for their family [OR=0.47, CI=0.31-0.71, p<0.001]. Respondents who worked full-time were found to be nearly 60% more likely than respondents who were housewives/househusbands were [OR=0.42, CI=0.25-0.72, p<0.01] and about 40% more likely than those who indicated student/unemployed/other [OR=0.59, CI=0.40-0.89, p<0.05] to find distance not a difficulty.

Appointment

Table 5 provides statistical results for binomial logistic regression models computed for the dependent variable appointment.

Subjective health satisfaction

Australian respondents who stated they were happy about their health were about 3 times more likely than those who were unhappy about their health [OR=3.10, CI=1.73-5.56, p<0.001] and almost 2 times more likely than those who stated that there we 'average' about their health [OR=1.78, CI=0.96-3.29] to state that appointment delays were not a difficulty factor.

In Korea, those who stated they were satisfied with their health were nearly twice as likely [OR=1.77, CI=1.16-2.71, p<0.01] to state that appointment delay was not a difficulty factor compared with those who stated they were dissatisfied with their health.

In Taiwan respondents who stated they were satisfied with their health were nearly 2.5 times more likely [OR=2.31, CI=1.52-3.51, p<0.001] to state that appointment delay was not a difficulty factor than those who stated they were dissatisfied with their health.

Financial situation in last year

In Australia those who stated they had saved money were about 45% more likely to state that appointment delay was not a difficulty compared with those who 'just got by' [OR=0.56, CI=0.39-0.80, p<0.01]. Similarly, respondents who stated they had saved money were about 40% more likely to state that appointment delay was not a difficulty than those who had 'spent some savings' [OR=0.62, CI=0.40-0.94, p<0.05], and about 50% more likely to state that appointment delay was not a difficulty than those who had 'spent savings and borrowed money' were [OR=0.50, CI=0.28- 0.88, p<0.05].

Self-rated health

In Japan, those who stated they were very dissatisfied with their health were approximately 70% more likely to state that appointment delay was not a difficulty factor than those who stated they were satisfied with their health [OR=0.31, CI=0.15-0.64. p<0.01].

Chronic health condition and appointment difficulties

In Australia respondents who indicated they had no chronic health condition were nearly 1.5 times more likely [OR=1.41, CI=1.00-1.98, p<0.05] to state that appointment delays were not a difficulty than those who indicated having a chronic health condition.

Sex

Within Australia, males were about 50% more likely to state that it was not difficult to make an appointment the last time they required to see a doctor/GP than females [OR=0.50, CI=0.37-0.69, p<0.001].

Age

Australian respondents in all age groups from 20 years of age and over were at least 6 times more likely to state that making an appointment was not a difficulty factor. For example, those who were aged between 30-39 [OR=6.97, CI=2.33-20.88, p<0.001] were about 7 times more likely to state that appointment was not a difficulty factor, and those who were aged 60 or above were about 14 times more likely to state that appointment making was not a difficulty factor [OR=13.86, CI=4.48-42.89, p<0.001].

Age was the only significant predictor of appointment difficulties for Hong Kong. Respondents aged 20 years or younger were about 85% more likely to indicate that scheduling an appointment was not a difficulty factor on the last occasion they required to see a doctor/specialist than those who were aged 60 years or over [OR=0.13, CI=0.06-0.27, p<0.001].

In Japan, those who were 60 years or older were nearly 2.5 times more likely [OR=2.37, CI=1.44=3.90, p<0.01] to state that appointment making was not a difficulty factor on the last occasion they required to see a doctor/specialist compared with those who were aged 20-29 years.

Marital status

In Australia, respondents who had never been married were about 55% more likely to state that appointment making delays was not a difficult factor than those who were married [OR=0.42, CI=0.27-0.70, p<0.01].

Work status

In Thailand, respondents who worked full-time were about 55% more likely to state that appointment delay was not a difficulty factor the last time they required to see a doctor/specialist than those who worked part-time [OR=0.45, CI=0.24-0.84, p<0.05]. Those who were full-time workers were about 65% more likely to state that appointment delay was not a difficulty factor than those who worked for their family [OR=0.34, CI=0.23-0.49, p<0.001].

Waiting time

Table 6 provides statistical results from binomial logistic regression models computed for the dependent variable waiting time.

Subjective health satisfaction

Australian respondents who stated they felt happy about their health were about 3 times more likely [OR=2.57, CI=1.54-4.28, p<0.001] to state that waiting times are not a difficulty factor.

For Korea, respondents who were satisfied with their health were approximately 1.8 times more likely [OR=1.78, CI=1.15-2.74, p<0.01] to indicate that waiting time was not a difficulty factor than respondents who were dissatisfied with their health.

Taiwan respondents who were satisfied with their health were over 1.5 times more likely [OR=1.56, CI=1.06-2.29, p<0.05] to state that waiting time was not a difficulty factor than those who were dissatisfied with their health.

Financial situation in last year

In Australia, those who stated they had saved money were about 35% more likely to state that waiting time was not a difficulty compared with those who 'just got by' [OR=0.66, CI=0.45-0.91, p<0.05]. Similarly, those who had saved money were about 60% more likely than those who had 'spent some savings' [OR=0.38, CI=0.28-0.67, p<0.05] and 45% more likely those who 'spent savings and borrowed money' [OR=0.56, CI=0.31-1.01] to state that waiting time was not a difficulty.

Taiwan respondents who had saved money were about 45% more likely than those who had spent some savings to state that waiting time was not a difficulty factor [OR=0.55, CI=0.36-0.85, p<0.01].

In Thailand, individuals who had saved money were about 35% more likely to state that waiting time was not a difficulty factor compared with those how 'just got by' [OR=0.66, CI=0.49-0.89, p<0.01]. Similarly, individuals who had saved money were nearly 50% more likely than respondents who spent savings and borrowed money to state that waiting time was not a difficulty factor [OR=0.48, CI=0.32-0.71, p<0.001].

Self-rated health

In Japan, those who rated their health as very good were about 30% more likely than respondents who rated their health as good to indicate waiting time was not a difficulty factor [OR=0.72,CI=0.58-0.89, p<0.05]. Again, those who rated their health as very good were about 50% more likely to indicate waiting time was not a difficulty factor than those who rated their health as fair [OR=0.53, CI=0.43-0.66, p<0.001] and approximately 60% more likely to indicate waiting time was not a difficulty factor than those who rated their health as bad [OR=0.43, CI=0.31-0.59, p<0.001] or very bad [OR=0.41, CI=0.23-0.75, p<0.01].

Sex

Only for Australia did the final logistic regression model show sex to be a significant indicator of waiting time difficulties, with males about 35% more likely than Australian females [OR=0.67, CI=0.51-0.88, p<0.01] to state that waiting time was not a difficulty factor on the last occasion they required to see a doctor/specialist.

Age

In Japan, than those who indicated to be under 20 years of age were about 40% more likely to state that waiting time was a not difficulty factor on the last occasion they required to see a doctor/specialist than those 30-39 years of age [OR=0.56, CI=0.34-0.92, p<0.05].

Work status

Respondents who worked full-time were about 40% more likely to state that waiting time was not a difficulty factor than those who worked part-time [OR=0.62, CI=0.41-0.95, p<0.05]. Respondents who were retired or pensioners were about 2.5 times more likely [OR=2.45, CI=1.67-3.61, p<0.001] to state that waiting time was not a difficulty factor, and respondents who were students/unemployed/other were about 1.5 times [OR=1.66, CI=1.06-2.60, p<0.05] more likely to state waiting time was a not difficulty factor compared with those who worked full-time.

In Hong Kong, respondents who worked full-time were about 30% more likely to state that waiting time was not a difficulty factor on the last occasion they required to see a doctor/specialist than those who stated they were retired/pensioners [OR=0.68, CI=0.34-0.13, p<0.001].

In Thailand, respondents who stated they worked full-time were about 50% more likely to state that waiting time was not a difficulty factor than those who worked for their family [OR=0.52, CI=0.35-0.76, p<0.01].

Cost

Table 7 provides statistical results from binomial logistic regression models computed for the dependent variable cost.

Household monthly/annual income

In Australia those who were in the highest income quartile were approximately 50% more likely to state cost was not a difficulty factor than respondents who belonged to the second lowest income quartile [OR=0.52, CI=0.33-0.81, p<0.01].

Subjective health satisfaction

Australian respondents who indicated they were happy with their health were twice as likely [OR=2.01, CI=1.15-3.50, p<0.05] to state that cost was not a difficulty factor than those who were unhappy with their health.

In Hong Kong, individuals who were neither satisfied nor dissatisfied with their health were about 2.5 times more likely [OR=2.41, CI=1.20-5.27, p<0.05] to indicate that cost was not a difficulty factor than those who were dissatisfied with their health. Respondents who were satisfied with their health were about 3.2 times more likely [OR=3.24, CI=1.58-6.62, p<0.01] to state cost was not a difficulty factor than those who were dissatisfied with their health.

Korean respondents who were satisfied with their health were about 2.7 times more likely [OR=2.68, 1.65-4.33, p<0.001] to state that cost was not a difficulty factor than those who were dissatisfied with their health.

Financial situation in last year

Australians who had saved money were about 60% more likely than those who 'just got by' [OR=0.67, CI=0.45-0.99, p<0.05] and about 70% more than those who had spent savings and borrowed money [OR=0.31, CI=0.18-0.40, p<0.001] to state that cost was not a difficulty factor.

In Japan, those who had saved money in the last year were about 40-50% more likely to state that cost was not a difficulty factor compared with respondents who stated that in the last year they spent some savings [OR=0.53,CI=0.37-0.76, p<0.01] or spent savings and borrowed money [OR=0.38, CI=0.23-0.65, p<0.001].

As for Korean respondents, those who had saved money were about 70% more likely than those who had spent savings and borrowed money to state that cost was not a difficulty factor [OR=0.32, CI=0.17-0.61, p<0.001].

Taiwanese respondents who stated they had saved money in the last year were about 70% or 75% respectively more likely to state that cost was not a difficulty factor than those who stated 'just got by' [OR=0.32, CI=0.21-0.51, p<0.001], or 'spent some savings' [OR=0.25, CI=0.14-0.44, p<0.001]. Those who had saved money were about 85% more likely to indicate that cost was not a difficulty factor compared with those who had spent savings and borrowed money [OR=0.16, CI=0.09-0.30, p<0.001].

In Thailand, respondents who had saved money in the last year were about 50% or 55% respectively more likely to state that cost was not a difficulty factor than those who stated 'just got by' [OR=0.55, CI=0.38-0.80, p<0.01], or 'spent some savings' [OR=0.45, CI=0.25-0.80, p<0.01]. Similarly, those who had saved money were about 55% more likely those who had spent savings and borrowed money to indicate that cost was not a difficulty factor [OR=0.48, CI=0.30-0.77, p<0.01].

Self-rated health

In Japan, those who rated their health as very good were about 50% more likely to indicate cost was not a difficulty factor compared to respondents who rated their health condition as fair [OR=0.48, CI=0.29-0.80, p<0.01]. Those who rated their health as very good were nearly 75% more likely to indicate that cost was not a difficulty factor than those who rated their health as bad [OR=0.27, CI=0.14-0.53, p<0.001].

Chronic health condition

In Korea, respondents who indicated having no chronic health condition were about 2.5 times more likely [OR=2.51, CI=1.25-5.04, p<0.05] to state that cost was not a difficulty factor compared with those who suffered from a chronic health condition.

Sex

In Australia, males were about 45% more likely to state that cost was not a difficulty factor on the last occasion they required to see a doctor/specialist than females [OR=0.54, CI=0.38-0.76, p<0.001].

Males in Korea were about 30% more likely than females [OR=0.72, CI=0.54-0.97, p<0.01] to indicate that cost was a not difficulty factor on the last occasion they required to see a doctor/specialist.

Age

In Japan, respondents who were 60 years or older were nearly twice as likely [OR=1.89, CI=1.22-2.94, p<0.01] to state that cost was not a difficulty factor on the last occasion they required to see a doctor/specialist than those who were between 20 and 29 years old.

Marital status

In Australia, respondents who had never married were about 50% more likely to state that cost was not a difficulty factor than those who were married [OR=0.48, CI=0.30-0.77, p<0.01].

In Hong Kong, respondents who were widowed were about 19 times more likely [OR=19.81, CI=5.37-73.05, p<0.001] to state that cost difficulties were not an issue on the last occasion they required to see a doctor/specialist than those who had never married.

Work status

Australians who were retired/pensioners were about 3.3 times more likely [OR=3.32, CI=1.84-5.99, p<0.001] to state cost was not a difficulty on the last occasion they required to see a doctor/specialist than full-time workers. Those who were housewives or househusbands were twice as likely [OR=2.03, CI=1.00-4.08, p<0.05] to state cost was not a difficulty than those who were full-time workers.

In Hong Kong, respondents who worked full-time were approximately 90% more likely to state that cost was a not difficulty factor compared with those who were retired or pensioners [OR=0.12, CI=0.64-0.21, p<0.001].

In Taiwan, respondents who worked full-time were about 70% more likely to state that cost was not a difficulty factor on the last occasion they required to see a doctor/specialist than those who worked part-time [OR=0.31, CI=0.18-0.53, p<0.01].

Discussion

The aim of this manuscript is to highlight disparities and differences in terms of the factors that seem to be important to distinguishing between poor and good access to healthcare across six countries. In the following we discuss these findings in relation to healthcare provision within each of these countries. We do not provide a comprehensive explanation of our findings but rather, we provide a level of interpretation around the country context for each of the findings. Our results for each country should be used as baseline data or as the basis for an intervention by researchers with knowledge of the local, social, cultural and political context.

Australia

The findings identified that respondents who are unhappy with their health have difficulty accessing services due to distance. This is obviously worrying, and is an example of the 'inverse care law' [ 23]. This is of concern given the potential for increasing inequities in health outcomes.

The findings regarding females having difficulty accessing services is also concerning. Studies from both high- and low income countries show higher rates of morbidity among women than men [ 67]. However, in line with previous research, the findings may also provide further evidence to suggest that health services are under-utilised (thereby rendering difficulties in access irrelevant) by men which has obvious implications for men's health in Australia. Data from the UK suggest that men are less likely than women to consult their general practitioners but have higher admission rates for chronic disease which suggests that men's health policy efforts may need to focus on promotion and prevention [ 68].

Finances, inclusive of annual income and difficulty with finances in the past year, were also found to be a predictor of poor access to healthcare across distance, appointment, waiting time and cost. Previous research conducted in Australia identified that patients with low socioeconomic status are likely to have shorter consultations with GPs despite the fact that, as a group, they have a significantly higher need for care [ 69]. Although Australia has publically funded healthcare via Medicare [ 70], waiting times and difficulties in being granted a medical appointment continue to be a problem in Australia. Individuals have the option of purchasing private services via out of pocket payment or private insurance schemes which minimises waiting times and permits more timely access to specialists via private appointments. However, figures from the ABS 2007-08 National Health Survey indicate that only half (53%) of the Australian population aged 15 years and over have private health insurance [ 71].

Hong Kong

Respondents in Hong Kong who spent their savings in the past year and who fell in the lowest income quartile were found to have difficulties accessing healthcare due to distance. We cannot explain this finding and suggest that more research is needed to understand the role of poverty in determining geographical inequity in access to services.

Older individuals (over 60, pensioners, retired) were found to have problems accessing health services do to difficulties getting appointments, waiting times and cost. At the time of data collection (the 2008-09 financial year), the Government of Hong Kong launched the Elderly Health Care Voucher Pilot Scheme (HCVS) for three years to provide five healthcare vouchers of $50 each to elders aged 70 or above annually to partially subsidise their use of private primary healthcare (PHC) services. There was recognition by government that programs were needed for the elderly to be granted better access to care and a continuity of care from their chosen providers. The additional aim was to reduce elderly reliance on public healthcare resources so that other members of the public who are in need of primary healthcare services would be benefit indirectly. Results from an interim review on the Scheme have demonstrated its success and the Government has decided to extend the Scheme for another three years from 1 January 2012 to 31 December 2014, increasing the voucher amount entitled by each eligible elder from $250 to $500 per year [ 72]. Our recommendation is to obtain a repeat measure of access to healthcare as a means of identifying the impact of this policy on access to healthcare for the elderly.

Japan

Japan has been argued to be one of the most equitable one-tiered (solely private) health systems in the world [ 3, 73]. Roughly 80% of Japan's hospitals and 94% of its physician-run offices (referred to as clinics) are privately operated; however all care is provided under a nationally uniform fee schedule which means that neither insurers nor providers have the freedom to negotiate individual fee schedules [ 74, 75]. Every citizen must be attached to one scheme but insurance premiums are calculated on the basis of income. Individuals can be on public assistance which is the only situation under which an individual does not have to be covered by an insurance scheme.

Our results identified that difficulties in the financial year prior to data collection was predictive of difficulties in accessing healthcare due to cost. Although insurance premiums are regulated, as noted above, these premiums are calculated based on income. It is possible that healthcare premiums are calculated in a manner that does not take into account current/recent income (i.e. people are charged more than they can afford until income is reassessed).

Additionally, in contrast to trends across the other countries, being satisfied with one's health was a predictor of difficulties in gaining an appointment. We cannot explain this finding and suggest that more research is needed to understand if health care service access is prioritised according to need (i.e. people dissatisfied with their health are priority).

Korea

Respondents who spent savings or borrowed money in the year prior to data collection were found to have difficulty in accessing care due to cost. This may be due to the nature of the South Korean healthcare system. All Koreans are entitled to the National Health Insurance Program (NHIP); however, Song (2009) reported that only 57.7% were enrolled in this service in 2006. Additionally, for those who do enrol, it is required that individuals pay a portion of the healthcare costs, which vary according to the level and type of healthcare institution being used. Some rates are as high as 50% of the total cost of treatment (i.e. for general hospital visits and treatments). Those who cannot afford co-payments are covered by the Medical Aid Program which pays for all medical expenses for those who are unable to pay. However, only 3.7% of South Koreans are eligible for this service (Song 2009).

Taiwan

A National Health Insurance (NHI) scheme covers 99% of Taiwan's population [ 76]. The objective of the NHI is to provide equal access to healthcare for all citizens and to maintain healthcare expenditure at manageable levels [ 77]. By law, regardless of age, gender, or employment status, any Taiwanese citizen with a local ID card or a foreign national living in Taiwan with an Alien Resident Certificate (ARC) is required to enrol in the program. Additionally, those eligible for the system must participate in the system (unless they lose their eligibility by being convicted of a crime, disappearing, giving up their Taiwan citizenship, moving abroad or having their Alien Resident Certificate expired) [ 78]. The premium for the insurance scheme is 100% subsidized for households below the poverty line. Despite this, we identified that difficulties in finances in the year prior to data collection and working part time were predictors of difficulties in access due to cost. Our findings may be explained by the fact that part-time workers or individuals who had difficulty in the financial year prior to data collection may not be eligible for subsidized premiums [ 79]. While the scheme is designed so that no single individual living in Taiwan will be denied healthcare for lack of means, low-to-middle income earners may fall short of eligibility criteria for access to these subsides.

Thailand

Employment status was the main predictor for difficulty in accessing healthcare in Thailand. Individuals who work for their family, do part time work, work within the household or are unemployed were found to have difficulty accessing services due to distance, difficulties getting an appointment and/or waiting times. This may be explained in part by the structure of the Thai social health insurance program. Thai individuals working in the private sector are provided with health insurance under the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Scheme. However, this social insurance scheme does not cover people working outside of the private sector, non-working spouses, child dependents or other family members. While there is a scheme used by the remainder of the population, referred to as the 30-Baht Scheme whereby a person pays 30 Baht to receive access to any health service required, Thailand still struggles to extend coverage to the majority of its population [ 80]. The 30-Baht Scheme may also explain the finding that respondents who had financial difficulties in the year prior to the data collection also found it difficult to access service due to cost, whereby some individuals may not be able to afford this prescribed payment.

Consistent across the findings, poor health and low income were identified as difficulties in access due to distance. In a similar vein, low income was found to be a predictor for difficulties in access due to cost. These findings echo previous cross-country research investigating access (Burkina Faso, Guatemala, Kazakhstan, Kyrgyzstan, Paraguay, South Africa, Thailand, Zambia), whereby it was found that wealthier population groups have a higher probability of obtaining healthcare when they need it, are more likely to be seen by a doctor, and to receive medicines [ 81]. Our findings present further evidence of the inverse care law - population groups with the highest levels of healthcare need (economically deprived, poor health status) often have the poorest access to services [ 23]. The findings suggest that regionally (Asia-Pacific), policy makers need to recognise the increasing inequities for these population groups and react accordingly which is inclusive of addressing the foundations of these inequities through policy/system change.

Excluding poor health and income, the picture is more complex when looking at trends in predictors within countries. For Thailand, the poorest level of access appears to be for respondents who work within the household whereas in Taiwan, part-time work is associated with difficulties in access. Within Hong Kong, results suggest that older (above 60) and retired individuals have the poorest access and within Australia, females and married individuals are the worst off. The countries involved in this study are in varying stages of socioeconomic and health development. The needs and functions of each country's healthcare system therefore vary and require policy reform tailored to the contours of their health systems. However, some conclusions can be drawn from the successes of these countries. While we identified health access to be problematic for older individuals in Hong Kong, recent policy has shifted to increase access to services for older individuals which indirectly, has been suggested to be delivering more equitable service for the remainder of citizens. Likewise, Taiwan has developed a system which was specifically designed to provide universal services for all individuals. Our findings also identify the need for national policies to address country-specific inequities.

Conclusion

It is recognised trans-nationally that public health policy and practice needs to focus on addressing the Social Determinants of Health in order to increase the health of the most vulnerable and disadvantaged groups [ 5]. This research has identified a number of social determinants which predict inequities in access to healthcare in six countries across Asia-Pacific. We have discussed our findings in relation to the political climate of healthcare in each of the six countries.

Recognition of these inequities, from a policy perspective, is essential for health sector policy decision-making [ 81]. Health policies shape health systems, and consequently, the broader determinants of health [ 82]. These policies should be informed by an understanding of the difficulties experienced by individuals when trying to obtain medical attention [ 36]. Despite the differences in political and economic climate in the countries under analysis, our findings highlight patterns of inequity which require policy responses. We argue that our data should be used as a means of deciding the most appropriate policy response for each country which includes, rather than excludes, socially marginalised population groups [ 83]. These findings should be of interest to those involved in health policy, but also in policy more generally because as we have identified, health is influenced by determinants outside of the health system [ 84].

Our results also provide baseline measures for identifying where and how policy should be altered to enable equitable access. Furthermore, as suggested for reforms in Hong Kong, these measures should be used for future policy evaluation to identify if shifts in policy have indeed improved access for the marginalised groups identified. An investigation into the possible causes of these inequities, and plans to address them, should be the focus of government agendas.

At this point, the authors wish to recognise and briefly discuss potential shortcomings stemming from aspects of the design, data collection and analytical procedures associated with this research. As presented in the results section, the amount of variance explained by the factors included in the models specified for all countries separately and combined was generally small as indicated by low Nagelkerke R2 estimates. It is therefore acknowledged that the (socio) demographic predictors included in the current investigation do not achieve substantial contributions to explaining response differences, hence further variables need to be investigated which might carry stronger predictive qualities for the outcome variables examined. Despite the comparatively small amount of variance explained, the models specified were (highly) significant which is taken as being indicative of small, yet significant contributions of (socio) demographic variables to various aspects of access to healthcare.

It is furthermore acknowledged that differences in survey format, the exact formulation of individual survey items and response options, as well as data collection in the different settings have potentially introduced biases when aggregating data and/or comparing the results. Maintaining data integrity and keeping the data collected as close to their raw form as possible meant particular predictor as well as outcome variable levels had to be collapsed and comparisons drawn between variables which are not 100% identical in terms of meaning, response format, etc. Several problems arise from this process, including the loss of fine-grained differences for certain predictor and outcome variable levels which may have resulted in slightly different make-up of significant regression models. Whilst this undoubtedly creates limitations for the extent to which the current findings can be generalised, this study presents the first attempts to conduct a secondary analysis of cross-country data collected for this specific purpose using study materials which have been generated with the aim to be applicable in different settings. The authors therefore acknowledge that limitations apply which mean the current results need to be interpreted and generalised with caution, and that replication is required to strengthen the existing body of evidence. Nevertheless, given the relative paucity of data in this area of interest, the current results add substantially to our current understanding of variables affecting access to healthcare in different countries.

Endnotes

¹The broader study from which the data in this manuscript emanate was based on Social Quality Theory (SQT). We have provided detailed manuscripts on SQT elsewhere Within Social Quality Theory, access to healthcare is identified as an indicator of social quality [ 52].

² Japan (Chiba University), Taiwan (National Taiwan University), Hong Kong (Chinese University Hong Kong), Thailand (King Prajadhipok Institute), Korea (Seoul National University).

³ The Japanese sample was not stratified according to health insurance type which may have implications for the interpretation of the Japanese data.

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Acknowledgements

We would like to thank members of the Asian Social Quality Network for assisting in developing the survey on which this manuscript is based. In particular, we would like to thank Prof Jaeyeol Yee and Prof Dukjin Chang from Seoul National University, Korea for driving the development of the survey. We would also like to thank those involved in the data collection in each of the participating countries and specifically, Prof Tetsuo Ogawa (Japan, Chiba University), Prof Lillian Wang (Taiwan, National Taiwan University), Prof Raymond Chan (Hong Kong, Chinese University Hong Kong), Prof Thawilwadee Bureekul (Thailand, King Prajadhipok Institute), Prof Dukjin Chang (South Korea, Seoul National University). Additionally we would like to acknowledge Flinders University Faculty of Health Sciences for funding this research via a faculty seeding grant.

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Authors and Affiliations

Discipline of Public Health, Flinders University, Sturt Road, Bedford Park, South Australia, 5042, Australia

Samantha B Meyer, Tini CN Luong, Loreen Mamerow & Paul R Ward

Corresponding author

Correspondence to Samantha B Meyer.

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The authors declare that they have no competing interests.

Authors' contributions

CNL and SBM participated in the design of the study, piloting and data collection. CNL and LM carried out the data analysis. All authors drafted the manuscript. PRW wrote the grant application and received funding for the study. All authors read and approved the final manuscript.

Samantha B Meyer, Tini CN Luong, Loreen Mamerow and Paul R Ward contributed equally to this work.

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Meyer, S.B., Luong, T.C., Mamerow, L. et al. Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries. BMC Health Serv Res 13, 238 (2013). https://doi.org/10.1186/1472-6963-13-238
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# data[].attributes.attachment_link.title
Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries - BMC Health Services Research

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Background Evidence suggests that there is a link between inequitable access to healthcare and inequitable distribution of illness. A recent World Health Organization report stated that there is a need for research and policy to address the critical role of health services in reducing inequities and preventing future inequities.

# data[].attributes.body
European Healthcare "One of the major similarities across healthcare systems in Europe  is that all citizens are included. Even in partially privatized systems, an individual mandate is in place (and strictly enforced) to ensure that healthy people are in the system to help offset the costs of sick people. Another commonality is that healthcare in Europe (regardless of system) is largely funded by tax dollars collected from employers and the public."

# data[].attributes.attachment_link.readable_text
The American healthcare system functions pretty differently than healthcare in Europe - and most healthcare systems in other first world countries, for that matter. With the ongoing healthcare debate in America (from repealing and replacing the Affordable Care Act to Senator Sanders' Medicare-For-All proposal), many people have begun to ask why we can't have a system like Canada, the U.K., France, or most other European nations. In order to decide whether or not those types of systems would be suitable for America (a debate we will not delve into here), we first have to understand how healthcare in Europe works.

How Healthcare in Europe Works

One of the major similarities across healthcare systems in Europe is that all citizens are included. Even in partially privatized systems, an individual mandate is in place (and strictly enforced) to ensure that healthy people are in the system to help offset the costs of sick people. Another commonality is that healthcare in Europe (regardless of system) is largely funded by tax dollars collected from employers and the public.

In many cases, this is through a simple payroll tax, similar to what Senator Sanders has proposed in his Medicare-For-All plan and how we already fund Medicare today. However, there are always other sources, including (but not limited to) earmarked Federal funds coming from income taxes, the insurance companies themselves, and additional taxes on tobacco and alcohol (similar to what some U.S. cities have called "sin taxes").

The Infamous "Single-Payer" System

In a single-payer system, the government funds a type of universal health coverage (meaning that the government is a health insurance provider), but most healthcare is actually provided by private entities. Hospitals are typically privately owned (although there could be some government run hospitals) and doctors operate their own practices.

Canada (while not actually a European nation, is still under Queen Elizabeth's rule) falls into this category. Citizens often purchase private insurance plans (as their incomes allow) to supplement the government provided healthcare.

Government Owned and Run Universal Healthcare

Although not entirely accurate, when most Americans think of healthcare in Europe, they're thinking of a socialized system. In this type healthcare system, the government typically has control of both health insurance and the providers within the industry. The government is essentially the only health insurance provider. It also runs (and owns) hospitals and employs healthcare providers, like doctors.

Britain, France, Italy, Norway, Spain, and Sweden use variations of this system. Every citizen is enrolled in the national healthcare system and a good portion of medical services are provided free of charge by doctors who are employed by the government.

In some (if not all) of these countries, there is some room for private insurance companies to operate and for doctors to run private practices. Of course, only those who can afford it would be able to purchase supplemental policies or pay to see doctors not employed by the government. In most cases, these policies are used for elective procedures and the doctors are specialists not included in the government system (although there are specialists within the system).

France, for example, has a substantial private system mixed in with their statutory health insurance system (SHI). Many French citizens gain eligibility for SHI through employment, but students, retirees, and unemployed adults who were formerly employed (and their families) are granted SHI eligibility as a benefit. It's rare for individuals to be granted an exemption from SHI.

Private health insurance can also be purchased as a supplement to the national healthcare system. These policies generally help cover the cost of "copayments for usual care, balance billing , and vision and dental care ([which is] minimally covered by SHI)." Oftentimes, these policies are purchased through employers and have varying degrees of quality that depend, in part, on the industry in which the employer operates. Some may be more expensive and provide better benefits, while those who couldn't afford such policies may end up paying more out-of-pocket.

But France didn't want some people being able to access better care than others - since part of the point of universal coverage is that everyone has equal access to quality care. So legislators passed a law in 2013 to help "reduce inequities in coverage stemming from variations in access and quality" among private policies.

The law mandated that by 2016, all employees would split the cost (50-50) of employer-sponsored insurance, which would help cover up to 125 percent of dental costs and €100 of vision costs (again,not typically paid for by SHI).

This type of system is essentially how Medicare, Medicaid, and the Veterans Affairs healthcare concepts are framed. Basic health insurance is provided through the government and supplemental policies can be purchased through private insurers, where available - although because Medicaid is for very low-income citizens, one would assume enrollees would be unable to afford supplements.

In many healthcare systems across Europe that allow for private policies, the structure is similar to what Americans are accustomed to, in that policyholders are responsible for coinsurance, copays, and balance billing.

Privatized, But Regulated

Those making more than that amount are allowed to bypass the public system to purchase private health insurance, although the vast majority of Germans choose to keep the public option. The main exceptions to this rule are the self-employed and civil servants, who are the largest purchasers of private insurance.

How Some Healthcare in Europe is Similar to the U.S. Healthcare System Under the Affordable Care Act

The Netherlands and Switzerland have systems very similar to the American Affordable Care Act (ACA), in that health insurance is mandated (and strictly enforced) to all citizens, but insurance is not provided by the government. Citizens are free to purchase insurance through whatever company they choose. Just like the ACA, insurance premiums are partially funded through subsidies provided by the government (through taxes) so that policies are truly affordable for everyone.

Because every citizen has to legally obtain health insurance, no insurer is allowed to refuse anyone for any reason. There is less regulation on supplemental policies, as they are not required by law, so it's possible that people could be denied coverage on those policies based on health information and history.

This model means that there are some out-of-pocket costs, such as a deductible, coinsurance and copays, but the costs are nowhere near what Americans pay and the system is far simpler.

What This Means for Employer Provided Benefits

Employee benefits still hold a place in Europe, but certainly not to the extent they do in America. In most cases, healthcare in Europe (regardless of the type of system) only covers medical care - and in some cases, very basic medical care, at that. In nations where insurance and healthcare are at least partially privatized (and where it's legal to do so), some companies offer employer-sponsored health insurance to supplement the government mandated policies.

These types of plans frequently include dental or vision insurance, policies that expand their network of doctors or covered services (like mental health), or premium-type plans that bump enrollees to the front of the line for elective or non-emergent procedures.

Is Healthcare in Europe Better Than in the U.S.?

Whether healthcare in Europe is really "better" simply depends on how you look at it and the metric being used. One of the main complaints of universal-type coverage is the wait time to see doctors for non-emergent conditions (this is especially true in Canada). Opponents of these systems typically list this as a major reason for wanting to keep the existing U.S. system.

However, most people who live in countries offering such systems much prefer it to what American citizens deal with. They may have to wait a few days to see a doctor, but they also don't have many out-of-pocket costs associated with their healthcare - and when they do, it's substantially less than what Americans pay.

For example, in France, the copay for a night in the hospital is €18. In America, you can hardly get a prescription for $18, let alone anything involving a hospital stay. A night in an American hospital could easily cost policyholders thousands of dollars.

The other major drawback opponents of universal care bring up is higher taxes. The tax burden associated with healthcare in Europe varies by country, but in some places, citizens forfeit half their salaries. This seems extensive to Americans - and it's definitely a lot - but in many cases, the amount those citizens pay in taxes is similar or equal to the amount Americans pay for taxes plus health insurance premiums. So in the end, their salaries could end up being similar, but Europeans would have fewer out-of-pocket expenses, as Americans would have higher copays, coinsurance, and deductibles hanging over their heads.

It's fair to say that no system is perfect. Healthcare in Europe has strengths the U.S. system doesn't, and vice versa. Each country has to work out a system that works the best for them, which takes time - and given that the U.S. is still quite young by comparison to most European countries, it's likely that we have a long way to go in determining what works best for us.

What advantages does healthcare in Europe provide for employers? Leave us a comment below or contact us . We'd love to hear from you!

# data[].attributes.attachment_link.description
The American healthcare system functions pretty differently than healthcare in Europe - and most healthcare systems in other first world countries, for that matter. With the ongoing healthcare debate in America (from repealing and replacing the Affordable Care Act to Senator Sanders' Medicare-For-All proposal), many people have begun to ask why we can't have a system like Canada, the U.K., France, or most other European nations.

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I decided to switch paths.

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16.10: Ensure public access to information and protect fundamental freedoms, in accordance with national legislation and international agreements

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16.10: Ensure public access to information and protect fundamental freedoms, in accordance with national legislation and international agreements

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"Number of verified cases of killing, kidnapping, enforced disappearance, arbitrary detention and torture of journalists, associated media personnel, trade unionists and human rights advocates in the previous 12 months"

I thought this goal was interesting because I believe it is extremely important to protect everyone, especially our journalists who are risking their lives to find the truth.

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Ongoing and new violent conflicts around the world are derailing a global path to peace and achievement of SDG 16. Onequarter of humanity lives in conflict-affected areas and as of May 2022, a record 100 million people had been forcibly displaced worldwide--more than double the number a decade ago. Citizens also face challenges accessing justice, basic services/legal guarantees and are generally underrepresented due to ineffective institutions. Moreover, structural injustices, inequalities and emerging human rights challenges are putting peaceful and inclusive societies further out of reach. To meet SDG16 by 2030, action is needed to restore trust and to strengthen the capacity of institutions to secure justice for all and facilitate transitions to drive sustainable development.

Globally, about 457,000 people were victims of homicide in 2021- the highest number of victims in the last 20 years. The noticeable spike in killings in 2021 can be partly attributed to the economic repercussions of COVID-related restrictions, as well as an escalation of gang-related and socio-political violence in several countries. The homicide rate was 5.8 per 100,000 population, marginally lower than in 2015 (at 5.9 per 100,000). Men and boys represent about 80% of victims and 90% of suspects.

In 2022, the United Nations recorded 16,988 killings of civilians in armed conflicts: a 53% increase compared to 2021, and the first increase since the adoption of the 2030 Agenda. Four out of ten deaths occurred in Ukraine. One in five was a woman. The proportion of deaths by heavy weapons and explosive munitions increased significantly, from 13% in 2021 to 39% in 2022, in contrast to the steady decline over the previous five years.

Based on survey data from 114 countries, on average, approximately 69% of the population report feeling safe or very safe walking alone around the area in which they live after dark, a figure that has remained stable over the period 2016-2021. Women continue to feel significantly less safe than men.

In 75 countries (mostly low- and middle-income) with available data from 2014 to 2022, 8 in 10 children aged 1-14 years were subjected to some form of psychological aggression and/or physical punishment at home in the previous month. In 70 of these countries, at least half of children experience violent discipline on a regular basis.

In 2020, the number of trafficking victims detected worldwide fell for the first time in 20 years, as COVID-19 preventive measures changed the dynamics of exploitation while compromising anti-trafficking responses. As more victims are likely to remain undetected, increasing efforts are needed to tailor responses to the real prevalence of the crime.

For the period 2014-2021, only 55 countries (mostly low- and middleincome) have internationally comparable data on sexual violence in childhood against girls and only 12 have produced such data for boys. Across regions with representative estimates, the prevalence of sexual violence in childhood (by age 18) among young women aged 18-29 years ranges from 1% in Central and Southern Asia to 7% in Oceania (excluding Australia and New Zealand).

In 2021, the global prison population was 11.2 million, remaining relatively stable between 2015 and 2021, except for a temporary decline between 2019 and 2020. Some 3.4 million of all prisoners are unsentenced detainees and their share among all prisoners has remained at around 30% between 2015 and 2021 and far from the target of equal access to justice for all.

While tracing is a key measure in the process of investigating and disclosing the origins of illicit firearms, its systematic implementation remains a global challenge. On average, Member States with available data successfully traced one-third of seized weapons that are potentially traceable between 2016 and 2021.

Globally, approximately 1 in 7 (15%) businesses face requests for bribe payments by public officials, based on establishment-level data from 154 countries surveyed during 2006-2023.

Multiple crises undermine budget credibility across all regions. The average budget deviations compared to the approved budget decreased from 5- 10% in 2015 to the target of less than 5% in 2019. However, budget credibility deteriorated and reached a deviation of almost 10% for some regions in 2020 - 2021.

In every region of the world except Europe, people under the age of 45 are significantly underrepresented in parliament relative to their share of the national populations.

By providing all children with proof of legal identity from day one, their rights can be protected and universal access to justice and social services can be enabled. In 2022 the births of around 1 in 4 children under age 5 worldwide have never been officially recorded. Only half of the children under five years of age in sub-Saharan Africa have had their births registered.

Access to information (ATI) laws provide legal guarantees of the right to information and were adopted by 136 countries in 2022, up from 105 in 2015.

Source: Progress towards the Sustainable Development Goals: Towards a Rescue Plan for People and Planet - Report of the Secretary-General (Special Edition)

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Goal 16 | Department of Economic and Social Affairs

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Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

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The number of killings of journalists, human rights defenders, and trade unionists decreased in 2023. There was a sharp increase of journalists and media workers being killed however in conflict zones.

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Goal 16 | Department of Economic and Social Affairs

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Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

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"In 2024, 140 countries had laws that specifically guaranteed the rights of citizens to access public information, up from 105 in 2015 and 14 in 1990."

During my research of the UN website, I felt compelled to add this because I got curious about the extent to which governments actually protect their journalists and people's freedom of speech, if they allow it at all.

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Goal 16 | Department of Economic and Social Affairs

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Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

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"Between 2006 and 2024, over 1,700 journalists have been killed around the world, and around 85 percent of the cases did not make it to court, according to a report by the UN Educational, Scientific and Cultural Organization (UNESCO)."

I found this while searching for journalist deaths, but was quite surprised to discover that most of the cases of their intentional killings never make it to court.

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85 per cent of journalist killings go unpunished

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Between 2006 and 2024, over 1,700 journalists have been killed around the world, and around 85 percent of the cases did not make it to court, according to a report by the UN Educational, Scientific and Cultural Organization (UNESCO).

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"[In 2024], the number of journalists killed in conflict zones reached a five-year high, that's according to Reporters Without Borders, a press advocacy group that tracks journalists slain all over the world.

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Number of journalists killed in conflict zones reaches 5-year high, according to RSF

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At least 54 journalists were killed covering conflict zones in 2024, according to Reporters Without Borders. NPR speaks with the head of RSF in the U.S., Clayton Weimers.

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After reading about just how many deaths of journalists occur, I was really curious to find out more information relating to this topic such as the motive, the forms of violence, and the frequency.

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Physical safety – FPU Knowledge & Quality

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Physical violence against journalists comes in many different forms: from assault to abduction and at its most extreme, killing. Overall, over the past decade, a journalist has been killed on average every four days. In 2018-2019, UNESCO recorded a total of 156 killings of journalists worldwide.[1] The year 2019 shows the lowest death toll recorded by UNESCO in the last decade with 57 deaths. Despite this decrease in killings, journalism remains a dangerous profession. The threats faced by journalists are many and ever-changing. Furthermore, in recent times fewer journalists were killed, but this is mostly due to the decrease of killings of journalists in armed conflicts, related to a decrease in armed conflicts. According to UNESCO’s numbers, in 2018-2019, 89 journalists were killed in countries with no armed conflict, whereas 67 journalists were killed in countries where there was an armed conflict. Killings occur everywhere, but in 2019 the highest number of fatal attacks occurred in the Latin America and the Caribbean region, representing 40 percent of the total killings registered worldwide, followed by the Asia and the Pacific region with 26 percent of killings.[2]

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There is a large psychological effect of being a journalist because of the situations you experience or witness. 57 journalists who worked in Kenya agreed to take a survey and the results showed that 11 were wounded while working, and many had a perceived level of threat at moderately severe.

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The psychological effects of reporting extreme violence: a study of Kenyan journalists - Anthony Feinstein, Justus Wanga, John Owen, 2015

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Objective To assess the psychological health of journalists in Kenya who have reported on, and been exposed to, extreme violence. Design Descriptive. Psychologi…

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In 2021, almost half of the accounted for journalist deaths occurred in the Asia Pacific region. Of those 21 deaths, "nine were in Afghanistan, one in Bangladesh, four in India, one in Myanmar, three in Pakistan and three in the Philippines."

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"The press freedom situation has worsened in the Asia-Pacific region, where 26 of the 32 countries and territories have seen their scores fall in the 2024 World Press Freedom Index. The region’s dictatorial governments have been tightening their hold over news and information with increasing vigour."

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Reporters sans frontières assure la promotion et la défense de la liberté d’informer et d’être informé partout dans le monde. L’organisation, basée à Paris, compte des bureaux à l’international (Berlin, Bruxelles, Genève, Madrid, Stockholm, Tripoli, Tunis, Vienne et Washington DC) et plus de 150 correspondants répartis sur les cinq continents.

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The EU has adopted media laws, however, politicians are still trying to reduce "the space for independent journalism." Three European countries top the Reporters Without Borders Index which basically means that European countries are treating their journalists well and better in comparison to others.

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Reporters sans frontières assure la promotion et la défense de la liberté d’informer et d’être informé partout dans le monde. L’organisation, basée à Paris, compte des bureaux à l’international (Berlin, Bruxelles, Genève, Madrid, Stockholm, Tripoli, Tunis, Vienne et Washington DC) et plus de 150 correspondants répartis sur les cinq continents.

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"Latin America is a dangerous place to practice journalism. According to the Committee to Protect Journalists, the region accounted for nearly half of all killings of reporters and media workers in 2022. And while Mexico topped the list as the world’s deadliest country for the press, alarming developments in the neighboring states of Central America have garnered less attention."

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Crime and Punishment: The Twin Threats Faced by Journalists in Central America

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In addition to extralegal violence, the region’s independent media have been subjected to repressive laws and politicized prosecutions.

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Techniques used to get journalists to not publish

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Techniques used to get journalists to not publish

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In many countries, there are now new techniques being used to keep reporters quiet such as labeling them as "terrorists" or "extremists" so governments are given a valid reason to rid of reporting that upsets them. In addition to the already known kidnapping and murders, financial pressure and defamation are being used too.

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Truth is in danger as new techniques used to stop journalists covering the news

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The truth is being suppressed across the world using a variety of methods, according to a special report.

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I think it's really interesting that there is actual proof that the more freedom of press there is, the happier the country is.

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Press freedom leads to happiness, environmental quality

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Researchers have found that citizens of countries with press freedom tend to be much happier than citizens of countries without free presses.

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For journalists, it is recommended for them to plan exit routes before going into the field as well as preparing for tear gas, being pepper sprayed or being shot. Some options are wearing a bullet proof vest and keeping a gun wound kit with you, having emergency contact info, identification, appropriate clothing, and food and water. Most importantly, make sure to rest and recover after draining assignments.

I personally find this to be very upsetting because I feel journalists should not have to consider this when entering the field to do their job. It simply is not something that journalists sign up for when entering their career.

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Risk Assessment and Physical Safety: What Every Journalist Should Know - PEN America

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Recent attacks on student reporters covering campus protests highlight an uncomfortable truth: Journalist safety is declining in the U.S.

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They provide:

Medical assistance: for injuries sustained in the course of the journalists work;

Subsistence costs: short term support for journalists who are not able to work, or costs to temporarily flee an unsafe or vulnerable situation;

Legal defense support: legal representation for journalists facing prosecution, disputable lawsuits, or any other form of legal intimidation related to their work; cover the costs of judicial proceedings; assist media workers that have been arbitrarily detained or imprisoned (and their families);

Psycho-social support: advice, referral, and funds to seek psychosocial assistance;

Work provisions: replacement of confiscated or destroyed equipment due to a work-related emergency;

Family support: temporary support for family members of journalists who are unable to work, who are imprisoned, or who are deceased;

(Preventive) safety measures: security advice, digital tools such as VPNs for digital protection, PPE protection materials like face masks, and safety equipment like ballistic vests.

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Reporters Respond: emergency & legal support

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Around the world, journalism faces increasing and unprecedented levels of repression, violence, intimidation, and judicial harassment. If journalists are being attacked and silenced, the media cannot provide their audiences with the independent and reliable news that people need in order to stay informed and thrive.

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chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://rsf.org/sites/default/files/medias/file/2024/12/RSF%20Round-up%202024%20EN.pdf

A third of the journalists killed in 2024 were slain by the Israeli armed forces

550 journalists detained

55 journalists held hostage

95 missing journalists

Due to the large numbers presented regarding the violence against journalists in Gaza/Palestine, I thought I should look deeper into just how bad the situation is along with how they are protected by outside forces.

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In 2024, the most dangerous region for journalists was Gaza which "accounted for nearly 30% of journalists killed on the job" by the Israeli army. In addition to this, Palestine was reported to be the most dangerous country for journalists "recording a higher death toll than any other country over the past five years" with over "145 journalists" being killed since October 2023, "including at least 35 targeted in the line of duty," according to RSF's latest data.

As mentioned in my previous post, I decided to look into the extent of violence against journalists in Gaza/Palestine and as shown here, it is obvious that this region is experiencing the worst. So, I decided that I would look into this region specifically.

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RSF’s 2024 Round-up: journalism suffers exorbitant human cost due to conflicts and repressive regimes

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The Reporters Without Borders (RSF) 2024 Round-up reveals an alarming intensification of attacks on journalists — especially in conflict zones, where over half of the news professionals who lost their lives this year perished. Gaza stands out as the most dangerous region in the world, with the highest number of journalists murdered in connection with their work in the last five years. Since October 2023, over 145 journalists have been killed by the Israeli army, including at least 35 whose deaths were linked to their journalism. What’s more, 550 journalists are currently imprisoned worldwide, a 7% increase from last year. This violence — often perpetrated by governments and armed groups with total impunity — needs an immediate response. RSF calls for urgent action to protect journalists and journalism.

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Goal: “single, strategic and harmonised approach to the issue of the safety of journalists and the impunity of perpetrators of crimes against them” proposed in the UN Plan of Action on the Safety of Journalists and the Issue of Impunity

RSF claims that the UN "lack[s] the coordination, resources and authority needed to promote actions proportionate to the gravity of the situation" and that their good intentions are not enough.

New plan advocated by RSF: Special Representative of the UN Secretary-General for the Safety of Journalists (SRSJ)

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A worldwide coalition of NGOs, media outlets, journalists and prominent public figures are supporting Reporters Without Borders (RSF) initiative for the creation of a Special Representative to the United Nations Secretary General for the safety of journalists. It is an urgent issue for all those who want to end violence against reporters and defend access to information around the world.

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I think I want to research Violence Against Journalists and Solutions Towards Peace which must be addressed to reach SDG #16. I will focus on Gaza and Palestine and find a definite solution due to the little solutions available at the moment. I want to research this because I find it unfair that people who are simply doing their job and helping others find the truth are being killed, held hostage, and kidnapped for doing so.

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What country's governments have legal protections for journalists? Is there evidence that those governments act on such laws or to what extent do they do so?

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What are the limiting factors to providing protections and international assistance to journalists in the Gaza region?

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Is there evidence that foreign correspondents are provided protections and precautions by their respective countries when reporting in Gaza and Palestine?

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I was struggling with deciding between Q1 and Q3, so I decided to combine them. I understand it is lengthy, but I will likely edit it once I begin the process of writing my paper.

What country's governments have legal protections for journalists? Is there evidence that those governments act on such laws or to what extent do they do so and do those protections follow them outside their respective countries, specifically in Gaza and Palestine?