Ensuring humanistic centered healthcare: the challenges in achieving health equity


ENSURING HUMANISTIC CENTERED HEALTHCARE: THE CHALLENGES IN ACHIEVING HEALTH EQUITY

 

Authors : Dawn Singerman (Canada, Co-chair), J. Antônio Cirino (Brazil), Rocío Escobar Ramírez (Spain), Cheng-Jung (Peter) Wu (Taiwan). Reviewed by Renee Bogues (YEL Alumni, United Kingdom)

INTRODUCTION

The fields of medicine and health sciences have advanced enormously over the course of the last decades. Medical advances, rapidly evolving technologies, investigation into new gene therapies, and research into improving treatments have increased average life expectancy, eradicated diseases that once killed millions, and improved the quality of life for many to levels that were once unimaginable.

Despite these advances, most people will be impacted by illness during their lifetimes, and the treatment options available to them will differ.  Many individuals, for reasons of race, religion, age, socioeconomic status and other perceived “differences”, will encounter systemic barriers to benefitting from the same quality of healthcare as offered to others.

Humanistic-centered healthcare is based on the notion it is a fundamental human right for everyone to achieve their best health (as declared by the World Health Organization (WHO) constitution in 1946[1]), and that all humans should have equitable access to quality healthcare to ensure the best outcomes possible.

Given the status of many healthcare networks across the globe, achieving humanistic-centered healthcare that allows for equitable service levels will be a long journey for many countries. Changing the perspective of health policies and care provided in the various organizations across the globe into a view focused on the human being will be challenging, because not all establishments are motivated by the same goals.  While some view healthcare as a fundamental human right that should be offered free of charge to all, others have developed systems based on financial profits. Despite the differences in underlying motivations, there are many lessons to be learned from sharing best practices of excellence around the world, that can be implemented to enhance humanistic-centered care across all health systems.

One of the greatest current challenges for healthcare leaders is that we still have work to do in order to ensure equity in the field of healthcare.  There has been increasing awareness and discussion in public forums in recent years about the systemic barriers some groups face (for example, worldwide Covax movement to accelerate vaccine access in developing countries, #BlackLivesMatter in the United States), and our generation must ensure these conversations translate into concrete actions in healthcare services to level the playing field.

EXAMPLES OF CHALLENGES AROUND THE GLOBE

1. Brazil: Health as a social right and the importance of listening to the population in order to provide humanistic centered care

Health is a social right guaranteed by the 1988 Brazilian Federal Constitution, which came only forty years after the declaration from the international movement led by the World Health Organization (WHO) in 1948[2]. The resulting creation of the Unified Health System (SUS) provided the structure for public policies that would offer accessible healthcare for all. Considering the dimension of the country and the differences between the five regions, this was a considerable challenge, and the ensuing success highlights SUS as one of the worldwide models for health systems.

Despite its financial challenges and, in some cases, management issues, SUS was conceived from the principles of universality (enabling access to health for all), equity (offering health care based on people’s needs)[3] and integrality (offering complete healthcare and looking at the individual entirely). As one of the ways to guarantee the principles of SUS, Hugol – State Hospital for Emergency Services, located in the central region of Brazil, developed an internal “User’s Council” as a way of listening to the population it serves in order to improve their processes.

With a focus on collecting feedback and suggestions regarding the care received, the Ombudsman of the health unit managed by the Social Organization Agir – Association for Management Innovation and Health Results, contacted a sample of patients randomly, providing opportunities that people of different profiles can participate.  The patients are invited to join a meeting, which began in-person and, due to the pandemic, was migrated to digital format. During the meeting, people were encouraged to bring their unique perspective of the healthcare provided, allowing the healthcare establishment to experience the journey through the patient’s experience.

Considering each step of the healthcare to patients as a moment to give their contributions, the “User’s Council” gets important information to improve the quality of the process. This data is discussed in a strategic meeting of the organization to construct a plan to make all the necessary improvements. Afterwards, the results are shared with the group for accountability.

In this sense, it is essential to structure strategies to listen to people and their different needs, to improve health processes aiming at offering a humanistic centered care, as highlighted in the Hospital Manager’s Manual of the Brazilian Hospital Federation – FBH.

 2. Canada:  Severe health consequences for Indigenous population as a result of 200+ years of inequity

 Canada is internationally renowned as a modern, democratic society with high quality of living standards. In fact, Canada was named the #1 country in the 2021 Best Countries Report from US News & World Report[4], after ranking #2 in 2020 and #3 in 2019.  Despite these international accolades, the sad fact remains that Canada has not treated its Indigenous population with the humanity and respect that all people deserve, and, as a result, there is a great inequity in its society in terms of health, education, and quality of life. The World Health Organization’s investigation into health determinants now recognizes European colonization as a common and fundamental underlying determinant of poor Indigenous health, and Canada is no exception to this finding[5].

A brief history

    • Canada founded: July 1, 1867
    • Indian Act (1876)[6]: Indigenous children forcibly removed from their homes by the Federal government and sent them to the Residential schools that were operated by Christian churches, with the express purpose to remove the children from their own culture and “assimilate them into the dominant Canadian culture”
    • Schools had childhood mortality rates 2-3x national average[7]
    • Sexual and physical abuse were rampant[8]
    • 1996: Last residential school closed[9]
    • 2016: Human Rights Watch[10] concluded “that the Canadian government has violated a range of international human rights obligations toward First Nations persons and communities by failing to remedy the severe water crisis”
    • 2019: Public Inquiry Commission on relations between Indigenous Peoples and certain public services in Québec came up with 142 recommendations to remedy the situation[11]

 

Facts about Indigenous population health in Canada

    • Average life expectancy lower than non-Aboriginal population[12]
    • 19.4% of Aboriginal people in Canada lived in a dwelling that was in need of major repairs [13]
    • 20% do not have access to potable water[14]
    • Chronic diseases such as diabetes and heart disease are on the increase[15]
    • Higher rate of respiratory problems and other infectious diseases among Indigenous children than among non-Indigenous children [16]
    • Indigenous children are three to four times more likely to die from unintentional injury than non-Aboriginal children of the same age[17]
    • Suicide rates are five to seven times higher for First Nations youth than for non-Aboriginal youth; for Inuit youth, the rate is among the highest in the world – 11 times the national average[18]

 

Given the many challenges outlined above, what can our hospital leaders do to improve healthcare quality, access, and outcomes for the Canadian Indigenous population to ensure equity with the non-Indigenous population?

Cultural barriers:

One of the biggest struggles highlighted by the 2019 Public Inquiry Commission is the huge gap between the Western view of health conveyed by many in the public health care system, and that of the Indigenous peoples. Over the course of the past three years, less than 3% of healthcare professionals in the province of Quebec have received any form of training with regards to cultural security and/or sensitivity[19].  Because one of the biggest barriers to equity is understanding, the Ministry of Health and Social Services of Quebec has now implemented a mandatory training course for public servants entitled “Awareness of Indigenous realities”, including modules on history, settlements, and best practices to adopt.  Although this is a great idea, it fails to go far enough by not including physicians, residents, and medical students in the population targeted by this mandatory education platform.

Access to services:

Given that the majority of First Nations and Inuit people live in remote regions, their population struggles to obtain an equitable level of access to healthcare services as other populations.  In the 1960s, the Montreal Children’s Hospital pediatricians began a grassroots program that is now referred to as McGill University’s Northern and Native Child Health Program[20].  Through this program, medical specialists visit over 20 communities twice per month, ensuring that over 2300 Indigenous children have access to highly specialized care in their own communities.  Approximately 300 children, and their parents or guardians, are transported annually to Montreal for advanced procedures, where they have access to a translator and specialized social workers to facilitate their care.

The Montreal Children’s Hospital was also the first in the province to introduce telehealth services in the 1990s, which allowed access to medical expertise to these remote communities on a real-time basis for the first time.

3. Taiwan:  The impact of social factors and government policies on population health[21][22][23]

 As a result of medical advances and the wide coverage of the National Health Insurance program, the average life expectancy in Taiwan increased by 2.3 years over 10 years, placing it near the average for OECD countries. Despite this encouraging progress in overall health, there are persistent and widespread inequalities in health within Taiwan. These health inequalities exist across a range of social and demographic indicators, including income, occupation and parental occupation, education, neighborhood quality, geographic region, gender and ethnicity.  These inequalities are closely related to social, economic, cultural and political factors – the social determinants of health.

It is essential to address the social determinants of health – the circumstances in which people are born, grow, live, work and age – as key determinants of health equity. These conditions of daily life are, in turn, influenced by structural drivers: economic arrangements, distribution of power, gender equity, policy frameworks and the values of society.

It is essential that the government, responsible for formulating policies, have the ambition to tackle health inequity. It is promising for the government to take universal actions with emphasis proportionate to people’s need so that issues of inequity are addressed across the whole of society.

The extensive discussion stemming from the shortage of COVID-19 vaccinations in Taiwan due to difficulties purchasing supplies internationally is one of example. Facing a limited number of vaccines, there has been diverse opinions on the order of distribution. People who desire to get vaccinated are obliged to receive their vaccine in the city where they are a registered permanent resident. Many trans-provincial workforces have to risk travelling in spite of the advocacy of avoiding unnecessary transportation. Given that the morality rate in certain age groups is relatively higher than the others, it is suggested the citizens to be prioritized in accordance with their risk factors associated with COVID-19 infection instead of being classified by geographic factor. It is also suggested that all vaccinations to be state-funded, in the hope that people who are at risk but economically unprivileged would not be discriminated against. For those who are disabled or who have difficulties travelling to the hospital, subsidized travel services may prevent them from being excluded from the protection from vaccination.

It is a person’s right to choose their way of life as long as it does not involve harming others. Having said that, there is a role of the government to construct a living environment which overall enhances people’s access to a healthy lifestyle. In 2003, for Taiwanese children aged 6 to 12 years, there were six cases of Type 2 diabetes for every Type 1 case.

This is due to the very high consumption of sugary drinks among children of elementary school age in Taiwan. In 2012, more than half the students had two sugary drinks per day (males 56.6%; females 53.7%). Furthermore, junior and senior high school students had high rates of hyperglycemia. In 2011, 30.4% and 24.6% of males in junior high school and senior high school, respectively, had hyperglycemia, while females had slightly lower values of 21.5% among junior high school students and 12.3% among senior high school students. Such statistics reveal that unhealthy diet habits contribute to a high rate of metabolic disturbance. Given that sugary drinks and fried chicken are less expensive than bottled water and a healthy lunchbox, such consumption behavior may not be driven by personal preference but is in fact a social issue. To address this problem, governments can enact policies to mandate nutritious and healthy meals at school canteens that would be beneficial for school aged children. Banning sugary drinks and other unhealthy snacks on campus should also be considered. This is one example of how government policies relating to education can influence the health outcomes of its population.

4. Spain:  Focus on childhood health reaps long term benefits

 The only way to reduce inequalities on a child’s health is by giving priority to the child’s health in government policies, which will lead to a new generation of adults with equal health opportunities. There is evidence that poverty is correlated to deficient education, scarcity of benefits, and poor social care support systems, which will result in poor health outcomes children affected by poverty.[24]  Ensuring early attention for children can alleviate these inequalities on health, and should be a strategy to leveraged on for populations at risk.[25][26]

In the 1980’s, Spain reformed its first healthcare services and it resulted in a great transformation of the health centers and achieved excellent results in child prevention. The reform permitted, among others, to perform congenital disease screening, to foster health advice and to cover immunization for the population.[27]  The reform also opted for the monitoring of healthy children in a systematic way through a health program to detect problems related to intrinsic and extrinsic vulnerability factors of the child in order to increase health equity.

In the 1990’s, Spain started a child health program whose objective was to reduce the differences amongst child and teen care. The Child Health Program (PSI) includes preventive and promotion activities from birth to 18 years. In 2009, the Spanish Pediatric Society lead the activities by groups within the national territory with the aim to avoid differences and to continue to promote the equity on health with PSI.

The PSI program involves the recruitment of the entire population, and healthcare providers carry out a series of visits with activities that include different screenings, follow-up and supervision, immunizations, health advice, risk assessment and derived interventions.  Within the different components of quality, the PSI addresses aspects related to scientific technical training, as well as training and education for health through health councils.[28]

These services are essential in achieving healthcare equity for the children of Spain, which will result in a healthier adult population in the future.

RECOMMENDATIONS

In order to improve the outcomes for all disadvantaged populations, several best practices can be adopted by health establishments:

Education: One of the primary barriers disadvantaged populations is face is a lack of understanding from healthcare providers. Establishments can improve their understanding by:

      1. Ensuring all health professionals follow mandatory training on respect, civility, and diversity; these are global concepts that should be fundamental to every professional certification and Code of conduct
      2. Providing specific training about local populations and challenges (as in the example for the Quebec Indigenous population)
      3. Training programs for health professionals so they can understand the possible scenarios and take suitable procedures for each context

Ensuring patients have a voice: By listening to people from different groups, healthcare providers can ensure that their needs and realities are contemplated so that humanistic centered care is equitable and can envision different social contexts.

        1. Form a patient or user council (as in the Brazil example) to assist management in reviewing policies and protocols, ensuring representation from diverse backgrounds
        2. Have a strong patient Ombudsman process in place, where patients can safely and, if need be, confidentially, express concerns[29]
        3. Ensure that patient education and patient consent is embedded in all clinical and research practices

Access to services: ensuring access to services is essential to address healthcare equity

      1. Remote populations are particularly vulnerable. By having country-wide standard, regardless of the regions (as in Spain’s PSI program), or specific programs that target remote regions (McGill’s program for Indigenous populations), healthcare systems can ensure that all individuals have access
      2. Telehealth: The COVID-19 pandemic has resulted in acceleration of telemedicine across the globe
      3. Uninsured patients: Programs can be developed with local charitable organizations, hospital foundations, physician groups willing to donate their services “pro-bono” to ensure poverty is not a barrier to receiving quality healthcare services, also it’s necessary structure the health system to dedicate taxes to fund the treatment of the uninsured patients
      4. Adapting protocols for different populations: Based on feedback from User Councils and patients, protocols can be adapted (e.g. body language, posture, vocabulary) to make vulnerable populations feel comfortable
      5. Translation services: Many large hospitals offer translation services, or patient guides with illustrations, to alleviate language and cultural barriers

Strong government policies: As we have seen in the examples above, government regulations that involve social and environmental factors (ex: Indian Act governing Canada’s Indigenous population) and education (ex: implementing nutrition standards in schools) can have deep impacts on health outcomes.

CONCLUSION

While scientific advances have improved overall healthcare outcomes across the globe, the examples above clearly demonstrate that inequities still exist that prevent all populations from achieving their best possible healthcare outcomes.

The ambition to tackle health inequity will require strong strategic leadership at the government level, while at the same time empowering communities and individuals. It is important for governments to design policies that act across the whole gradient and address the barriers facing the people who are the most vulnerable. It is imperative that healthcare establishment design their policies and protocols to promote humanistic-centered care, and have the appropriate governance structures, such as Ombuds personnel and User Councils, to achieve this it is equally important for every individual in the healthcare sector to be aware of systemic barriers to healthcare equity and ensure that they educate themselves to help eliminate biases.

It will take leaders across all sectors – government, hospitals, healthcare establishments, education, social services – to make healthcare equity a priority for humanity, and, as members of the International Hospital Federation’s Young Executive Leaders program, it is our duty to lead the way to: 1) Promote health and culture literacy and patient autonomy (Patient´s voice); 2) Create new ways of access to healthcare services; 3) Implement cross-cutting health policies to all society sectors.


REFERENCES

[1] Constitution of the World Health Organization, 45th edition, October 2006.  https://www.who.int/governance/eb/who_constitution_en.pdf

[2] PAIM, Jaimilson Silva. O que é o SUS? (What is SUS?) [online]. Rio de Janeiro: Editora FIOCRUZ, 2009.

[3] MATTA, Gustavo Corrêa. Princípios e diretrizes do Sistema Único de Saúde (Principles and guidelines of the Unified Health System). In: MATTA, Gustavo Corrêa; BRIDGES, Ana Lucia de Moura (Org.). Políticas de saúde: organização e operacionalização do Sistema Único de Saúde (Health policies: organization and operation of the Unified Health System). Rio de Janeiro: EPSJV/FIOCRUZ, 2007.

[4] US News & World Report, 2021.  https://www.usnews.com/news/best-countries

[5] Reading, C.L. & Wien, F. (2009) Health Inequalities and Social Determinants of Aboriginal Peoples’ Health.  Price George, BC:  National Collaborating Centre for Aboriginal health.

[6] Moss, Wendy & Elaine Gardner-O’Toole.  Aboriginal People: History of Discriminatory Laws.  November 1987.

[7] Dr. Bryce Report 1907, Medical Inspector, Department of Indian Affairs.

[8] Dr. Bryce Report 1907, Medical Inspector, Department of Indian Affairs.

[9] Truth and Reconciliation Commission of Canada.  2015.  https://nctr.ca/records/reports/

[10] Human Rights Watch.  Make it Safe: Canada’s Obligation to End the First Nations Water Crisis.  June 7, 2016.

[11] Public Inquiry Commission on relations between Indigenous Peoples and certain public services in Québec: listening, reconciliation and progress.  Government of Quebec.  2019.

[12] Statistics Canada.  Life expectancy of First Nations, Métis and Inuit household populations in Canada.  Census of Population, 2016.

[13] Statistics Canada.  The housing conditions of Aboriginal people in Canada.  Census of Population, 2016.

[14] Statistics Canada.  Living arrangements and housing.  Census of Population, 2016.

[15] Statistics Canada.  Health and well-being.  Census of Population, 2016.

[16] Statistics Canada.  Health and well-being.  Census of Population, 2016.

[17] Statistics Canada.  Health and well-being.  Census of Population, 2016.

[18] Statistics Canada.  Health and well-being.  Census of Population, 2016.

[19] Ministère de la Santé et des Services sociaux.  La sécurisation culturelle en santé et en services sociaux.  Government of Quebec.  March 2021.

[20] Abley, Mark.  Taking a pulse of the North.  McGill News.  https://mcgillnews.mcgill.ca/s/1762/news/interior.aspx?sid=1762&gid=2&pgid=1180

[21] Shu-Ti Chiou, Michael Marmot. Health inequalities in Taiwan . Health Promotion Administration. 2016.

[22] Lin YC, Wu JC, Chiou ST, Chiang TL. Healthy living practices in families and child health in Taiwan. Int J Public Health. 2015 Sep;60(6):691-8.

[23] Lin YC, Li YF, Chiang TL. Healthy living practices in families and child health: 5-year follow-up of Taiwan Birth Cohort Study. BMJ Open. 2020 Jul 21;10(7):e033613.

[24] Revista de Estudios Empresariales. Segunda Época. No 1 (2014) Pages 40-51. Visited the 28th August 2021 available on https://revistaselectronicas.ujaen.es/index.php/REE/article/view/1369/1202

[25] Rajmil, L., Starfield, B., Informe de expertos: Hacia la equidad en salud. Capítulo IV. Desigualdades en salud Infantil. Ministerio de Sanidad. Visited the 28th August 2021 available on https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/promocion/desigualdadSalud/docs/CapIVDesigSaludInfantil.pdf

[26] Propuesta de políticas e intervenciones para reducir las desigualdades sociales en salud en España. May 2010. Ministerio de Sanidad. Visited the28th August 2021 available on https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/promocion/desigualdadSalud/docs/Area_5_infancia.pdf

[27] Programa de Salud Infantil. Asociación Española de Pediatría. 1st Edition. January 2009. ISBN 978-84-95028-83-9 visited the 28th August 2021 available on https://www.aepap.org/biblioteca/programa-de-salud-infantil

[28] Díaz Huertas, J. A., Vall Combelles, O., Ruíz Díaz, M. A., Informe técnico sobre problemas de salud y sociales de la infancia en España. Ministerio de Sanidad y Consumo. Madrid 2005. Visited the 28th August 2021 avalaible on https://www.aepap.org/biblioteca/programa-de-salud-infantil

[29] AFONSO, Thaísa Cristina; CIRINO, José Antônio Ferreira. De onde vêm as melhorias? (Where do the improvements come from?). In: CIRINO, José Antônio Ferreira; PRESTES, Andréa; LOLATO, Gilvane. Estratégias para a Acreditação dos Serviços de Saúde (Health Services Accreditation Strategies). Curitiba: Appris, 2021.

 

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