T03P07 - Urban Policies & Health Inequalities

Topic : Policy and Politics sponsored by Policy & Politics Journal

Panel Chair : Daniel Weinstock - directoradmin.ihsp@mcgill.ca

Panel Second Chair : Shona Hilton - shona.hilton@glasgow.ac.uk

Objectives and Scientific Relevance of the panel

Call for papers

Session 1 Identifying & Explaining Urban Health Inequalities

Discussants

Daniel Weinstock - directoradmin.ihsp@mcgill.ca - Institute for Health & Social Policy - Canada

Comparing the effects of China’s three basic medical insurance schemes on the equity of health-related quality of life: using the method of coarsened exact matching

Min Su - sumin1227@126.com - School of Public Policy and Administration, Xi’an Jiaotong University - China

Background: Health equity has long been considered as an essential goal pursued by health systems. Previous research suggested that medical insurance could reduce health inequity. China has launched three basic health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS). However, few studies were available to compare the effects of different medical insurance schemes on the equity of health-related quality of life (HRQoL). This study aimed to compare the equity of HRQoL of the insured residents between two of the medical insurance schemes.

 

Methods: The data were derived from the 5th National Health Services Survey of Shaanxi Province. The coarsened exact matching method was employed to partly solve the potential confounding influences before comparing the health equity of different health insurances. The final matched sample consisted of 6,802 respondents between UEBMI and URBMI, 34,169 respondents between UEBMI and NRCMS, and 36,964 respondents between URBMI and NRCMS. HRQoL was measured by EQ-5D-3L utility value based on the Chinese-specific tariff. The concentration index was adopted to assess the health inequity and it was further decomposed into its contributing factors.

 

Results: Based on the coarsened exact matching method, the results showed that the mean EQ-5D utility scores were 0.9589 and 0.9449 in UEBMI and URBMI, 0.9579 and 0.9473 in UEBMI and NRCMS, and 0.9505 and 0.9605 in URBMI and NRCMS respectively. Furthermore, the horizontal inequity indexes of EQ-5D utility scores were 0.0036 and 0.0045 in UEBMI and URBMI, 0.0035 and 0.0058 in UEBMI and NRCMS, and 0.0053 and 0.0052 in URBMI and NRCMS respectively. The horizontal inequities were mainly explained by age, educational and economic statuses for both rural and urban insured residents.

 

Conclusions: The findings from our study have demonstrated that residents insured with URBMI or NRCMS had worse HRQoL than those insured with UEBMI in Shaanxi Province. The pro-rich health inequity was much higher for the rural basic medical insurance scheme than that for the urban basic medical insurance scheme. This study highlights the need to integrate the basic health insurance schemes in China. To reduce pro-rich health inequity in Shaanxi Province, strategies that aim to improve the health conditions of the aged population, narrow the economic gap, and reduce educational inequity, are essential.

 

Keywords: Basic medical insurance schemes; Health-related quality of life; Coarsened exact matching; Health equity; Decomposition; China

'Natural Advocates of the People?' Evaluating the Social Responsibility of GPs in Tackling Scotland’s Health Inequalities

Breannon Babbel - bebabbel@gmail.com - University of Glasgow - United States

Context: In Scotland, socioeconomically disadvantaged areas suffer disproportionately from high levels of premature multimorbidity. The potential role of general practitioners (GPs) merits attention in helping to address these health inequalities, particularly as they have been described as ‘advocates for the people’. Inherent within this social responsibility model is that GPs have obligations beyond individual patients to the communities they practice and within the wider health system. However, minimal research has been done to understand how they view this role and what they think can be done in primary care to address health inequalities.

 

Research Question: This paper aims to address the research question of how GPs working in disadvantaged, urban neighbourhoods view their potential role in tackling health inequalities. 

 

Methods: This study uses semi-structured interviews with 24 GPs selected from the 150 most socioeconomically deprived practices in Scotland. Interviews took place during fall/winter of 2014-15 in participants’ practices located in urban, socioeconomically disadvantaged communities primarily in or around Glasgow, Scotland. Analysis of participant discourse was aided by NVivo software and was focused on establishing a hierarchy of GP engagement.

 

Findings: This paper reveals that beyond their traditional frontline work and clinical duties, GPs felt they could contribute to tackling health inequalities through advocacy efforts ranging from individual, community, and policy/political levels. Thus, GPs felt responsibility not only for their patient’s individual clinical care, but also for addressing wider social issues. In line with this, many of the participants also noted the need to provide a voice for the disadvantaged communities in which they work. A group known as ‘General Practitioners at the Deep End’ has been particularly vital in providing a clear platform for the organisation of this advocacy.

 

Conclusions:  In Scotland, GPs working in disadvantaged, urban communities feel a social responsibility to not only address individual patients’ clinical and social care, but also to influence policy and politics which relate to the social determinants of health. Consequently, this paper provides critical insight into the use of GPs as key actors in working towards the integration of health and social care to address social inequalities in health. It provides further benefit to the panel through its in-depth study of GPs working in Scotland’s most disadvantaged urban areas.

Charting mental health inequalities: integrated mental health atlases as policy instruments

James Gillespie - james.gillespie@sydney.edu.au - Menzies Centre for Health Policy, University of Sydney. - Australia

Jennifer Smith-Merry - Jennifer.smith-merry@sydney.edu.au - University of Sydney - Australia

Most mental health care remains hospital centric and fragmented; it is riddled with gaps and poor alignment of spatial distributions of need and services. These limitations create major barriers to recovery. Reform must be built on better knowledge of the shape of existing services. Mental health atlases are an essential part of this knowledge base, enabling comparisons over time and between regions and jurisdictions. Mapping must be based on a rigorous system of classification of services.

This paper presents the implications for policy of a major international program of mental health service mapping. Regional integrated mental health atlases are being used to enhance policy-making and priority setting through more fine grained evidence on local services and systematic international comparisons. The paper draws on recent mapping exercises in Australian cities, especially the Western Regions of Sydney, with comparisons from the application of the same methods in Finland, Spain, France and Chile.

Methods. A standard classification system, the Description and Evaluation of Services and Directories in Europe for Long-term Care model (DESDE LTC), developed under the leadership of Luis Salvador-Carulla, is used to describe and classify adult mental health services at regional level. The paper looks closely at the recent use of this coding scheme to produce accessibility maps and to analyse the provision of care for people with a lived experience of mental illness. The integrated map of Western Sydney mental health services is used to compare service provision with patterns of need. Comparisons are made with similar regional maps– internationally and at national level - to identify gaps or unusual patterns of service delivery.

The Atlas provided the foundation for other forms of health service analysis – including qualitative and historical methods to explain persistent service configurations.

Policy analysis. The paper looks at the identification of service gaps and inequalities identified in recent Australian mapping exercises.  It explores some of the challenges of extending the mapping model to lower income settings.

Analyzing on the inequality of health human resource from the year of 2005 to 2014 in China

Li Dan - 1310407250@qq.com - China

Background: With the deepening of the reform and opening up, especially the new round health-care reform in November 2009, the health human resource in China had made great progress. However, the current situation of “Kan Bing Nan, Kan Bing Gui” (medical treatment was difficult to access and expensive) was increasingly prominent, and the problem could trace its roots to the unequal health resources, especially health human resource. This paper aims to contribute to a better understanding of the inequality of health human resource throughout China from 2005 to 2014, and furthermore, to decompose the inequality of HRH based on economy and region. This study will provide the government theoretical basis for optimizing health resource allocation.

Methods: After collecting data from the National Bureau of statistics of China from 2005 to 2014, the method of descriptive analysis was employed to describe the distribution of HRH. ArcGIS 10.2 (Esri China Information Technology Co., China) was used to draw the distribution of in China. The Concentration index and the Gini coefficient were employed to analyze the inequality of HRH.

Results: The number of physicians, nurses and the number of physicians per 10 000 population, nurses per 10 000 population showed an growing trend from 2005 to 2014. The total Gini coefficient of physicians and nurses fluctuated greatly, but they were still less than 0.35. The economic-related Concentration index was positive, with the ranges of 0.0881~0.1689, 0.1082~0.2157 respectively. And the Concentration index of physicians per 10 000 population was smaller than the nurses. The region-related Gini coefficient of physicians/nurses in seven regions showed a downward trend in the last decade, and reached the minimum at 0.0586, 0.0438 respectively in 2014. The proportion of economic factor’s contribution to the inequality of physicians per 10 000 population slightly increased, while the regional factor’s contribution showed a downward trend. The proportion of economic factor’s contribution to the inequality of physicians/nurses showed an upward tendency in fluctuation, while the regional factor’s contribution showed a fluctuating downward trend.

Conclusions: The inequality in the national distribution exsited in the last decade, but it was relatively satisfactory. The economic-related inequality changed and fluctuated; the regional-related inequality was relatively low, and showed a downward trend over time. In consequence, there was a general need to improve the inequality of HRH by adjusting the unreasonable structure of the HHR , formulating the inclination policy to underdeveloped areas and optimizing the regional layout constantly.

Urban politics, health policy, and frontline state practices: Explaining low-quality health care in urban India

Radhika Gore - rjg150@columbia.edu - Columbia University, Mailman School of Public Health - United States

Studies widely highlight a "know-do" gap in health care delivery in low-middle income countries. In the case of urban India, they show how doctors in state-run primary care clinics possess requisite medical knowledge, but do not expend adequate effort to treat patients. Researchers have commonly explained this gap in terms of the doctors’ skills and incentives to perform. Conceiving health care as a transaction (an exchange of medical advice for financial and affective rewards), they argue that doctors underperform because the micro-institutions that drive doctors’ clinical behavior are faulty.

In this paper, I challenge this dominant perspective, showing how urban policy shapes local health care practices and contributes to health inequalities in urban India. Conceiving health care as a social act (shaped by collective narratives and social relations), and viewing public sector doctors as both medical practitioners and state agents, I argue that health service outcomes depend on how the doctors interpret and implement policy mandates and relate to the communities they serve. My analysis is based on an ethnographic study of doctors employed in municipal government clinics and hospitals in Pune, a rapidly growing city of three million in India. During year-long fieldwork (2013-2014), I observed municipal doctors’ clinical and non-clinical encounters and conducted 102 interviews with doctors, other health workers, elected officials, administrators, NGO staff, and academics. To situate this street-level evidence in historical perspective, I examined how urban development programs, health policies, and administrative arrangements for urban health care have configured municipal doctors’ work conditions, especially since economic liberalization reforms beginning in the 1980s.

By thus examining both local policy implementation and extra-local policy decisions, I demonstrate that municipal doctors regularly confront dilemmas stemming from (1) a legal obligation to deliver urban primary care inside an outdated urban governance structure and under-resourced municipal health system, and (2) an avid and largely unregulated private health care sector that city residents widely prefer. Unable to remedy these challenges in everyday practice, doctors circumscribe their actions, seeking, as one doctor put it, only to ensure the ordinary. My findings suggest that transaction-specific interventions to improve performance, like enhancing doctors’ skills and incentives, will do little to circumvent these local effects of policy neglect. The study shows how urban politics and policy shape medical practices in ways that effectively deny care to the urban poor, thereby contributing to intra-urban health inequalities.

 

This study integrates analysis of urban politics, health policy, and frontline health care delivery in an Indian city. Whereas much urban health research focuses on the environmental determinants of urban population health, this paper analyzes the less-examined political determinants of urban health care. It offers a novel methodological approach—combining study of institutional history, state practices, and cultural frames—to examine how urban policy contributes to urban health inequalities.

Session 2 Policies and Interventions

Discussants

Daniel Weinstock - directoradmin.ihsp@mcgill.ca - Institute for Health & Social Policy - Canada

Right Here Right Now: piloting novel approaches for (near) real-time research to inform health policy within an urban context

Shona Hilton - shona.hilton@glasgow.ac.uk - University of Glasgow - United Kingdom

Health policymakers rely on appropriate evidence to inform decision-making, however, social, political and economic change often outpaces researchers’ capacity to produce meaningful evidence in a timely manner.  Widespread adoption of social and mobile technologies has increased opportunities for capturing context specific, real-time, concurrent data on people’s everyday experiences. Utilising these technologies could help to address some of the shortcomings of traditional research approaches, particularly in relation to timeliness and flexibility, and could increase public engagement in the processes of evidence generation, knowledge translation and policy decision-making.

In order to explore contemporary population health issues from the perspectives of citizens in near real-time researchers from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow collaborated with the Glasgow Centre for Population Health, the Institute for Design Innovation at the Glasgow School of Art and NHS Health Scotland to develop the Right Here Right Now pilot study. Based in Glasgow, Scotland, where there are stark health inequalities, researchers engaged with stakeholders and citizens to design an inclusive and user-friendly study, which made use of online technologies. Over a period of six months a sample of 180 ‘community researchers’ from across all areas of the city contributed their insights on a range of topical question sets developed with project stakeholders working in government, NHS and third sector organisations. Data were analysed thematically and key findings disseminated to all community researchers and stakeholders within two weeks of question issue.

The Right Here Right Now pilot provides key insights around the opportunities for developing new methods for gathering qualitative data in near to real-time that could inform our understanding of the impact of policies on health and social inequalities, and expand traditional views on engaging citizens in decision-making processes. This presentation will introduce Right Here Right Now and discuss the data collection methods employed, project outcomes, and next steps.

Public and Private Efforts in Averting Morbidity: Seeking Evidence for Indian Urban Households

Althaf Shajahan - althaf.sf87@gmail.com - Indian Institute of Management Bangalore - India

Arnab Mukherji - arnab@iimb.ernet.in - India

Rapid and unplanned urbanization leads to increased congestion and this lowers the quality of housing and hygiene conditions in the settlements of urban poor. Often the households in these slums and squatter settlements face poor conditions of drinking water, sanitation and hygiene. This has serious health implications given that these heavily congested settlements could easily be prey to epidemic outbreaks. Due to the huge negative externalities posed by the meagre sanitation conditions in the neighborhood, most private investments or private health inputs by these slum households may turn out to be ineffective in averting morbidity due to preventable environmental diseases. So,we explore  public and private efforts in averting morbidity and investigate how public efforts to tackle  the problem of flies and mosquitoes have enhanced the protection of the slum households in India against environmental diseases.. We use data from the 2012 wave of the National Sample Survey (NSS) on Housing Conditions. We find that as the level of investment rises the likelihood of both the stomach disorders and malaria declines. The largest reductions are associated with the public efforts and these gains are largest for slum resident households rather than non-slum households. Thus, this work suggests the social policy trying to alleviate the stresses and strains from urbanization should specifically consider vector control programs and programs to improve hygiene. Not only do these have a direct impact on health that is stronger in slum resident households, it also provides coverage to households who are less likely to be able to invest in private efforts to disrupt disease transmission channels. The study use propensity scores to address the problems of confounding and find significant treatment effects for such public programs.

Telecare Service Project Evaluation: A Case of Kaohsiung City

Wei-Ning Wu - weiningwu@mail.nsysu.edu.tw - National Sun Yat-sen University - Taiwan

Solutions to complex problems of service performance and low level of service users’ participation often must be developed by encouraging more and more service users to make their voices heard through the various approaches as well as enhance their willingness to experience in the service. Telecare Service Project (TSP) has the functions of health track and development of positive health behaviors. However, this service is users-initiated contact. Using TSP is an easy and free technically for citizens, but ensuring some degree of service users’ engagement has been challenging for the managers of health organizations. Despite calls for the importance of TSP in the service and information delivery process, fair treatment and access to use of health information, to the best of our understanding, very few empirical studies explore citizens’ TSP behaviors in the micro and individual level in Taiwan. This study provides a comprehensive understanding of the TSP evaluation, helps managers know citizens’ perceived perspectives toward the use of TSP , and assists these managers to develop an effective TSP in the future.

The impact of Uber’s Introduction on Drunk Driving in South Africa

Mark Daku - mark.daku@mcgill.ca - Montreal Health Equity Research Consortium - Canada

Jonathan Huang - jon.huang@mcgill.ca - McGill University - Canada

The advent of mobile phone-based ride sharing services such as Uber promise many individual benefits including reduce transportation cost and improved transparency and accessibility. One consequent population health benefit projected by proponents is a reduction in alcohol or other impaired operation of private vehicles and attendant reductions in motor vehicle collisions, related injuries, and ultimately deaths. Recent investigations in the United States, however, found little evidence to suggest introduction of Uber caused a reduction either in general road traffic-related or specific drunk-driving related mortality. However, other contexts may prove to be more amenable to the potential impact of ride sharing on in reduction of injuries and deaths.  We examine the case of Uber’s introduction in three urban centers in South Africa in order to assess whether or not the South African context creates the conditions for the purported health benefits that ride sharing may provide. We combine qualitative field research with difference-in-difference and regression discontinuity analysis to examine how the introduction of Uber may impact drinking and driving in three major South African cities. Important differences between contexts – and potentially between groups of consumers –mediate any impact that ride share services may have on drinking and driving outcomes. While a potentially useful intervention, policy makers who are considering limitations or incentives for ride sharing services should be mindful of the ways in which populations are differentially affected by these services. Any potential reduction in drunk driving, and resulting improvement in health outcomes, may only apply to certain populations.

Mobile Public Service: A New Way of China 's Urban Management Service —Taking the Urban Mobile Public Service in the Minority Areas as an Example

ShengWang Miao - miaoshengwang0123@163.com - School of Public Management - China

Yinxi Liu - yinxiliu@126.com - Inner Mongolia University - China

Yang Yang - yangyangnd@163.com - Inner Mongolia University - China

[Abstract]Since the reform and opening up, China's urbanization is advancing rapidly, and the contradictions have been gradually highlighted. Many problems have prompted the government administrators to innovate the means and methods of management innovation, and put the city management in an important position. The sharing of basic public services within the city is of great significance to maintain regional social stability and promote the development of urbanization. In recent years, the practice of "mobile police room", "mobile library", "mobile hospital" and "mobile library" in the Mainland is the innovation of urban management service driven by the modernization of the country's grass-roots governance. Supply innovation has reduced the quality and quantity of the basic public services within the city, and satisfied the local people's demand for all kinds of basic public services, and promoted the rapid advance of urbanization.

"Mobile Public Service" has certain advantages in exploring the modernization of urban grassroots governance capacity, realizing the sharing of public services within the city, promoting the equalization of basic public services, guiding the healthy development of the city and establishing a service-oriented government. The author believes that the "mobile public service" in the field of urban development and public governance, especially in promoting the process of urbanization has a trial, the promotion of practical significance. Therefore, to improve the level and capability of urban management services and realize the rapid advance of urbanization, we can promote the communication and cooperation between the departments through the promotion of the concept of governance and the ability to govern, based on the concept of "mobile public service", to build a trust and cooperation platform, Reasonable and perfect mechanism of responsibility and strengthen the construction of service-oriented government, and so on to promote the process of modern urban development.

Keywords: mobile public services, service innovation, governance modernization, urbanization development

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