Does universal health care coverage mean universal accessibility? Examining the Canadian experience of poor, prenatal women

Does universal health care coverage mean universal accessibility? Examining the Canadian experience of poor, prenatal women

Does Universal Health Care Coverage Mean Universal Accessibility? Examining the Canadian Experience of Poor, Prenatal Women A. Michel Morton, RN, MScN...

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Does Universal Health Care Coverage Mean Universal Accessibility? Examining the Canadian Experience of Poor, Prenatal Women A. Michel Morton, RN, MScN Cynthia Loos, RN, MEd School of N u r s i n g , Lakehead University, T h u n d e r Bay, Ontario, C a n a d a

ecently, Americans have been grappling with the complexities of health care reform. President Clinton advocated for radical reform. He wanted guaranteed health coverage for every individual. However, this push towards universal health care coverage met with considerable opposition from a variety of sectors. Opponents ranged from insurance companies to doctors and the small business lobby. Many concerns were voiced including the high cost of such coverage and the possibility that client confidentiality could be compromised by a government-run health insurance system. Ultimately, the possibility of universal health care coverage became less and less likely, but some interest in this type of reform remains. Presumably, universal coverage would have meant increased accessibility to health care and, therefore, better health. This system of universal coverage could have been of great benefit to women whose health care is frequently compromised. The current health care system has historically failed to fund women's health concerns adequately.1 Universal health care coverage could have helped address this discrepancy.

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THE CANADIAN EXPERIENCE Universal coverage has been a cornerstone of the Canadian health care system for a number of decades. This system and the coverage it offers are admired worldwide. In addition, the Canadian people are some of the healthiest in the world. Besides universality, the principles that support this system of coverage are accessibility, portability, comprehensiveness, and public administration. 2 However, the Canadian experience indicates that universal

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coverage does not equal universal accessibility to health care. Barriers to accessibility have been identified that relate to culture, geographic location, and socioeconomic status. 3 Consider the appalling health statistics of Canada's Native people. Culturally inappropriate approaches that render health care less accessible have been suggested as important factors contributing to the much higher morbidity and mortality rates of these people. The concerns expressed by those in the underserviced communities point to the lack of accessibility due to location. Much of Canada's population is located near its southern border. In these areas, health care is readily available. However, in communities farther north, there is a lack of health care practitioners. In some communities, emergency departments have been closed after hours due to the lack of available physicians. Attempts have been made to rectify some of the problems related to accessibility due to culture and geography. Initiatives, such as programs designed to train Native people as health care practitioners, as well as incentive programs to attract physicians to underserviced areas, have been established. However, barriers to accessibility remain, including those related to poverty. Susan Smith and Miriam J. Stewart, two Canadian nurses noted for their antipoverty work, identify the poor as a vulnerable, powerless population whose access to appropriate health care is inhibited by the bias of the Canadian health care system and its workers. Traditionally, the system has not seen poverty as a problem for health. Thus, health care resources have not been allocated in ways that are accessible to the poor. 4'5 When programs are designed for the poor, their needs and realities are frequently misunderstood, and the underlying problem is often the lack of consultation with those who are poor. s'6 Health care workers frequently have little understanding of the implications of poverty, its endless, debilitating cycle, and the lack of real choices available to the poor. 4"5 In examining the links between poverty and health, McBarnette suggests that health care professionals do not view poverty as a phenomenon related to health, so factors implicated in poverty are not considered when planning care. 7 In Canada, health is related to income. The poor have poorer health, ~'9 and women make up a greater percentage of the poor. Thus, many women with universal health care coverage have poorer health than Canadians of higher income. Although universal coverage is not the sole determinant of health, it is an important one and bears further examination.

THE CASE OF PRENATAL WOMEN WHO ARE POOR In examining Canadian programs for prenatal women who are poor, the authors found evidence of lack of consultation. However, prenatal women are one client group that presents with critical concerns in relation to poverty. Poverty not only affects their health, but has implications for their children and subsequent generations. Prenatal education programs generally are viewed as an effective method for imparting information to pregnant women in hopes of improving their health and that of their children. Yet the authors' research and comprehensive review of relevant prenatal literature revealed that there is little indication that poor women were consulted when prenatal programs were developed for them. Instead, programs were designed by middle-class health care professionals and were rooted in the beliefs and values of the middle class. 1° Such programs are unlikely to meet the needs of this target population, although as early as 1981 the literature indicated that the likelihood of poor, pregnant women attending prenatal programs increased when programming reflected their life-style. LI

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In describing access to health care by poor Canadians, Stewart characterized the poor as having a sense of isolation and feelings of powerlessness and fatalism, as well as being concrete and present-oriented in their thinking. 5 These people are caught in a never-ending cycle of poverty. Few Canadian prenatal programs are designed to address these characteristics of the poor. Instead of reaching into the isolation to encourage poor women to attend prenatal programs, there is an expectation that women will identify and attend programs of their own volition. In addition, most programs reflect a future time orientation, focusing on teaching about up-coming events such as labor and delivery. Such a strategy does not necessarily reach people who are present-oriented and concrete in their thinking. The authors have found that dealing with the women's present concerns and then linking these realities to future events such as labor and delivery is a better approach, though this technique is seldom central to current program delivery. Most prenatal programs also reflect the belief that the women can proactively influence their health. This belief, however, is in direct opposition to the women's belief that they are powerless. In order to foster a sense of personal power, programs must start where the women are, in the domain of powerlessness, and work to change that belief. Generally programs do not do so. Thus, poor women are unable to access responsive prenatal programs, although these women have universal health care coverage.

CONCLUSION The difficulty poor, prenatal women have in accessing appropriate health care has been discussed in light of Canada's universal health care coverage. In addition, the realities of other Canadians, whose accessibility to health care is compromised by cultural and geographic factors, have been briefly examined. In Canada, poverty, culturally inappropriate approaches, and remote geographic location are the barriers identified as limiting access to health care. As the American people work towards developing the best health care possible, they might reflect on the Canadian experience that indicates that implementing universal coverage is, at best, an imperfect method of providing universal access to health care. Is the answer, then, to look at other barriers to accessibility in the United States and develop strategies to deal with these barriers? Determining the barriers could be an arduous task. However, utilizing the Canadian experience can assist in developing a framework to drive this process. In addition, as the Canadian experience illustrates, public participation and consultation are integral to supporting the principle of accessibility. Consultation can also assist in developing appropriate strategies to deal with the barriers identified as limiting accessibility to health care.

ACKNOWLEDGMENT Preparation of this article was supported, in part, by a grant from the National Health Research Development Program.

REFERENCES 1. Elders MJ. Remarks for the Jacobs Institute of Women's Health. Women's Health Issues 1994;4:60-2. 2. Canada health act, In: Revised statutes of Canada. Ottawa: Queen's Printer for Canada, 1985: Chapter C-6, 1-13.

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3. Stewart MJ, Lanqille LL. Primary health care principles: core of community health nursing. In: Stewart MJ (ed). Community nursing: promoting Canadians' health. Toronto: Saunders, 1995. 4. Smith S. "Why no egg?" Building competency and self-reliance: a primary health care principle. Can J Public Health 1991;89:16-8. 5. Stewart MJ. Access to health care for economically disadvantaged Canadians: a model. Can J Public Health 1990;81:450--5. 6. Echenberg H. Reducing inequities. In: Health and Welfare Canada. (ed). Knowledge development for health promotion: a call to action. Ottawa: Minister of Services and Supplies, 1989:23-8. 7. McBarnette L. Women and poverty: the effects on reproductive status. Women Health 1987;12(3/4):55-81. 8. Rootman I. Knowledge development for health promotion: a summary of Canadian literature reviews. Health Promotion 1988;27(3):2-7. 9. Health and Welfare Canada. Canada's health promotion survey. Ottawa: Minister of Supply and Services, 1988. 10. Loos C, Morton AM. Promoting reproductive health: strengthening community prenatal education programs and strategies. Linking research to action: a literature review [research report]. Thunder Bay (Ontario): Lakehead University, 1991 June. 11. McClure BG, McKenna M, Ritchie JWK. The background to perinatal care. Maternal Child Health 1981;6:412-7.

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