EU Action to Reduce Health Inequalities

Consultation Paper

EU action to reduce health inequalities

IPPFEN contribution to the European Commission’s consultation on health inequality - April 2008

The IPPF European Network (IPPF EN) is one of six regions of the International Planned Parenthood Federation (IPPF) the world's largest voluntary organisation in the field of sexual and reproductive health and rights. IPPF links national Member Associations (MAs) in more than 166 countries worldwide, with the aim of increasing support for, and access to sexual and reproductive health services. The IPPF European Network has Member Associations in 41 countries and is active in several more throughout Europe and Central Asia. All people, particularly the poor, marginalized, the socially-excluded and underserved are able to:

exercise their rights,
to make free and informed choices about their sexual and reproductive health,
and have access to sexual and reproductive health information, sexuality education and high quality services

The health challenges the European Union and its neighbouring countries presently face are manifold. One of the main issues and challenges is how to ensure equitable access to health education, health information and health services, especially for those who are marginalized and/or poor.

IPPFEN welcomes the Commission’s initiative to consult on the fight against health inequalities and is pleased to submit its contribution. We are not in the position to reply to all the interesting and challenging questions of the consultation but we hope to provide some inputs that can be useful food for thought.

The information included in this paper is the outcome of internal discussions and is based on recommendations that we made in our policy statements.

Introduction

We would like to start our contribution highlighting the difference between poverty and social exclusion and stressing how both phenomena affect health inequalities.

For poverty we support the definition provided by SIUDA, the Swedish development aid agency: The essence of poverty is not only lack of material resources but also lack of power and choice

As for social exclusion we will follow the definition provided by the UK government: and we define social exclusion as :"What can happen when people or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime, bad health and family breakdown".

Key factors that contribute to being out of the system are:

deprived neighbourhood and rural areas
homeless;
people not in education, training or employment;
truancy and school exclusion.

Our observation is that there are several reasons why lower socio-economic groups have worse health among them are:

work related health problems –poor people usually have jobs which are more harmful for their health
live in poorer housing
have more mental problems caused by stress, worries, stigma, self stigma and social exclusion
have more physical problems caused by stress, depression (link with mental health) as well as late diagnostics.

Poor people and people socially excluded in general do not access primary health care and tend to wait until symptoms are serious and can no longer be ignored. This leads to later diagnosis and poor health, and a heavy burden of cost on the health service in the longer term

less access to health care services
lower education about how to take care of one health
focus on short-term: the fact that the life of the "poorer" is harder can make people less prone tothe additionalsacrifices required to take care of one's health (stop smoking or drinking alcohol, eating healthy, doing exercise etc...). Taking care of one´s health is a longterm investment, andfor many people the sacrifices of the short term are so big that they cannotthink of the long term...

Barriers to progress and other challenges

•inequities related to gender and sexual orientation (need to monitor both women and man’s access)

•poor respect for human rights

•exposure to risk

•inequities related to poverty and other vulnerable situations (exclusion from access to services)

•reforms and weakness of health systems

The impact of poverty, marginalisation and social exclusion in the field of sexual and reproductive health and rights means:

Lack of access to sexual and reproductive health services and information
Lack of freedom, choice and ability to demand one’s rights

The impact of this inequality in our field is:

Increased risk of maternal mortality/morbidity,
Unsafe abortion,
STI/HIV infection,
infertility……

The barriers that we see in our field are typical and therefore should be considered in the strategy to tackle health inequalities. They are the following:

Lack of self esteem and culture of ‘rights’
Gender inequality
Socio economic factors
Stigma
Language
Culture and religion
Legal status
Discriminatory attitude of service providers
Ignorance
Physical barriers

Below we make some concrete examples based on our experience in our sector:

Poverty and social exclusion increase vulnerability to sexual exploitation, rape, violence etc, and reduce access to SRH services as well as women’s ability to make choices on their sexual and reproductive lifetrafficked women can not negotiate sex, condom use, abortion, children

The literacy level and the command of the national language have a big impact on the ability to access information, education and services. Gender inequality and culture can be other barriers. E.g. a person that does not know in the first place how

he/she may get infected with an STI or HIV, will never go for a testing. Awareness and access to good education key for the uptake of services.

Often, marginalized groups such as illegal migrants, trafficked persons, asylum seekers etc. do not have health insurance. Health care policies in most EU member states only cover legal residents and citizens. This in turn, means that they cannot have access to affordable sexual and reproductive health services

Stigma and discrimination of people living with HIV can lead to their social exclusion (employment, relationships, etc.). Consequently family income may be reduced, and with it the family’s ability to invest in such goods as education and health care. Mitigating the economic impact of the disease requires attention to both prevention and treatment, as well as to other efforts to lessen its social impact. And, stigma and discrimination of e.g. HIV may lead to a rise in HIV infections that remain undetected because people do not access the testing services.

IPPF EN has identified the following groups as facing specificbarriers to access to SRHR and therefore to be particularly at risk:

Homeless
young people and particularly marginalised ones
Illegal immigrants (e.g. trafficked people, asylum seekers
and refugees) and ethnic minorities (E.g. Roma)
Lesbian Gay Bisexual and Transgender
Drug users
Sex workers
Prisoners
People in institutions
People living with HIV
The ‘INVISIBLE’ people

For invisible we mean the populations that are included in the system and have rights but their needs are not taken into consideration in the design of services and are not demanded by the members of these communities because of the stigma they face or fear to face: e.g. gay and lesbians sexual and reproductive needs, disabled and their sexual and reproductive needs, people living with HIV and their sexual and reproductive needs, senior people and their sexual needs…

Lessons learned to share with the European Commission and principles of a successful approach

We saw in our programmes that:

Key is people’s empowerment and a genuine participatory approach in policy making

Our strategy to address inequality is:

- Take tailored SRH services to target groups

- Use a inter-mediator to help people navigate the system

- Have an inclusive culture (involvement and participation in all programs)

- Integrate package of services and information

- Implement a quality of care model based on clients’ rights and service providers’ needs

- Include a clinical electronic management system to help monitoring and evaluation and ensure an institutional learning culture

We believe that any policy development or area of legislation aiming at addressing health inequalities should, besides the specific subject, take into account some issues which are cross-cutting and very important to achieve the best results

These issues are gender, diversity, participation of target groups, service providers and civil society; the need for a multi-sectoral approach and a right based culture

We stressedthat roots of health inequality are multidimensional. The lack of financial means of vulnerable populations is a crucial, but not exclusive cause.

Combating health inequality must include empowerment of people affected by poverty and social exclusion and this requires a multidimensional, structural, long term and dynamic approach; it also requires the implementation of tailor-made measures;

The empowerment of people experiencing inequality accessing the health system needs action on three levels: on building individual capacity, on supporting social networks, and on stimulating participation in policy-making processes;

Governments at national and local levels, target groups and the representatives of civil society have a key role to play separately and in partnership in countering health inequalities poverty and in empowerment of those affected by it;

The effective implementation of coherent and sufficiently ambitious policies against health inequalitiesat EU, national and local level requires that necessary financial and human resources are made available and key responsibilities are defined;

Suggestions on how to address health inequality

New investments in health information strategy to address low levels of health literacy among EU citizens, and particularly in large sections of vulnerable poor and socially excluded population through the use of appropriate language, communication format and dissemination channels.
Adjustments to be made to the healthcare delivery process in order to increase its effectiveness among the target populations e.g. through promoting extended opening hours of primary care services, outreach services and staff trained on working effectively with target patients. We could share our model for ‘youth friendly services’ if there is an interest.
The systematic collection and availability of sex, ethnic, age disaggregated data for use in planning, implementation and evaluation of primary care service delivery.
On the Commission to build on existing expertise and fund the development of the first publicly-funded report on the state of socially excluded people’s and poor people’s health in Europe.

More visibility to be given to surveys on migrant issues especially undocumented migrants, migrants, asylum seekers and refugees, trafficked victims at national.
An important model to work with migrant community is the ‘community health mediator’. We have experience with health mediators for Roma community in Bulgaria and is very useful. The health mediator is a key link between service providers and the community. It facilitates access to health care for the most underserved groups and can be of great value in reaching out to migrants, internally displaced people, refugees as well as specific key populations hard to reach. In Bulgaria the Roma health mediators are funded by municipalities although we support a model funded by the state to avoid ‘inequalities’ among reach and poor municipalities. The profession of health mediators should be institutionalised and recognised in the Health system as well as monitored and evaluated. This Model is used in Bulgaria and Romania, cultural mediators are also used in Finland and Italy.
It is important that Ministries of health and general practitioners cooperate and get sensitized and trained in working in multi ethnic environment
The inclusion of gender and its relevance to the effectiveness of health interventions in the curriculum and continuous training of all health professionals including pharmacists and health promotion and prevention campaigners.
The training of policy makers and health service managers in interpreting and making the most effective use of sex disaggregated data in a gender-based culturally sensitive approach to service delivery.

Regarding inequalities between Member States

In some countries there is a problem with good governance in the health sector (namely corruption, bribes…) therefore we would propose also to look into:

Monitoring delivery of health care to different socio-economic groups in the Member States.Both quantity and quality of health care provided should be monitored, as well as coverage of health insurance and co-payment.

Monitoring of working conditions of health care personnel.

Priority to investment in health care infrastructure andprogrammes for tackling health inequalities in Structural Funds. Programmes

Within a country of the European Union

It might be useful to prioritise"Health inequalities at Work" in the workplan of the European Agency for Safety and Health at Work and ‘the Right and Access to Health’ in the work plan of the EU Fundamental Rights Agency to monitor the situation with regard to vulnerable groups.

Please find enclosed below a number of Annexes with our best practices in relation to addressing health inequalities in our policy work and in our service delivery.

You will find examples of quality of care and clinical management built on a right based approach, policy recommendations on the inclusion of the ROMA and a very successful research program to combat stigma and discrimination of people living with HIV based on the participation and ownership of the target group.

We hope that you will find the information useful for your work.

April 2008

If you need more information please don’t hesitate to contact me:

ANNNEX

IPPF Best Practices

1. Quality of Care model

We welcome the commitments that the European Commission has made to tackle health inequality. It is a promise and a challenge. The challenge is to make rights a reality even when resources are scarce. As NGO and service delivering agency we know the challenge very well. IPPF developed a world tested Quality of Care model to make sure that we apply a right based approach and at the same time ensure the highest possible quality.

IPPFEN believes in innovative management models.We created a Quality of Care system based on clients rights and service providers’ needs that governments could use as a reference if they feel appropriate.

Some of our members operating in very poor settings and in countries where there is no health insurance system and in which getting funding from government is difficult consider that the Quality of Health model is a potential solution to increase access to health services of the poor and social excluded.

Clinics and service providers that provide high quality attract clients, including the wealthy ones. The income generation help making the services sustainable and can also be redistributed to alleviate health inequalities. Namely by allowing a number of poor clients to access the service for free because of the fees charged to the wealthy ones.

Good quality of care enhances clients' satisfaction and their use of services. It increases job satisfaction and motivation among service providers, and leads to greater sustainability of services. It does not necessarily require big investments but has a big impact on the quality of service delivery.

In IPPF, quality of care is based on the 'Rights of the Client' and 'Needs of Service Providers' framework. To ensure good quality of care, clients have the right to information, access to services, choice, safety, privacy and confidentiality, dignity and comfort, continuity of services, and opinion.

To fulfill these rights, the needs of service providers must be met as well. These include the needs for: training, information, proper infrastructure and supplies, guidance, backup, respect and encouragement, feedback on their performance, and opportunities for self expression.

Starting from this framework, IPPF launched the 'Strengthening the Quality of Reproductive Health Care' program in 2001. The project is moving the quality of care concepts into practice, by:

Updating essential standards for the provision of reproductive health care
Establishing systems of quality improvement that include self-assessment and planning with participation of service providers and managers at all levels of the service delivery program
Instituting improved medical and technical training for providers of care
Increasing the availability and quality of medical and technical information
Instituting a system of recognition for good quality of care by means of a 'Quality of Care' award

The Quality of Care model was created for reproductive health services but can be adapted to any type of health services. 34 Member Associationsin 34 countries across all six of IPPF's regions are currently taking part in the programme. In the future, we hope to expand the programme to additional Associations.

2. Clinical Information Management System – how to monitor access of vulnerable population to health system

The “Clinical Information Management System” (CMIS) was developed by the IPPF and consultants on the basis of the “Open Electronic Management Record (OpenEMR) system source. This is the tool for clinical management that handles together client data, income data and services and product data.

Main characteristics

The system aims to facilitate clinic management covering all services and product delivery. The OpenEMR project includes:

Creating client records and finding clients in the system
Entering client demographic and medical history data
Scheduling of clients by service provider
Billing and inventory basic functions
Reporting to Headquarter/service statistics
Local analyses reports including client, financial, service, product information
Paper-based backup system.

What is the electronic medical record?

The electronic medical record incorporates: 1) Client’s demographic profile, 2) Client’s static clinic history, 3) Client’s dynamic clinic data, and 4) Client’s visit-related data.