Regional barriers to financial inclusion and health - part 2: what people have told us
In case you missed it, in part one of this blog we discussed existing research on financial inclusion and health equity. The two main points of part one were financial exclusion is a barrier to good health and wellbeing and financial inclusion is a component of health equity. If you like, you can go back and read it here
In part two, we’re moving on and sharing some insights from two recently completed co-design projects our team has undertaken into two separate health system areas where consistent themes on health and financial exclusion have emerged. The projects are below if you would like to read further:
Social Prescribing Co-Design: COORDINARE - South Eastern NSW PHN
Mental Health Literacy Initiative Co-Design Project: South Western Sydney PHN
Let’s jump into what we heard.
Financial barriers to good health
From just a practical sense, we consistently heard that cost of services is a barrier to getting the support someone needs.
“We are a low socioeconomic area. People ask ‘how am I ever going to get better if I can’t afford the things I need?... so they end up sitting at home thinking about their condition”.
Not just practical things though, we hear about the limitations of health services to tackle the things that underly or contribute to health issues
“service providers are powerless to deal with big issues like poverty and low pay”
“it’s all medicalised... so you can get some free counselling but that's not what you need… you need a job.”
We hear about how those financial barriers to good health can be perceived, rather than actual. They can be cumulative — people often seeing multiple providers and need to see them regularly for a treatment effect, with most publicly funded services having constraints that don’t align.
And they can be the hidden costs, like transport…
“Whenever we try to refer someone, first question we get asked is 'how much is it going to cost?' That's the barrier that stops them from participating. Could be cost of a gym membership or just down to cost of a bus ticket.”
Then zooming out even more from financial barriers to health care to thinking about how financial and social inclusion are a fundamental part of someone’s health status:
“The role of poverty is not acknowledged enough — and role of social exclusion. lack of capacity and resources to participate in anything.”
“I've never been asked about my social situation in a health consultation - it is always assumed that I am fine and life is fine and this when sometimes it hasn't been,”
Health barriers to financial and social inclusion
Now flipping that around and thinking about the health barriers to financial and social inclusion.
Again, starting with the practical:
“People have claims/benefits cut off because they can't get to appointments… Nobody checked that they couldn't get there, didn't have transport”
We often heard about this concept of people with health conditions getting stuck in a cycle of being a patient and not having the time, space and resources to focus on other aspects of their life that impact financial and social inclusion:
“Not being seen as a whole person — referred to as the diabetic, or the heart failure patient… rather than Mr Smith who used to be a mechanic.”
“A lot of appointments make up the week — living with chronic pain steals your joy and motivation and hopefulness”
“[there needs to be] better support for people in hardship without creating dependency or people getting stuck in the system.”
“People haven't done anything in 10 years: not going to work, just been seeing doctors and taking medication. What's the point of getting better if you're not able to do those things?”
So what do people experiencing health issues really need (and want)?
Acknowledging that these thoughts are provided in the context of social prescribing service and mental health programs, they are pretty well able to be generalised to any health service that is holistic and able to meet the diverse and interconnected needs of someone presenting with a health concern.
What the services are:
“Contact with other human beings is often limited… [this] even applies to people who appear socially connected on the outside… [but] particularly a gap for people with chronic health conditions.”
“Non-clinical interventions give people a chance to step outside the box of being a collection of their symptoms”
“People have to be able to laugh, move and learn things… these are universal human needs
How the services work with people:
“Services that work to overcome barriers experienced by patients (particularly GPs) —. transport, financial costs”
[a service should] know the situation deeply enough to know what that person’s capacity to pay for the service is”
Two examples here that really stand out:
“Networks built — where people are able to help others, not just be helped themselves… it’s the 3 hours of my week where I don't feel like an injured worker"
That was someone talking about a program that was set up around supporting people who had been injured at work to recover and return to work There’s good evidence that the longer someone is away from work after illness or injury, the less likely they are to ever return to the workforce
The other example we heard:
“There used to be this program of people teaching others about something they know about or are good at. People got paid a small amount but it was more about value they can share with other people. Some success stories [where] some of them went and did more study, started businesses… [The’ confidence and identity shift that comes out of sharing knowledge and learning with others.”
So these things that keep people motivated, engaged, skilled up and confident are critical needs that you can see have a direct link to someone’s financial inclusion
And looking into the future, what kind of responses could our health system be providing people to better meet their needs?
“So many different things could be the ‘prescription’”
“[It is] very easy to overestimate what it takes to give people a sense of purpose. Giving people an appointment might be enough to get people out of bed that day
Things are already happening in community you don't have to spend money on”
And this last one which I think is incredibly well put, by someone who runs a general practice and who told us her perspective shifted about the health systme just in being involved in these conversations:
“I now look around the waiting room and don’t think we’ll solve the world’s health problems with prescriptions or diagnoses”
Where to from here?
The answer is in how health systems are able to apply a health equity approach to how it plans, delivers and evaluates how services and resources are used to improve the health and wellbeing of communities.
We know that many groups experiencing disadvantage is because they are disengaged or disempowered — traditional forms of data collection that are used to inform how health systems are working don’t hear from people about these experiences, so the decisions about what is needed doesn’t adequately include them.
In the co-design process we did in South Western Sydney, we asked people, many of whom were either experiencing a persistent mental health issue or caring for a loved one who was, and/or identified as being from a culturally diverse background, to map the journey that someone would take to seeking help for a mental health issue in their community.
A couple of really interesting points emerged:
Many of the barriers cited for why something wasn’t available to them or it didn’t work, was linked to issues of financial inclusion.
Many of the services and supports people valued most in finding information, talking to someone they trusted, getting their needs for connection and joy met — were being met by informal, community-based supports that we don’t think of as part of the health system.
Similarly with the other project where we looked at social prescribing. There was a sense that both overcoming financial barriers to things like gyms or support groups or whatever it might be that someone needs for their health is important — but there’s already lots going on in communities that can be tapped into, and the ‘thing’ is less important than what it gives them, which is meaning, purpose, joy, connection and motivation to contribute to one’s community and manage their health. All of which are key ingredients in social capital, which we know is a key ingredient in financial resilience and wellbeing.