Author: Gregory Kwegyir-Afful, Degree Programme: BS Nursing Student, Novia UAS
Supervisor: Anita Wikberg, RN, RM, PhD, Senior lecturer, Novia UAS      

Abstract

Health inequality is often viewed as a chiasm between developed nations and developing nations however, this issue is universal. Health inequality is not just apparent among nations and regions but also within national borders too. Due to this, the distinction between health equity and equality must be kept in mind. Health equality is about ensuring equal opportunity, whiles health equity is about ensuring that help is given based on individual needs. A developing country may have much work to do in achieving health equality in the first place. A developed nation with universal and affordable healthcare, on the other hand, may have more work to do in ensuring that immigrants (both legal and illegal), the elderly, and native citizens with minority status, who may be facing factors that the average citizen is not exposed to, are given the same opportunities. These minorities should also be considered when landmark legislation is being deliberated. Preventative healthcare can be a useful way to understand these distinctions between health inequality and inequity. This is because the four levels of preventative healthcare (primordial, primary, secondary, and tertiary) deal with the environmental, economic, political, social, behavioral, and cultural factors that lead to health inequality and inequity.

Introduction

When we think of health inequality, we usually tend to think of mainstream ideas like the massive difference between developed nations and developing nations in the world. This difference is real and has been for ages however, the problem with health inequality is closer to home than we think. “Health inequalities are avoidable, unfair and systematic differences in health between different groups of people” (Williams et al., 2020). However, it is important to keep in mind the difference between health inequality and equity when discussing health. Health equality is about making sure that everyone is given equal opportunity. On the other hand, health equity is about making sure that everyone receives help based on their status. For example, giving free family planning sessions (in Finnish) to all Finnish couples is health equality (Nall, 2020). But better health equity would be achieved if people were given those said sessions in their native language. Keeping this difference in mind is crucial since there might be better health equality in some countries, like Finland, with room for improvement in health equity for marginalized groups such as immigrants, low-income families, substance abusers, and the elderly. This makes discussion about health inequality globally more complicated since many countries, especially in developing nations, may have a lot of work to do in providing standardized and affordable healthcare for the general public in the first place.

Preventative Healthcare and Health Inequality

Preventative healthcare is the prevention of “disease, injury, or illness” (Amadeo, 2021). It is divided into four different stages. They are Primordial prevention, Primary prevention, Secondary prevention, Tertiary prevention, and Quaternary prevention. Primordial prevention deals with the society as a whole and is based on the “alteration of societal (i.e., environmental, economic, social, behavioural, cultural) structures that affect disease risk” (Ali & Katz, 2015). In other words, the focus is to prevent the formation of the risk factors that can cause illness. Primary prevention is “the action taken prior to the                    onset of disease, which removes the possibility that the disease will ever occur”. This can be done through health promotion measures such as “health education” and “nutritional interventions” and specific protection such as “legislation and enforcement to ban or control the use of hazardous products (e.g., asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets)” (“Primary, secondary and tertiary prevention”, 2015).

Secondary prevention is the reduction of “the impact of a disease or injury that has already occurred”. This must be done in the immediate on-set of a disease or injury in order “to halt or slow its progress”. Examples of secondary prevention are “regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer)”. Tertiary prevention is the utilisation of all measures that can “soften the impact of an ongoing illness or injury” in an individual and “improve as much as possible their ability to function”. Examples are “cardiac or stroke rehabilitation programs” and “chronic disease management programs” such as, diabetes. Thus, in all, preventative healthcare can be a useful way to understand and comprehend the trends that lead to health inequality and equity in the society. This is because, any changes to the indicators of healthy inequalities and equities will have to focus on changes to environmental, economic, political, social, behavioural, and cultural factors. (“Primary, secondary and tertiary prevention”, n.d)

Health inequality: A Global Problem

The World Health Organization argues that “the lower an individual’s socio-economic position, the higher their risk of poor health”. An individual’s socio-economic position is affected by “social factors, including education, employment status, income level, gender and ethnicity”. Therefore, the sum of these factors is directly responsible for the subpar performances of the wellbeing indicators of some groups/ nations. For example, the WHO states that children in sub-Saharan Africa are “14 times more likely to die before the age of five”. The WHO further states that “developing countries account for 99% of annual maternal deaths in the world”. Tuberculosis is also coined as “a disease of poverty” with close to 95% of death cases from the disease occurring in developing countries. The WHO also explains that since health care costs for non-communicable diseases (NCDs) can quickly drain household resources”, “87% of premature deaths due to noncommunicable diseases occur in low- and middle- income countries since individuals in such countries are more likely to fail in paying for hospital treatments that are otherwise taken for granted in high income countries. Another health indicator exposing health inequality is life expectancy. The “WHO states that life expectancy in low-income countries is 62 years. On the other hand, the average life expectancy in high income countries is 81 years.  (WHO, 2018)

Health Inequality in Africa

There is also a substantial amount of evidence demonstrating that countries in the same region have differences in health inequality irrespective of how developed the region is. For example, in a study conducted by the WHO between African nations, evidence was found showing large discrepancies in wellbeing between African nations. For instance, in DPT3 (diphtheria, pertussis, and tetanus), vaccination coverage, the WHO found that “DPT3 vaccination coverage ranges between 11% and 75% (a near seven times difference between Nigeria (11%) and Chad (12%) with the lowest coverage and Ghana with the highest coverage)” (Asbu et al. 2010, 179). Another indicator of inequality stated in the study is skilled birth attendance (SBA) coverage. In the WHO study, SBA coverage “ranges between 6% and 87% (a more than fourteen times difference between Ethiopia with the lowest coverage and Gabon (87%), South Africa (86%) and the Republic of Congo (84%) with the highest coverage)” (Asbu et al. 2010, 181). On modern contraception use, the WHO, states that “women with expressed need for contraception ranges between 3% and 58% (a more than nineteen times difference between Chad with the lowest utilization rate and South Africa and Zimbabwe (57%) with the highest utilization rates)” (Asbu et al. 2010, 91). The use of bed nets, for prevention of malaria, by children “ranges between 2% and 52% among the 19 countries” (Asbu et al. 2010, 183). Use of bed nets by pregnant women “ranges widely between 2% and 73% among the 19 countries” (pg 184). The use of antimalarial drugs during pregnancy ranged “between 0% and 80% among the 19 countries” (pg 185). Counselling for HIV during antenatal care ranged “between 6% and 52% among eight countries with data including Cameroon, Ghana, Guinea, Kenya, Mozambique, Nigeria, Senegal and Tanzania” (Asbu et al. 2010, 186). Access to safe water and sanitation ranged “between 16% and 84%” (Asbu et al. 2010, 187).

Health Inequality in Europe

A book by Forster et al. on (2018) Health Inequalities in Europe found that life expectancy and healthy years of living varied with countries like Spain having one of the best statistics whiles countries like Bulgaria ranked among the lowest. On inequalities in self-reported health by income, Forster et al. write that there is a gap between low income and high-income persons on self-reported health within European countries. They continue that “the countries with the highest and lowest proportion of adults in self-reported good health” were “21.5 percent in Ireland and 37.9 percent in Lithuania” (Forster et al. 2018, 25) respectively. In other words, inequality in self-reported health is at worst in Lithuania and it’s best in Ireland. On education as a social determinant of non-communicable diseases in Europe, Forster et al. write that on “the relative likelihood of 14 self-reported non-communicable diseases (NCDs) by education for persons aged 25 to 75 in Europe”, “someone with low education is 3.12 times more likely than an individual who has completed tertiary education to report depression” (Forster et al. 2018, 26). On the risk of being a daily smoker by education, Forster et al. state that “in all European countries except Portugal, the likelihood of smoking daily is higher for individuals with primary or secondary education than for their highly-educated peers” (Forster et al. 2018, 27). On alcohol consumption, Forster et al., explain that there is a paradox in the sense that “highly educated individuals are more likely to consume alcohol more than once per week compared” (Forster et al. 2018, 29) to the less educated however, those of lower education “are more likely to engage in binge drinking at least weekly” (Forster et al. 2018, 27) thus exposing them to “more adverse social and health effects of alcohol” (Forster et al. 2018, 27).

Health inequality in Finland

In previous texts, it was mentioned, in passing, that health inequality cannot only be seen when comparing regions but also within national borders. Finland, where this work originates from, is a country with five and a half million residents. Finland is a Nordic country and is often described as a welfare state and has great figures on all economic indicators, such as the Human Development Index and the Gini coefficient (coined by the statistician Corrado Gini). In fact, Finland has been ranked as the happiest country in the world for four consecutive years. Despite all this, challenges are still evident. This chapter will discuss inequality in Finland namely, about the debate around the new healthcare bill and the status of immigrant health in Finland.

Current situation and the new SOTE Bill

In recent times, the debate about the new SOTE bill (Sosiaali- ja terveydenhuollon uudistus- I.e., the social and healthcare reform bill) in Finland has garnered much attention on the availability of healthcare services for all Finnish peoples. Political candidates have also begun to sound alarming bells about the risk of smaller municipalities losing their voice in the decision-making process with the new SOTE bill (Luotonen, 2021). In fact, in an article, Tarja Kivimäki, (2017) claims that the chief researcher at the Finnish Institute for health and welfare (THL) has expressed concern that Finland’s equality in health care will worsen with the new healthcare bill. Kivimäki argues that expenditure on healthcare is not distributed fairly. Kivimäki explains that the Finnish healthcare system is divided into three main parts: the public healthcare sector, occupational health sector, and Kela funded private healthcare system. She argues that this kind of system is unique in the whole of Europe. Kivimäki cited a study on OECDC countries that found Finland to be the fourth most unequal healthcare system. She states that the most vulnerable in Finland use healthcare the least even though they are the group that need help the most. She continues that the public healthcare sector is among the smallest in the Nordic countries at 70% and that bottle neck issues exist due to shortages in doctors in rural areas. Kivimäki also states evidence, from OECD records, that showed Finland having the biggest share of customer payments for healthcare expenditure among other Nordic countries (Kivimäki, 2021).

The state of wellbeing of foreigners

In a study for THL, Castaneda (2018) writes about the health inequality in Finland between foreigners and native Finns. She explains that there has been a great shift when it comes to migration in Finland. In the past, she writes that Finns would immigrate to other countries such as, Sweden and the United States of America. There has however, been a change since the 1990’s with about 384 thousand foreigners residing in Finland as of today (2021). Castaneda writes that although some foreigners migrate to Finland on a refugee basis, the great majority do so because of family relations and work. Because of this, Castaneda cautions against analysing foreigners in Finland as a single homogenous block. She continues that the employment of foreign men in Finland is about the same as their Finnish counterparts. However, the employment rate for foreign women is much lower than the national female average. The problem with employment opportunity is mostly based on lack of qualification for refugee immigrants however, for immigrants with higher education the inability to find work is because of lack of language skills and over-qualification. Castaneda argues that the afore-mentioned socio-demographic qualities are strongly linked to the health and wellbeing of foreigners. Thus, they can help explain some of the trends seen among foreign residents.  For example, those from war-torn countries might still be impacted by such events even after residing in Finland for years.

Furthermore, women from some Muslim-dominant countries are forced to genitally mutilate– a traumatic experience that can have repercussions on one’s wellbeing both physically and mentally.  In fact, Castaneda states that one of the key aspects where there is a clear difference in health inequality is on psychological wellbeing. She also adds that many life-style related illnesses are more common among those of foreign origin. These include diseases such as obesity, diabetes, physical impairments. Additionally, foreigners in Finland are less likely to use healthcare services compared to the national average. (Castaneda, 2018). In a presentation for Kuntaliitto, Häkkinen et al. (2020) write that all municipalities and healthcare professionals are mandated by the healthcare law (Terveydenhuoltolaki (1326/2010) 50 §) to administer urgent care to immigrants irrespective of their residential status. The foreigners are however supposed to pay the fees incurred back. Municipalities may apply for compensation from the state if the said undocumented immigrant is unable to pay. Despite this, Häkkinen et al (2020). state that five municipalities (Helsinki, Turku, Oulu, Joensuu, and Tampere) offer other healthcare services, in addition to urgent care, to undocumented immigrants. Although these five represent a significant portion of the Finnish population, there is a huge risk for undocumented immigrants living elsewhere in Finland to have unequal care in comparison to the national average. As it can be logically deduced that health complications (ranging from accidents to illnesses) that could otherwise be prevented and cured early will be missed. Thus, the cost of treatment will be higher in the future with far reaching effects on indicators such as life-expectancy and years lived with disability (i.e. YLD). In all, it can be argued that the health problems facing immigrants is more about equity than equality. Policies that work for the native people may not work for foreigners. Afterall, Finland does have an affordable public health sector but by understanding health equity, it becomes clear that these immigrant groups need specific policies that take their background into consideration, thus helping to maximize the efficacy of the health care system. 

Conclusion

In all, health inequality is a global issue that can be observed across all regions. In developing nations, such as in African countries, the focus should be on providing affordable and universal healthcare. Health indicators like skilled birth attendance and vaccination prove that governments in Africa have not succeeded in providing equal opportunity in the access to care. On the other hand, in developed nations, such as in European countries, the problem with health inequality is more about issues with equity. This can be seen for instance, in the health performance gap between different income groups indicating that solutions should focus on policies that improve health equity. This is also evident in Finland. As previously discussed, Finland has a three sectored healthcare system with the public sector being the largest. The other two being occupational healthcare and Kela funded private healthcare. The problem with this is that marginalized groups are likely to be left with no other alternative than the public sector. For example, an unemployed Finn cannot access the services provided in the occupational healthcare sector which, as previously discussed, has some structural issues.  These issues include the urbanisation of Finland that results in municipalities with substantial elderly populations losing their voice in the political arena. This leads to trends whereby health services centres are shut down resulting in further travel distances for the elderly. Furthermore, rural municipalities are left at a disadvantage when competing for health care professionals, such as doctors. Additionally, it was established that policies that take into consideration the backgrounds of foreigners and Finnish people with a different cultural background could help achieve better health equity for said groups. Lastly, preventative healthcare was established as useful in understanding health equality and inequity since environmental, economic, political, social, behavioural, and cultural factors are major themes in both.  

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