Prioritisation of health equity within the design and implementation of health system reform initiatives

Although government policies often assert health equity as a health system priority, they frequently fail to address inequity and there remains a dearth of evidence on effective policy reforms in this area. This thesis aimed to identify opportunities to promote, prioritise and address health equity as a part of health system reforms. The research was embedded within Collaborative Commissioning – a New South Wales (NSW) government reform initiative to implement decentralised, integrated care delivery models to improve health system performance. Taking a participatory approach with a consumer advisory panel, the following studies were conducted: i. a scoping review of the literature to identify and characterise strategies implemented to address health equity as part of reform processes ii. a qualitative study to identify health equity expectations of implementers and identify factors that influenced health equity prioritisation iii. two quantitative studies to determine opportunities to promote visibility of diverse populations and determine variation in health service utilisation across different population groups using linked health data iv. a cost-consequence analysis to consider the costs and health equity implications of an urgent care service v. an exploratory mixed-methods study to determine health care provider perspectives on the drivers of disparities in the provision of an integrated healthcare initiative targeting older people with frailty. Numerous multi-level strategies to promote address health equity were identified in the literature including leadership commitment and vision at multiple health system levels; power sharing and inclusive decision-making via formalised governance structures that involve community; continuous adaptation of services and systems to address equity barriers; and use of disaggregated quality data to improve visibility of marginalised populations. The qualitative research identified several risks to health equity prioritisation, particularly where there were limited policy guardrails to prioritise health equity and when policy makers and implementers had competing priorities (such as balancing health equity and efficiency). Mitigation against these risks required explicit accountability for health equity at multiple health system levels; an aligned understanding of health equity goals and actions amongst stakeholders; adaptable and tailored approaches to implementation according to local context; and flexible funding models. The analysis of a large NSW Health linked data asset comprising over 5 million people identified: (1) a large but heterogenous proportion of the NSW population that might be considered historically marginalised; and (2) a large variation in service utilisation patterns for these groups. The study uncovered misconceptions of these populations as peripheral, homogenous, small groups. It also identified opportunities to promote greater visibility and accountability for prioritising these groups in a historically siloed health system with split oversight amongst different levels of government. Linked data were leveraged for an economic evaluation and for a mixed-methods study of two regional Collaborative Commissioning initiatives (urgent care services for low acuity conditions and comprehensive care delivery for older people with frailty). The economic evaluation of the urgent care services for low acuity conditions initiative determined that urgent care services were being used by a diverse population at a lower cost than emergency departments. However, people with severe mental illness or drug or alcohol related conditions were underutilising the service. The mixed-methods study of an integrated healthcare initiative for older people with frailty highlighted the importance of data driven processes to identify older people at-risk of hospitalisation to reduce selection bias. It also identified the need for flexible patient eligibility criteria to support equitable representation of marginalised groups. From this research a health equity implementation framework was developed. The framework emphasises the importance of explicitly integrating health equity strategies with broader health reforms and implementing these strategies at all health system levels in an iterative and recursive manner. This appears to require macro- and meso-level health system actors to promote robust governance structures, relinquish aspects of power, and delegate some decision-making to meso- and micro-level actors. It also requires that actors at the macro- and meso-levels support service coordination and provide adequate technical assistance when needed. Attention to these factors can ensure health equity responsibilities and accountabilities are clearly delineated and foster an equity-oriented health system.