Here's a recipe for a more equitable health care system in Australia

Private health care is internationally almost always concentrated in cities. It thus makes it more difficult to staff services in rural and remote areas, as the incomes to be obtained in the private sector make working in the cities more attractive.

Community preferences for equity

At a 2000 meeting of the WA Medical Council, a randomly selected group of Perth citizens and a group of senior health-care professionals, both groups argued for greater investment in public health and for greater equity. It is significant that the Perth citizens voted altruistically for more resources to be allocated outside of Perth. In 2001, where the topic was narrowed to equity, citizens' juries argued for both horizontal and vertical equity. Of the three areas of inequity with which they were presented - Aboriginal health, rural and remote health and aged care - their greatest preferences for spending more health service money was in Aboriginal health.

In a mailed survey of the South Australian community, respondents were asked about the principles (including equity) they wished to underpin their health services. One half were randomly given basic information about Aboriginal health and the other no information. Both groups argued for vertical equity/ positive discrimination. Those given the information about Aboriginal health discriminated more positively although the difference was not statistically significant. Clearly any attempt to elicit the preferences of the community needs to try to ensure that the community is adequately informed as well as being aware of the resource consequences if their preferences were to be used.

The evidence is tentative but it seems that the public wants some greater degree of equity in health care. It is disturbing that so little research has been conducted on this issue.

There is poor recognition of the need to allow articulation and elicitation of the values of the disadvantaged who are deemed to be being treated inequitably. In this context there is no single value system that extends all the way across advantaged and the various disadvantaged groups. We need to find a paradigm that does not rely on a single value system. One is proposed below.

Implications and conclusions

A number of changes are needed to pursue greater equity in Australian health care. First, it is less "natural" in Australia (than in Denmark, for example) to have a social value structure that promotes compassion and concern for the less well off. We need a more compassionate society, an idea echoed by Sen when he writes of the "overwhelming role for intelligent and equitable social policies" and "an appropriate social commitment".

To move to a more compassionate society and a more equitable health-care system will require strong political leadership. As Nussbaum argues: "We want leaders whose hearts and imaginations acknowledge the humanity in human beings."

There are thus severe limits to making progress with equity in health care in Australia without the appropriate political will. Neo-liberalism and market values dominate so much of the value system of Australian society (and not just the Australian economy). The standard health-economics approach will not get us an equitable health-care system. That is why I advocate the adoption of a new paradigm, based on communitarianism, which involves recognition that the community is something to be valued in and of itself.

Crucial are two other factors: first, recognition that autonomy is social; and second, an emphasis on freedom. A community-determined "constitution" or set of principles is the vehicle for expressing this communitarianism, based on Vanberg's "constitutional paradigm", which "draws attention to the procedural foundations that organizational action is based upon".

This may best be done through "communitarian claims". Communitarian claims "recognise first that the duty is owed by the community of which the candidate is a member and secondly that the carrying out of this duty is not just instrumental but is good in itself ".

Further, the idea avoids the need for a common construct of health or health needs, and for different groups to have the same ability to manage desire, one of the main criticisms that Sen makes of more conventional schools of economic thought.

Third, since equity lies at the heart of public health, there is a responsibility in public health to promote debate about issues that have a potential impact on the health of the public.