Differences, Access, Primary Healthcare, general praactitioner, health visitor, roma, equal opportunity, prejudice, ghetto, mortality, morbidity, demography

Differences in Access to Primary Healthcare - Structure, Equal Opportunity and Prejudice

Brief Summary

One of the purposes and a fundamental question of our research is to establish whether various social groups, including Roma and others that suffer multiple social and economic disadvantages, have full and equal access to primary healthcare services. If there is unequal access to basic services, what are the causes of this inequality, and what are the actual differences in access among the various social groups? Because our research focuses partly on the access of Roma, when determining which doctors and health visitors we would question - that is, the actual group that would constitute the subject of our survey - we selected settlements where, on the basis of authoritative estimates , the percentage of Roma inhabitants equalled or exceeded 1%. Consequently, the results are representative only of those GP practices and health visitor districts that are located in these settlements.

General practitioners

Structural issues

We began by analysing the national statistics that are relevant in terms of establishing whether the presence or absence of a GP in a settlement is in any way related to the settlement's social standing, the number of its inhabitants, the age distribution of those living there, or to the ratio of unemployed persons or of Roma within its population.
The data suggests that settlements with multiple disadvantages do not offer local practitioner services directly. These settlements, mostly because of an aging population and the lack of local funds also tend to be lacking in other basic institutional services.
If we look at the national picture, we find that the number of pensioners is generally higher in settlements that do not have a local GP. However, the older segment of the population, with its greater health concerns and higher health risks, suffers from the lack of local health services only to a slightly greater extent than does the population as a whole. This slight difference, however, is significant when we look at the actual number of pensioners affected: approximately 128,000 out of over 2 million.
However, the ratio in the Roma population shows a dramatic difference. Excluding Budapest, 18.6% of the country's total Roma population lives in a settlement without a local GP.
The social and material conditions of Roma and pensioners living in settlements where there is no local GP are significantly worse than average, especially since the social and economic circumstances of these small settlements tend already to be among the worst in the country. The local and social disadvantages may well compound the problems arising from a lack of direct access to a local GP.
We know that the high rate of health problems among Roma is due directly to poverty fac-tors, and in this regard, the Roma population of the poorest small settlements - amounting to more than 100,000 individuals - is in an especially grave situation: it simultaneously suffers from poverty, a high incidence of health problems, and the lack of direct and immediate access to the services of a local GP.
To summarise the local inequalities of access to healthcare on the basis of national statistics, the country is "divided" in terms of the population of smaller settlements, especially small villages. Small settlements with a local GP are well supplied in respect of the patient/doctor ratio, despite the fact that the population of smaller settlements tends to be older, have higher unemployment rates and inadequate funds, and to suffer from poverty.
In settlements where there is no general practitioner or where the GP post is unfilled, the ratio of Roma tends to be significantly higher, and the number of pensioners is also high. The inhabitants of these settlements suffer multiple disadvantages: they are affected by the unfavourable position of the settlement with all its consequences, and by the lack of local and immediately accessible healthcare.

The analysis of national data shows that the significant inequality of access based on location also adds to the doctors' workload. A little over 80% of doctors work in one settlement, almost 10% work in two settlements, but the maximum number of settlements served by one doctor is eight, according to our data.
The characteristics of a settlement, and the administrative status and size of settlements, fundamentally determine the access of their inhabitants to health services, as well as the workload of their GPs. Just as there are considerable differences in access among patients, so there are significant differences between GPs in terms of their workload, how many patients they serve directly, how long their office hours are and how many hours they are on call.
The distribution by age of doctors is not consistent among practices with considerably differing workloads. The oldest GPs can afford to avoid a practice with a higher workload. The youngest ones do not choose practices with higher workloads but are forced to take them in the absence of other options.
An aspect of structural inequalities is the amount of time (attention and work) a GP can spend on a patient. We have observed great differences, which are a result of structural inequalities.
GPs' offices also differ in how well equipped they are, and we have found considerable differences. However, the causes of the presence or absence of equipment are not structural. The practices of the youngest doctors are significantly more well-equipped, middle-aged doctors' practices are more often moderately well-equipped, the offices of older doctors are more often than not below average in equipment. The analysis demonstrated that age is a factor but education is not. Younger doctors have better-equipped offices even when their level of training is lower.
Socially disadvantaged, poor or Roma patients tend to be taken care of by GPs who belong to the younger generation, specifically because in settlements where the number of Roma, for example, is higher, doctors tend to be young. Because young doctors have better-equipped offices, Roma patients are usually served by better-equipped practices.
However, the structural advantages or disadvantages seem to be stronger and more significant than, for example, the equipment of a doctor's office.

Equal opportunity and social status

In analysing doctors' attitudes, the issue of whether equal or unequal access is provided to patients of different social status seemed to us more widespread and deeper than the issues of prejudice. In our research we considered prejudicial attitudes as a subsystem of mechanisms that promote inequality. We did so because it is obvious and clear from our analyses thus far that one of the most important bases of inequality is structural.
According to our data, latent discrimination against various social groups, which may not be a result of prejudice, is more frequent than blatant discrimination.
Certain GPs offer less expensive medical services to poor, unemployed, Roma or other socially marginalized patients than to others, their communication with these patients is below average, and conflicts occur with greater frequency than average. The social deprivation of these patients is a causal factor because, among other things, doctors believe that these patients' potential to reduce health risks is low.
GPs perceive these patients on the basis of their socio-economic and socio-psychological status, while certain significant dimensions of a GP's practice are defined by these differences in status and not by the patient as a social being.
In addition, GPs determine the level of institutional care on the basis of patients' social and socio-psychological status, and therefore the level of institutional care is determined by status and not by a selected protocol.
A certain number of GPs provide therapy at a lower institutional level to patients that are socially marginalized. The social deprivation of patients, as we have seen in relation to the cost of examinations, is a contributing factor. The low assessment of patients' potential to reduce risk to their own health is also an important factor in this regard.
GPs' compassion, or lack thereof, in terms of their taking into consideration the cost of medicine is an independent dimension and has an independent effect on the affordability of the cost of medicine paid by socially disadvantaged patients. A number of GPs can be shown to lack this type of compassion.

A significant number of GPs are not at all or not sufficiently familiar with the considerably higher incidence of disease among Roma and the risks associated with this. Therefore, they do not regard the Roma community as more eligible for increased screening and prevention or in-tervention which might reduce the incidence of disease among them.
Anti-Roma sentiment or the lack thereof is a measurable factor that impacts the perception of Roma and the level of services provided to them. The causal impact of rejecting anti-Roma sentiments is significant and explains whether a GP has a more or less clear picture of the level of health problems among Roma. It can be proven that the primary cause of the lack of information about the higher incidence of disease among Roma is not extreme anti-Roma feelings, but a common and average prejudice. On the other hand, a rejection of anti-Roma feelings is an easily discernible cause of a clear understanding among doctors of the incidence of Roma health problems.
Anti-Roma sentiments have an impact on medical practice extended to Roma; however, the attitude towards them is to some extent independent of how doctors generally relate to their socially marginalized, poor, and socially disadvantaged patients. This may not be that surprising, since the propensity for anti-Roma feelings appears to have "a life of its own" and is becoming increasingly widespread in society.

Certain versions of anti-Roma feelings do not necessarily result in detrimental situations for Roma with respect to primary healthcare. Even among GPs whose anti-Roma prejudices are strong, there are few who, in comparison with doctors who do not share this prejudice, provide a lower level of services to their Roma patients.
Anti-Roma feelings have a demonstrably negative, even though not significant, impact on the Roma-doctor relationship. Certain doctors with anti-Roma feelings do not provide the same level of services to their Roma patients as they do to others. However, according to our study, anti-Roma feelings are not a significant factor in primary healthcare services because they can be modified given the right methods.

More important than the damaging effect of negative attitudes towards Roma is the marginalization of poor, disadvantaged segments, regardless of ethnicity.

We would like to make the following note in closing. It cannot be proven that the apparent inequalities between the level of care received by the social elite and the disadvantaged respectively is caused by direct and open discrimination. In addition, a study conducted among doctors providing the services cannot demonstrate the actual chances for recovery and rehabilitation of socially deprived patients. We can only assume that if the cost and institutional level of care provided to them is lower, if follow-up among them is more infrequent, and the affordability of medications is not always considered, their chances of health maintenance, recovery or rehabilitation will be negatively affected.

Our research has shown, however, that the basic principle that each citizen must receive the same level and the best possible service regardless of social status or ethnicity, suffers.

Health visitors

The designation of health visitors' districts, and the number of health visitors in the various counties and settlements, fail to meet requirements, and in some cases actually run counter to them.
Health visitors' tasks are unevenly distributed. While the majority of health visitors work in one settlement on average and perform one basic task at low or moderate levels of intensity, one fifth of health visitors perform several tasks at a high level of intensity in a number of settle-ments.
Behind the distribution of health visitors' districts at the level of counties and settlements there are very serious inequalities in access caused by a structural imbalance. In disadvantaged, poorer areas consisting of small villages, a smaller number of health visitors carry higher work-loads and perform extra services, while counties and settlements in more favourable positions employ more health visitors with lower workloads.
More than one fifth of all the health visitors studied carry high workloads and also care for a high number of Roma.
In most cases the high number of Roma is a simple accompanying feature of the settlements' characteristics. The reason why health visitors work with so many patients and in several settlements is not because Roma live there, but the opposite: Roma tend to live where health visitors already have a higher workload.
However, the differences between workloads resulting from serious structural imbalances does not mean that health visitors with higher workloads invest less energy in their work or attend fewer training courses.
Health visitors in districts with high Roma percentages did not participate in more hours of training than in other places, and the high number of Roma does not (so far) indicate a greater participation in training.

Therefore, the distribution of health visitors' districts points to serious structural inequalities. In many cases the actual number of patients is three times the optimum number specified in the relevant government decree (quite apart from the other work commitments). Structural inequalities arise regardless of the percentage of Roma, and therefore can deeply affect the level of care that the Roma receive. It is a fundamental problem that the local distribution of operating health visitors' districts and the fluctuating number of patients are both contrary to the letter and the spirit of the decree, and do not serve the principal of equal opportunity and equal access.

Health visitors' training and their attitude towards their patients determine the extent to which they take into consideration the needs of their patients. Counselling, the communication of basic information and health-related advice that comprise a health visitor's tasks are interactive processes that greatly depend on the health visitors' attitudes (and not so much on the characteristics of their patients). This observation, however, is more relevant to their attitude to Roma patients than to others.
A fairly large percentage of health visitors are well-trained, care for many persons and are also committed to what they do, which means that they have an excellent grasp of their patients' needs.
A higher percentage of highly trained health visitors who are tolerant towards Roma understand that their Roma patients have numerous healthcare needs.
On the other hand, health visitors with lower levels of training and who are unable to perceive their patients' needs, and health visitors who have some form of anti-Roma attitude have a lesser understanding of their Roma patients' needs. This "blinkered" attitude hinders the true perception of Roma patients' healthcare needs.
The occasional lack of understanding with respect to patients' needs interferes with the provision of equal services because counselling is an interactive activity which is performed through communication between the counsellor and the patient. If a counsellor creates a communicational space that the patient perceives as inadequate in assessing his/her real needs, the counsellor will be unable to help because an atmosphere of mistrust has been created (towards the potential help).
Health visitors who demonstrably display some form of anti-Roma attitude have been proven to be less effective in meeting their clients' needs, despite any subjective wish they may have to be of help. As a result, on the basis of our knowledge of the communicative dynamics of service-oriented professions, these health visitors are less effective than average in assisting their Roma patients.

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