Health inequity, treatment compliance, and health literacy at the local level: theoretical and practical aspects

The economic status is a projection of income inequity, which has direct relation to health inequity. However, the differences in income are also known to reflect the differences in the level of education, the professional background. The educational status in many countries is used as the major indicator of people’s status in the socio-economic inequity hierarchy, while the economic status, in turn, is viewed as the indicator of the return from the investment into the cultural capital. Apart from that education can be considered as an indicator of an increased capacity to take and process information, as well as make decisions allowing taking proper and meaningful approaches to maintaining and caring for one’s own health. There is an obvious relation between income and profession. Low income is typically connected with unqualified heavy physical labor, which, in addition, contains the risk of being injured or maimed.

A separate issue that requires solution within health inequity is marginalized groups that are to be found in any country and in any society. Unfavorable working conditions that potentially exacerbate the impact of environmental risk factors are mostly typical of marginalized groups, such as refugees and migrants even though they could pose a problem for people with a low level of education. The concept of “unfavorable working conditions” may embrace such types as working with no contract signed, child labor, as well as forced and coerced (as a pay for a debt) labor. Working with no contract signed is the major source of inequity in relation to the environment and health, as well as violation of regulations for national labor safety, working hygiene, and working conditions, which involves various negative effects on the health of the employees.

In Hungary, for instance, 15 % of Gypsy settlements (Roma) were located within 1 kilometer from illegal dumps, and 11 % – within 1 km from the places for destroying dead animals (Gyorgy et al., 2005). In Serbia similar settlements had a 2–3 times lower water supply and hygienic facilities (Sepkowitz, 2006).

Therefore health inequity has along historical context; this issue is determined by many factors and is found anywhere regardless of the socio-economic level of development of the country as a whole. Yet, in view of ethical, legal, economic, and medical-social implications this issue requires urgent response at all levels, from local to global.

Health inequity in Russian Federation: state of things

The issue of inequity in income distribution in the post-socialist area has been a subject for wide discussion both in our country and abroad. This point has always been the focus of researchers and politicians, from time to time giving raise to acute socio-political debate. Russia is no exception here given the significant changes it has undergone in the latest decade. Quite a tough issue is developing human potential under rapidly progressing market conditions and similarly rapidly disappearing social benefits for the disadvantaged. In view if this, experts define two types of challenges: on the one hand the country is facing typical of poor countries troubles like spread of communicable diseases, regions with stagnating poverty (still present in Russia), undeveloped infrastructure and high death rate. On the other hand the country is suffering from healthcare and education crisis, and such issues are common for advanced post-industrial countries as well.

Poverty profile in Russia

Poverty in Russia has a number of typical features. For instance, most vulnerable are families with children and, therefore, children themselves, who are under 16. Note to be made though that this issue is not common for most countries. As for retirees they are under lower risks of being affected by poverty because most of them work and the social benefit system is oriented, first of all, at the elderly.

Special mention should be made of the fact that working population is the larger part of the poor group even despite of salary growth. In order to reduce the number of poor people among the working population the minimum salary should be at least 150 % of the minimum cost of living. In the April of 2009 25 % or the working population received their salaries below this minimum. 70 % of them had children. 37,4 % of the working population received salaries below 200 % of the minimum cost of living.

This level of pay for labor is sufficient for meeting the minimum needs of one employee and one child. Therefore, even in a situation where two parents are employed such salaries cannot be enough to support two children at the minimum level.

The largest share of the poor population is accounted for by the people who are able to work, especially youth. Countrymen are more vulnerable to poverty than urban population. Besides, the maximum poverty risk affects the unemployed population, economically inactive groups, as well as those living on social and disability benefits.

Level of poverty and inequity

The dynamics of poverty and inequity is determined by the consumption share for the 20 % of poorest against the total volume of consumption. Up until 2000 this index was about 5,8–6,1 %. Later on the share of the poorest 20 % has gone down, which serves perfect evidence of the fact that the poor have got no access to the results of economic growth.

(The World Bank in Russia Russian Economic Report, No. 21, March 2010, http://siteresources.worldbank.org/INTRUSSIANFEDERATION/Resources/305499-1245838520910/6238985-1269435660465/RER21rus.pdf).

The liberal economic reforms went along with a significant fall in the standard of living and an increase in the socio-economic differentiation. The growing economic inequity has become a serious challenge both for the people and for the government. Our country now has significant inequity in terms of health and accessible medical assistance due to polarization of income and opportunities, which means limited and clearly deficient current social policy carried out in our society. The recent research findings have provided quite a clear demonstration of significant differences in people’s opportunities at birth, during the preschool and school period, in terms of getting access to higher education, housing, transportation, shopping, recreation and fun activities, relationships with the state, access to medical services, life expectancy, maintaining health status and healthy lifestyles, religious affiliation, funeral services, inheritance, etc. Just 20–25 years ago when the disproportion was not so extreme some specialists in social hygiene and healthcare arrangement even talked about potential homogenous conditionality of health in our country.

We must admit that health inequity is a new and, obviously, a long-term issue in Russia. Even though there have always been differences in people’s health status this point never got so much attention. One of the sources of social tension in any country is the gap between people’s welfare, in the level of their prosperity. The level of prosperity is determined by two factors:

1) the size of (any kind of) property possessed by individuals;

2) the size of the individuals” income (Дашкевич П. Р., 1995; Денисов П. Р., 1997).

One of the criteria of civilization in any country’s social sphere is maintaining the respective appropriate living standard for the groups (families) that for some reasons cannot meet even the minimum standards and customs (food, clothing, leisure, etc.). One of the most urgent social issues in Russia that came into being because of economic changes is unprecedented inequity in income. According to the Russian Statistics Agency (Rosstat), by 2006 the income of the most prosperous groups was 16 times the share of the least prosperous ones (Российский статистический ежегодник, Россия в цифрах, 2006). However, if we take into account that the official statistics often underestimates the socio-economic differentiation in Russia not taking into view the shadow economy, then the true gap in question may be much larger. According to the data provided by T. Zaslavskaya (2005) the inequity gap between the 10 % at the extremities is 30–40 times. As noted at the Report on Poverty Evaluation made by the World Bank (2004), this fast growth of income inequity in Russia was close to a record – Russia here is very much different from other countries including Central and East Europe, where they also had a transfer to the market economy. Experts say that socio-economic differentiation similar to Russian should be looked for in Latin America rather than in European societies (Murphy, Bobak, Nicholson, Rose and Marmot, 2006). The social stratification trend in our country that became especially obvious in the 1990-s is still there under the rather long process of economic growth noticed in the recent years – income differentiation was detected in 2007 as well (Щербакова Е. М., 2008).

The high rate of economic and socio-structural changes in Russia that were ahead of most people’s adjustment capacity brought to many increased levels of chronic stress, loss of control over life circumstances, and resulted in prevalence of behaviors related to health risks, first of all high alcohol consumption (Cockerham, 2000; Bobak, Pikhart, Rose, Hertzman, and Marmot 2000; Cockerham, Hinote, Abbott, 2006).

All this could not but affect Russian people’s health, which is well seen from the growing death rate and reduced life expectancy.

As a result, by the early 21st Century (2000) the death rate brought Russian into one line with African countries located south of Sahara, namely 15 deaths a year per 100 people, which is nearly double the index of developed societies (Римашевская Н. М., Кислицина О. А., 2004).

The recent years have witnessed quite clear a vicious circle where the national Russian healthcare system has found itself – the more funding is invested into specialized inpatient care and hi-tech clinics the less funding is given to prevention and early detection, which results in an increased number of patients, adds to the severity of their conditions, detection of diseases at later and even very bad untreated stages, and chronization of pathologies, which requires even more funding for tertiary healthcare.

Therefore, the modern Russian healthcare system could be described with a high level of inequity in distributing health opportunities among individuals and groups of people, as well as with a conflict between the state and the society, with erosion of the aims and objectives in the sphere of healthcare (Сизова И. Л., 2007).

The impact of social inequity in the Russian society has been especially seen the young generation, whose origin and development came onto the reforms.

Under the reforms in Russia, apart from traditional disturbances there have come into being new trends in youth’s health: “psychization” and “psychologization” of diseases, increasing social disadaptation, loss of confidence about one’s strength, increased feeling of “social loneliness”. This aspect creates the necessity of a sociological reflection on the changing social conditions and their impact on new deviations in youngsters” health, and the development of new practices in certain classes and social groups.

Even though we have already discussed poverty as the most important factor of inequity, Vladimir Putin’s words – Russia is a rich country of poor people – make us turn towards the issue again, yet in the context of the Russian reality.

On the initial stage of the economic reforms in Russia the core group of the poor was traditionally represented by the so-called vulnerable groups including retirees, disabled, large families and one-parent families with children. Nowadays the focus is definitely shifting towards a different risk group – the “working” poor, the part of the society that are able to work and, due to various reasons have low income, which keeps them from supporting themselves and their families properly.

Quite often poverty has also socio-psychological preconditions. One of them is the “overtaking” poverty. This term could be used to describe a phenomenon implying prestige consumption. It is typical for youth, rather than for older people, to dress well and to look no worse than others. The things that prosperous parents” children have (fashionable and expensive clothes) set up certain example attracting children whose parents cannot afford that. If a prosperous parent can buy something never feeling and financial issue then a poor parent’s budget may be seriously affected by the same purchase. This prestige consumption makes many people live beyond their financial capacity. Those from poor families feel uncomfortable due to their own position and that of their family, which does not allow them live better. This causes a generation conflict where children blame their parents for not wanting or not being able to “make money”, even despite all the morals. As a result poor people’s children find illegal ways to make money, which they need to “catch up” with the rich ones, to live up to the standards imposed on them by the middle or the upper class (Падиарова А. Б., 2008, 2009).

The poor’s focus is shifted towards negative evaluation of the reality, pessimism, and despair. They are often unable to build proper relations within their families – high voice in the family, mutual reprimands, obscene words and abusive language become a common thing. Such conditions develop a special lifestyle and a value system, which could be described by restraint and voluntary isolation, economic and social dependency, lack of clear behavior role models, separation and political passivity, absence of future plans and self-confidence; increased disposition to conflicts in family relations (rude talks, quarrels between parents and children, frequent divorces) (Кислицина О. А., 2005).

Other reasons responsible for acute aggravation of health inequity in Russia during the transition period include:

1. Actual shift in healthcare from caring for health to clinical medicine, i.e. from mass recreational and preventive measures to individual treatment.

2. Increased share of paid services, development of new relationships with patients, which destroy the basics of medical ethics, and which make it possible to view the patient as another source of income; chronic deficit of funding with a large number of various sources of that, which never contributes to financial transparency.

3. Sharp increase in inequity in terms of people’s access to medical services, while the majority of these people are socially disadvantaged.

4. Prominent inequity in doctors” incomes.

5. Unequal access to medical services for certain groups of people: homeless people, neglected children, migrants, and just financially vulnerable people.

4. Continuing practice of increasing the share of costly and expensive medicine, a huge gap between the quality and quantity of medical assistance in cities and in the provincial areas, and the gap between the assistance provided to rural and to urban residents is increasing.

5. Obvious and neglected mismatch between people need for preventive medicine, treatment and rehabilitation, and the funding allocated to the area. All this makes medicine spontaneous, paid, creates new issues and even power abuse, which may result in undermining the entire structure of the system. Since recently, instead of improving medical assistance, managers in healthcare have started talking about lifestyles, thus trying to avoid responsibility for current state of things in medicine and shifting it onto people who abuse tobacco, alcohol, stick to unhealthy diets and just do not take care of their own health, even though, actually, all this is one of the tasks for the system of healthcare.

6. Overly complexity of the very system of healthcare and, as a result, its poor controllability and efficiency (Комаров Ю. М., 2010).

Thus, we believe that in order to reduce the urgency of health inequity it takes comprehensive intersectoral measures, which should be initiated by the public health sector, while all the municipal agencies and public groups should be involved as equal partners.

Measures for reducing health inequity

Health inequity determinants lie within areas of public life other than healthcare alone; then it is obvious that there is a need for a policy in all these areas aiming at assessing their impact on health, especially on the health of the most vulnerable groups, which would allow coordinating the policy respectively.

From the viewpoint of social policy, first of all there is a need to realize the scale of the issue. This is why the top aim for a social policy in this area should be activity for, at least, limiting the impact of poverty and income inequity on people’s health.

The Committee for socio-economic determinants recommends the following

– to carry out a quantitative assessment of potential effects on the health of different groups of the population due to particular risk factors;

– to detect the risk factors (including social determinants) whose effect could be prevented;

– to carry out a differentiated analysis of the impact on health that competing risk factors have, e.g. such as tobacco smoking and diet;

– to detect and carry out a deeper analysis of the cumulative effect of multiple impacts;

– to investigate additional and synergetic (or, which is less likely, antagonistic) interaction between socio-economic factors and the negative environmental factors;

– to get to deeper understanding of the nature and gender differences in the vulnerability of children, older people and the elderly to negative environmental effects (CSDH, 2009).

The countries looking for counter-measures in order to reduce social and environmental inequities should take into account their driving forces and the underlying reasons. No doubt, there are no easy ways to eliminate the inequities, proof to that being the social processes that have been going on in the latest decades. The key to success of the strategies that are being implemented is a clear division between short– and long-term objectives, and reducing socially determined environmental issues takes various approaches.

?In the long-term outlook disadvantaged groups will gain the maximum benefit from interventions aiming at creating a safer environment just because these groups are more often subject to negative environmental impact.

?The long-term measures that should be part of the local, national, and international agenda must include special events and campaigns aiming at serving the groups with the detected risk of the most serious or specific unfavorable effects of environmental inequity.

Since poverty is one of the key factors determining health inequity, this inequity cannot be resolved unless this key issue is resolved.

The major stream in overcoming absolute poverty is ensuring productive employment, increasing labor efficiency, creating conditions allowing the working population earning more thus supporting themselves and their families.

In this case the size of the salary comes out as the major guarantee against poverty. The role of the state here implies establishing market conditions for increased competitive capacity in the national economy through increased competitive capacity of the Russian enterprises – implementing the required industrial policy, proper adjustment of the system for staff training, introducing measures for supporting the national manufacturer.

Higher selectivity in offering social assistance, application-based priority, and individual social benefits – all these make up an efficient way of eliminating poverty.

When selecting socially vulnerable groups there is a need to match the officially established poverty line with their income, the officially established minimum property standard with the property that they possess. Special attention should be paid here to the issue of homelessness, neglected children, and children in crisis families.

An important task for social policy is detecting the obstacles on the way to obtaining social support and benefits.

The current system for revealing and supporting poor families and people providing them with various benefits, advantages, sand other types of assistance is far from being perfect and needs adjustment to market economy. The funding allocated nowadays to provide social support to the poor is not efficiently distributed and will often go to the families that are poor indeed. As a result the truly poorest population remains even in worse condition.

The international practice includes the following measures to combat poverty:

– Redistribution of income.

First of all there should be measures for the development of an efficient labor market. This issue implies resolving two key tasks:

– Measures for reducing the number of low-paid employees;

In the major measures aiming at the reduction of the number of low-paid employees the following can be defined:

– Increased salaries for public employees through bringing up the expenses for remuneration of labor;

– Implementing a policy aiming at reducing illegal types of labor remuneration, which contributes to impoverishment of the working population (delayed pay, payment in kind). Such a policy must include economic and administrative measures targeting, first of all, the employer;

– Encouraging employment for those who want and can work, new workplace establishment. To ensure prompt the establishment of new workplaces takes stimulating the priority in the development of the economic areas that can provide new workplaces with minimum investment. This is, first of all, small– and middle-scale business.

– measures for reducing income inequity at the expense of social transfers and increased minimum guarantees in social security sphere;

– introducing a progressive income tax for individuals. Officially the gap between the 10 % of the poorest and the richest is 15 times (CSDH, 2009).

No doubt, apart from solving general healthcare issues, the measures for reforming the national healthcare system should also contribute to reducing health inequity in Russia. Such organizational measures include:

1. A multifunctional network of healthcare institutions with its internal and external connections, which would allow calling this network a healthcare system.

2. A rather branchy system of medical examinations, check-ups and measures. There should be extensive work to offer general public training in self-help in certain cases (in case of trauma, bleeding, etc.) and self-examination (regular examination and palpation of breast, taking the pulse, blood pressure, etc.); this will take circulation of special literature.

Besides, the tasks for healthcare both in general and locally (by health criteria) include:

– bringing closer to densely populated areas shopping malls offering everyday goods, pharmacies, institutions for primary medical assistance, recreational institutions, schools and preschool institutions, places of everyday use, public transport, etc.;

– Improved facilities, reduced environment pollution, improved quality of water, air, and soil;

– Improved local environment, planting of greenery, establishing recreational areas;

– Improved structure and quality of food, efficient control of food safety;

– Increased level of culture and education, encouraging involvement of children and adolescents into activities based on their interests, organizing their spare time and creating conditions for public physical activities (stadia, swimming pools, skating rinks, skiing paths, sport gyms, etc.);

– Strengthening the value of family, crime prevention;

– Activating the movement for health and mobile lifestyles;

– Eliminating drug abuse, tobacco smoking, alcohol consumption, preventive work with children, youth and adolescents;

– Sanitary education of the general public, increasing the level of sanitary literacy and culture, teaching simplest ways of primary self-help and mutual assistance;

– Combating prostitution, STDs, and AIDS;

– Vaccination and immunization;

– Establishing paramedical and nurse respite service, integrated medical support at home (day-time or day-and-night), establishment of municipal or neighborhood nursing homes or hospices;

– Health and working capacity recovery, establishment of rehabilitation centers;

– Conducting preventive, special periodic medical check-ups, early diseases detection, primary medical assistance;