Health disparities monitoring in the U.S.: lessons for monitoring efforts in Israel and other countries

Health disparities or inequities are defined as “avoidable and unjust differences in exposure and vulnerability to health risk factors, health-care outcomes and the social and economic consequences of these outcomes” ([1]: p 15). The reduction/elimination of health disparities has been a public health priority for the past several decades; with the recognition, particularly in high-income countries, that a framework for systematically measuring and tracking disparities is essential to achieving this aim [2, 3].

This article focuses on health disparities monitoring systems developed in the U.S., which is a high-income country that faces formidable challenges to overcoming health and healthcare disparities, both because it lacks a national healthcare insurance framework, and it has higher poverty and income inequality rates than most OECD countries [4]. Nevertheless, it began to address and document the problem of health disparities in the 1980s, so it has a well-developed systematic infrastructure for health disparities measurement and monitoring [2]. This integrative article identifies lessons from the U.S. experience that are of relevance to other countries, both in terms of the processes through which the health disparities monitoring system was developed, and its content.

We will take Israel as a case in point for applying lessons learned from the U.S. experience, because an initiative of Israeli health policy makers provided the impetus for undertaking this endeavor. In the past decade in particular, the Israeli Ministry of Health (MOH) mobilized resources to develop a comprehensive health disparities reduction program [5]. As a part of its initiative, the MOH Reduction of Health Inequalities Section sought to review the measurement and tracking literature from other countries, with both similar and dissimilar healthcare systems (e.g., those with [U.K.] and without [U.S.] national health insurance) [6], in order to inform Israeli efforts.

Due to the breadth of health disparities field, and the specific questions being raised in Israel to strengthen its health disparities program, this article limits its focus to health disparities monitoring. The description and evaluation of programs/interventions and policies to reduce/eliminate health disparities are beyond the scope of this paper. Clearly, monitoring health disparities is not an end in itself. It is, nevertheless, an essential stepping stone on the path to eliminating health disparities/achieving health equity, and is currently a question of interest for Israeli health policymakers charged with the responsibility reducing health disparities.

We will use the term “inequality parameters” for the factors in which differences in health status and outcomes have been found across population subgroups (e.g., race, ethnicity, sex, age, education, income, geographic region, nativity/immigration status, sexual orientation) [7], and which have been selected for monitoring in efforts to reduce/eliminate health disparities. We will use the term health outcome/indicator for health, healthcare and health determinant factors (including social determinants of health) that are monitored for disparities by the inequality parameters.

We will preface this integrative article with a brief overview of health disparities and disparities monitoring in Israel because this is the setting from which our research questions arise, and to which we seek to apply the lessons that emerge from the U.S. experience. In Israel, academic publications and data that are routinely collected by various governmental bodies (e.g., the Israel Central Bureau of Statistics [CBS], Israel Centers for Disease Control [ICDC], MOH) have documented disparities between population groups for decades [8‐12]. Like the U.S., Israel is a country with higher poverty and income inequality rates than most other OECD countries (even after taxes and income transfers) [13], and persistent disparities in health have been documented along the socio-economic gradient [12]. There are ethnic disparities in health outcomes, disease risk factors, and mortality rates in Israel [9, 14, 15]. The indigenous Arab minority population (which makes up approximately 21% of the total population, and has a poverty rate of 52.6%, compared to that of 13.6% among Israeli Jews [16]) exhibits higher age-adjusted chronic morbidity and mortality, and shorter life expectancy, than the majority Jewish population [8, 9, 17‐19]. In addition to this ethnic disparity, the Jewish majority is comprised of groups that differ by ethnicity, and/or nativity/immigration status, across which health disparities have been found. Jews of Middle Eastern/North African origins, and more recent immigrants, have been characterized as having a lower socio-economic position and poorer health outcomes than those of European/North American origins and longer residence/nativity in Israel [14, 20‐22]. Disparities by religion or religiosity have likewise been found, as these factors are also aligned with socio-economic status (SES) and/or ethnicity. Disparities in health and healthcare access by geographic region have also been documented, with those living in more peripheral regions having poorer access to certain levels of health care [20, 23]. Many of these inequality parameters intersect or overlap, such that low SES ethnic groups are also likely to live in peripheral geographic regions [16].

Israel enacted a national health insurance law in 1995 that entitled all Israeli residents to access to primary, secondary and tertiary healthcare services, and to a comprehensive and continuously updated “basket” of health technologies (e.g., drugs, devices), regardless of ability to pay [24‐26]. Healthcare services are delivered by four not-for-profit health funds [HFs], and paid for by progressive health payroll tax premiums and an allotment of resources to the HFs on the basis of an age, sex and residential area-adjusted capitation formula as a proxy for varying healthcare needs [27].

The National Health Insurance Law represented an important step toward reducing healthcare access disparities, since prior to its enactment, the proportion of uninsured was higher among low SES and minority populations [24, 26, 28]. However, a number of access barriers remain. Shortly after its establishment, the National Health Insurance Law allowed the HFs to begin offering supplemental insurance to cover services not included in the basket of health services, for an additional fee [24]. The subsequent growth of the supplemental insurance programs, together with the introduction (and increase over time) of co-payments for medications, physician visits, medical imaging, etc., has resulted in a clear socio-economic gradient in the utilization of services requiring co-payments [25, 29]. In addition, there is a substantial ethnic disparity in the purchase of supplementary insurance, which reaches 87% among the total adult population, but only 54% among Arab adults [25].

In 2010, the Israel MOH made the reduction of health disparities an official policy priority. It focused primarily on impacting midstream factors (e.g., with in the healthcare system, which are under its direct purview), such as improving access to critical healthcare-service infrastructures in peripheral areas; eliminating financial and other access barriers to care for low-SES population groups; reducing disparities in access to and quality of healthcare services due to cultural barriers; developing incentives and tools that support the efforts of ‘agents of change’ in combating health disparities among target groups, and establishing a national health disparities database [5, 30].

Reporting on and monitoring of health disparities was an integral component of this new policy. Although, as mentioned above, various Israeli governmental and healthcare agencies routinely collect a wealth of data relevant to health disparities [31], there was no consistent methodology or comprehensive database to enable the systematic monitoring of health disparities according to uniform standards in Israel [5]. The MOH health disparities program began producing annual health disparities reports that presented health outcome data from various sources by available inequality parameters [6, 23, 32‐35]. A summary of the quantitative data contained in the reports is presented in Additional file 1: Table S1. Disparities monitoring capacities in Israel have been limited by the fact that data on many factors were not consistently collected annually (e.g., Israel CBS Health Survey conducted only in 2009, and Social Survey with battery of health questions conducted in 2010 and 2017). Most of the indicators tracked annually included health outcomes (e.g., infant mortality, life expectancy,) and regional disparities in the distribution of infrastructure/services, hospital beds, and human resources (see Additional file 1: Table S1) [6, 23, 32‐35]. Notably, as many of the inequality parameters intersect, the MOH disparities reports sometimes present the health outcome data stratified by more than one inequality parameter simultaneously. This illuminates the compound effect of intersecting inequality parameters (e.g., highest infant mortality rates are found among ethnic minority populations in resource-poor/peripheral regions).

In addition to the MOH health disparity reports, a health disparities knowledge center was established that publishes additional data on health disparities based on in-depth data analyses of the CBS surveys as well as original research [30, 36]. Other organizations, such as the ICDC and the National Program for Quality Indicators in Community Healthcare (QICH) produce periodic reports from survey, surveillance or registry data (ICDC) or aggregate patient data from the HFs (QICH) under their purview [9, 10]. However, information on population characteristics is limited in these data sets, hampering their ability to track health disparities in a comprehensive manner [37].

The important upstream role that social determinants (e.g., education, employment, social services) play in health disparities was acknowledged and discussed (primarily qualitatively) in the MOH health disparities reports, along with updates on indicators of SES inequalities in Israel (e.g., poverty rate, Gini index) [6, 23, 32‐35]. However, because of its limited control of policy outside of the healthcare scope, MOH monitoring of and involvement with these upstream factors have been intentionally limited. The MOH health disparities program leaders noted that “finding a way to achieve a substantial impact of each governmental decision on social gaps in general and health disparities in particular …is still a challenge in the Israeli system.” [5, p. 24] Nevertheless, in the past 2 years MOH has committed to a new strategic plan to address health inequalities which includes action items on the social determinants of health such as poverty, racism and social exclusion [38].

U.S. health disparities monitoring programs provide useful lessons for the international community, and we will now consider how these lessons might be applied to the Israeli context. The starting point for this article was the interest of the Israeli MOH in choosing a set of health outcomes/indicators/determinants and inequality parameters to be used for the systematic monitoring of health disparities in Israel. Resources such as the Health People Leading Indicators, and the CDC health disparities reports provide useful and specific criteria for choosing outcomes. In addition, the U.S. experience of explicitly defining inequality parameters, and requiring, through legislation, that health outcome data be collected by these parameters in DHHS/government surveys, may also be applicable in Israel.

Use of the monitoring process, as was done in the U.S., to systematically identify gaps in the data for specific inequality parameters/categories, would make it possible for Israeli policymakers to develop plans for closing the data gaps and building a comprehensive health disparities monitoring system.

The Israeli health disparities program has thus far dedicated most of its resources and its most consistent monitoring efforts to tracking and reducing the impact of low SES/regional disparities and language/cultural differences on access to health services. It has, nevertheless, from the outset, recognized the critical role of the social determinants of health. Israeli governmental agencies/ministries collect a wealth of data that could be used for systematic monitoring of disparities in the social determinants of health. The MOH has addressed the need for horizontal and vertical, cross-ministry cooperation to implement such a monitoring system. One of the major challenges that it continues to confront is the difficulty of “leveraging the problem of inequity into a pan-governmental responsibility” [30, p. 10].

Although direct action to affect the social determinant-outcomes is largely beyond the purview of the MOH, the U.S. model of formally tracking them from data routinely collected by other governmental departments is relevant to the Israeli context as well. The MOH health disparities program has quite consistently reported on poverty and income inequality rates. The U.S. model shows how this can be strengthened and enriched by tracking inequalities in their predecessors, such as educational achievement, employment, etc. In addition, existing, publically accessible data makes it possible to track these social determinant-outcomes by relevant sub-population disparities parameters, which is something that was not done in the MOH social determinants of health disparity reporting to date. Such routinized data tracking and reporting would provide the MOH with an evidence base to help it to more effectively achieve its commitment of:

Active involvement … in maintaining awareness at the highest decision-making echelon of the importance of narrowing social gaps, and the high priority that should be given to this struggle. The health authority should emphasize the relationship between social disparities and health disparities and the need for a national endeavor to tackle them. It is recommended that the health authority leader should present the government with an annual update on progress in this arena [5: p. 23].

Finally, the use of information technology in the Israeli healthcare system is extensive, and comprehensive data on healthcare utilization and morbidity is collected in the digital databases of the four HFs and by the MOH. Furthermore, information on the social determinants of health (e.g., education, employment, income) by inequality parameters (e.g., ethnicity, immigration/nativity, geographic region) is regularly collected by various government departments (e.g., Ministry of Education, National Insurance Institute of Israel, Israel Central Bureau of Statistics). The linkage of these national-level data on the social determinants of health to data on health outcomes and health service utilization would provide an unparalleled resource for understanding, tracking, and intervening to eliminate health disparities. However, these datasets have not been systematically linked in practice due to legal, organizational, financial and other barriers preventing data sharing and secondary use of healthcare data in Israel. This issue was recently discussed in a workshop for national-level health policy executives, and the workshop summary called for regulatory action to reduce these barriers [88].

The U.S. infrastructure for health disparities monitoring provides a model of global relevance in terms of how inequality parameters and outcomes can be determined, how data collection systems can be established (using legislative measures and broad cross-governmental resources), and how data gaps can be identified, tracked and eliminated. It also provides a model for how disparities data can be shared to support the design and implementation of policy, clinical and community interventions. Furthermore, it highlights the value of high-level political commitment and legislation.