A few years ago, a Canadian researcher, Professor Dennis Raphael, took a look around the world to see how various countries were addressing health inequalities and the social determinants of health.
He subsequently published two papers in Health Promotion International (let me know if you’d like a copy), comparing both the rhetoric and the actions of countries identified as liberal, social democratic, conservative or Latin welfare states.
Raphael, a professor of health policy at the School of Health Policy and Management at York University in Toronto, concluded that governments of liberal or social democratic welfare states are more likely to make explicit rhetorical commitments, but that liberal welfare state nations (like Australia) fall well behind other countries in implementing public policies that provide “the prerequisites of health”.
He noted that Australia has produced many policy documents about health inequalities and the social determinants of health, although these have mainly came from state governments (he singles out NSW, Victoria, SA and Tasmania for particular credit).
The current Federal Government had made some progress with its focus on social inclusion, he said. While this was not explicitly addressing the social determinants of health, it at least “recognised that political, social, economic and cultural contextual factors influence health”.
But it’s not just what you say that matters, it’s what you do.
Raphael adds:
“Findings indicate that it is important to consider what nations actually do in the realm of public policy—rather than say in their statements and documents—about providing the prerequisites of health.
The liberal welfare states of Australia, Canada and England are usually held out as leaders in health promotion. But despite their governmental authorities’ commitments to the provision of the prerequisites of health, these nations actually have a rather poor track record of providing the prerequisites of health through public policy action when compared with numerous other OECD nations…”.
Raphael’s papers suggest we could learn plenty about addressing health inequalities from countries such as:
• Finland, which has set a target of reducing health inequalities – defined as differences in death rates among genders, those of differing educational levels and of differing occupation status – of 20% by the year 2015.
• Norway, which has a longstanding history of emphasising a structural approach to promoting population health and reducing health inequalities. Its 2007 National Strategy to Reduce Social Inequalities in Health aims to reduce social inequalities that contribute to inequalities in health, health behaviours and use of health services.
Updating the state-of-play in Australia
So, how should we assess the Federal Government’s response to the release this week of a new report attempting to generate some public and political support for action on health inequalities?
The report, The Cost of Inaction on the Social Determinants of Health, was undertaken by the National Centre for Social and Economic Modelling (NATSEM) at the University of Canberra, for Catholic Health Australia (CHA).
Health economist Professor Gavin Mooney gives an overview of the report’s findings towards the bottom of this post. His article, first published in Crikey on Monday, drew this response from one mental health policy analyst, John Mendoza.
But the best that the Minister for Social Inclusion, Mark Butler, could come up with was a statement saying that the Senate Standing Committee on Community Affairs “has received representations on the issue and will consider the matter for their work program for this year.”
Here is a bit of wider context to explain why this tepid response is disappointing:
• It’s been seven years since the WHO established the Commission on the Social Determinants of Health and four years since the Commission’s report urged member states to, amongst other things, “measure and understand the problem and to assess the impact of action”.
• It’s been two years since the release of England’s response to the WHO report, Fair Society, Healthy Lives.
• It’s been two years ago since another report from CHA and NATSEM, Health Lies in Wealth, put the issue into the political and public spotlight. It found that 65 per cent of people in low income groups have long term health problems, compared to only 15 per cent in high income groups. These outcomes, the report finds, have more to do with education level, stability of housing and employment, and the size of your social and familial network, than they have to do with access to health services.
• CHA and others have been pushing for a Senate inquiry for some time, while Professor Fran Baum, who was a member of the WHO Commission, has been arguing for a systemic response, such as establishing a Standing Commission (much like the Australian Competition and Consumer Commission) with a brief to work across government to establish and monitor mechanisms to encourage action in all government departments on the determinants of overall population health and to reduce inequities.
• More than four years of endless debates and discussions about health reform have failed to put concerns about health inequalities to centre stage on either the political or public agenda.
The Government has had years to wrap its collective thinking cap around this issue. It would seem reasonable after all this time to expect they might have come up with something more than a wishy, washy “we will consider it” sort of response.
Meanwhile, here is Professor Gavin Mooney’s analysis of the report.
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The hidden “illness” that puts tens of thousands into hospital each year
Gavin Mooney writes:
There is an illness that is causing untold pain and suffering and premature death across the globe. Here in Australia there are half a million Australians who are chronically sick as a result of it.
Of these 60,000 are admitted to our overstretched hospitals each year. Just think of the costs of this illness – the costs of PBS and Medicare services are getting on for half a billion dollars a year!
The illness? Well, there are several names for it. A new report from Catholic Health Australia and prepared by the prestigious National Centre for Social and Economic Modelling calls the illness ‘The Cost of Inaction on The Social Determinants of Health’.
Other names might be Class Differences or The Malaise of an Uncaring Society or again Not Spreading the Benefits of the Mining Boom. Fundamentally the ‘illness’ can be summed up as poverty and inequality.
When we look across the planet as a whole it is immediately clear that to argue that malaria and heart disease and so on are the major health problems misses the point. Better to see these as symptoms of a wider malaise – poverty and inequality. This is also true in Australia but in the clamour of competing voices and vociferous vested interests in the media, the impact on this nation’s health of these social determinants of ill health has not been so readily acknowledged.
Thus in Australia one of the sad things about this illness is that so little is being done about it and when some minor efforts are made to address the major inequalities that exist in power and income, as in the recent budget, the cries go up (from the well heeled) of ‘class warfare’, ’envy’ and so on.
This is despite the current toll of these social determinants of ill-health, as the report states: “There are no regular reports that investigate and monitor trends in Australia in health inequality over time nor whether gaps in health status between ‘rich’ and ‘poor’ Australians are closing.”
Does any other illness of such proportions go un-investigated and un-monitored?
The good thing about this illness is that it is largely curable and doing so will not cost a fortune. The health benefits are potentially staggering: “If the health gaps between the most and least advantaged groups were closed, i.e. there was no inequity in the proportions in good health or who were free from long-term health conditions, then an estimated 370,00 to 400,000 additional disadvantaged Australians in the 25-64 year age group would see their health as being good and some 405,00 to 500,000 additional individuals would be free from chronic disease.”
I haven’t worked it out yet but given all these benefits and the cost savings that would follow, the benefit cost ratio here must be massive.
But there’s a snag. Cost benefit analysis is not good at dealing with issues of redistribution and what is needed if this ‘illness’ is to be addressed is major redistribution of income, wealth and power.
The economics, as this report clearly demonstrates, points to action on these social determinants of health and especially on poverty and inequality. Getting the action however is not economics; that is politics.
The Opposition will brand this report a salvo in the class warfare and won’t have a bar of it. But the ALP, which was founded on the principles of social justice, just might. In doing so instead of listening to the mining magnates, they might resurrect these principles, get to grips with this malady and, who knows, maybe retain government.
It would not be hard. The PM could simply ask all Ministries to recognise that each and every one of them – but especially the Treasury – has a responsibility to foster the health of the nation. Each ministry might then conduct a health impact assessment of its existing policies and see how these might be altered so that they would be aimed at addressing specifically these social determinants of health.
The Treasury would then have to arrange funding of the ‘best health buys’ but in doing so recognise that the way that funding is organised can assist the process by being aimed at reducing one very important social determinant of ill-health – income inequality.
As the NATSEM report states: “People’s satisfaction with their lives is highly dependent on their health status.” If people were happy with their lives, might they not be happier with their government?
• Professor Gavin Mooney (http://www.gavinmooney.com/) is a health economist with honorary positions at the University of Sydney, and the University of Cape Town, and visiting positions at Aarhus University in Denmark and the University of New South Wales.
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The media’s role
Back to Dennis Raphael, who has also been investigating the relationship between media coverage and action on health inequalities. In another recent paper, titled, Mainstream media and the social determinants of health in Canada: is it time to call it a day?, he suggested that it was so difficult to get media (and thus policy) attention for the social determinants of health that perhaps it was time to bypass the mainstream media on this issue.
Instead, advocates should develop alternative means of communicating with the public in order to develop a citizens’ movement to create health promoting public policy.
Raphael acted on his own advice and created this online resource, including a free book on the social determinants of health, which he says in a video clip has been downloaded by more than 40,000 people.
CHA’s media summary shows that this week’s report has had quite a bit of media coverage, including this piece today, Prescription for better health: give the have-nots a hand up, from the SMH economics editor, Ross Gittins.
But it seems that most of the reports – with headlines like New action on health ‘could save billions’ – are covering only part of the story. There doesn’t seem to have been much investigation of why the Government has been so slow to act.
Perhaps it’s beyond the remit of journalists and the media; perhaps what we need is some probing research to identify both the roadblocks and the ways forward.
What exactly are the institutional/bureaucratic/professional/political/cultural barriers? And how might they be overcome?
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(Declaration: I contributed to a book that CHA’s Martin Laverty and Liz Callaghan produced last year: Determining the future: a fair go and health for all.)
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More reading
• This site links to a range of initiatives in England addressing health inequalities.
• A recent Canadian report exploring the links between various housing interventions and health.
• An article about inequality, in The Guardian, by Joseph E Stiglitz, a Nobel laureate in economics, professor of economics at Columbia University, and the author of a new book, The Price of Inequality: How Today’s Divided Society Endangers our Future.
• A wrap of recent news and research on health inequalities, from the Kaiser Foundation in the US.
While I support efforts to reduce health inequalities, the report (linked) prompting discussion this week is not of a high quality. A couple of preliminary issues come to mind:
1) It is purporting to count the benefits for a treatment that doesn’t exist, and I feel, disrespecting the social determinants of health. Income and education are extremely predictive of health status and life expectancy all across the world (and across time). This report asks, ‘what if this disparity did not exist’? How exactly is this equalization supposed to be achieved?
2) Like many economic evaluations built for advocacy purposes, it counts the (very hypothetical) benefits of equality, but not the costs. Reduced health expenditures on a per year basis need to be evaluated on a life-course perspective, as presumably we are also reducing inequities in life expectancy. Likewise, seniors transfer payments ought to be included.
Claims that a magical reduction in health inequity are likely to result in a “benefit cost ratio (that) must be massive” as Dr. Mooney does are entirely unfounded, and more reflective of a political argument than one based on evidence. If we can’t identify the changes to society that are required to lead to these benefits, how can they possibly be costed?
There are moral and political arguments for equality. There are arguments based on evidence. Advocates of progressive policy do themselves a disfavor when they attempt to stretch evidence to get the public’s attention.
Steve Arrow claims to support efforts to reduce health inequalities but is then critical of the NATSEM report as being ‘not of high quality’. How one judges quality can be tricky but here I think quality must be in terms of the technical skill involved in the analysis and I certainly would not question that, especially when the report is out of the NATSEM stable.
It may not be possible to achieve equalisation but we can go a long way through reducing poverty and inequality and providing more equal opportunity for education and housing. There are examples of societies which have gone down this road and achieved remarkably good health for their income levels. So the ‘treatment’ is not perfect but it does exist, albeit imperfectly.
I did not present the costs but as an economist I anticipated that readers would assume that I would know that there would be costs. (“Seniors transfer payments” by the way are not costs; they are transfer payments.)
What is interesting to me is that much of what is needed to promote the SDH is a reduction in inequality. If income were to be redistributed from rich to poor, given the concept of the ‘diminishing marginal utility of income’ (the idea that an extra dollar is valued less the more we already have), then the value of the benefit of such redistribution is positive.
Given these points I disagree that my claims ‘that a magical reduction in health inequity are likely to result in a “benefit cost ratio (that) must be massive”’ are ‘entirely unfounded’.