health equity & social determinants - university of otago

Overview

Health Equity & Social Determinants

1

Professor Tony Blakely, University of Otago

Index

Preliminaries

Acknowledgements:

• NZMA and University of Otago teams

• Co-funding– New Zealand College of Public Health Medicine

Acknowledgements and conference pack

– New Zealand College of Public Health Medicine

– Public Health Association

– Prior Centre

Conference Pack:

• Power points of all presentations

• NZMA Equity Statement

• Fact and Action sheets

• Other2

Structure

• Purposes of today

• Background:

– Health inequality facts and trends in New Zealand

– Policy actions in recent decades

• Frameworks and perspectives:• Frameworks and perspectives:

– What is health inequity?

– Early childhood and life-course – current examples

– Universalism ↔ targeting, and ‘progressive universalism’

– “But can we afford equity?” …. joining up current agendas

• Where to next for Aotearoa New Zealand?:– A possible top-ten list

– A few specific comments from myself (aka my 7 slides)

• Risk factors (e.g. smoking)

• Health services and changing drivers of inequalities 3

Purposes of today

1. To sustain and enhance a focus on health inequities.

2. To learn from the English and WHO experience, and assess what might be applicable to New Zealand.

3. To explore visions and objectives for next steps to address health inequalities in New Zealand.

We have included a list of next best 10 actions to take on reducing

inequities in health in New Zealand in your conference pack – please

consider it, debate it (e.g. during panel session), and improve it (e.g.

submit your improvements to www.uow.otago.ac.nz/HIRP-info.html)

4

Life expectancy trends by ethnicity

70

75

80

85

The last 60 years

5

45

50

55

60

65

70

1941 1951 1961 1971 1981 1991 2001

Non-Māori Male Non-Māori Female

Māori Male Māori Female

Life expectancy trends by ethnicity

50

60

70

80

Non-Māori Male

The last 130 years

6

0

10

20

30

40

1866 1886 1906 1926 1946 1966 1986 2006

Non-MāoriFemale

Māori Male

Māori Female

Source: Woodward and Blakely, History of Life Expectancy in New Zealand, work in progress

Causes of death driving ethnic ineq

CVD most important, but ↓ over time; cancer ↑

7

Socioeconomic mortality inequalities

Parallel tracking → constant absolute, but ↑ relative ineq

8

• Mostly parallel tracking in absolute terms

• 30% and 41% decreases for low and high income males, respectively

• 27% and 37% decreases for low and high income females, respectively

NZ used to have lowest child mortality

<1 year old males

0.1

1

Australia

Canada

Denmark

Eng & Wales

Similar pattern females, 1-5 yrs, 5-14 yrs, 15-24yrs

9

0.001

0.01

1860s 1880s 1900s 1920s 1940s 1960s 1980s 2000s

Finland

Norway

NZ Māori

NZ non-M

Scotland

Sweden

Source: Woodward and Blakely, History of Life Expectancy in New Zealand, work in progress. [Primary source; Human Mortality Database.]

NZ used to have lowest child mortality

Could our high child poverty rates be part of the reason?

10

Source: MSD (2010) Household incomes in New Zealand. Cited in: Gleisner et al. Working Towards Higher Living Standards for New Zealanders. New Zealand Treasury

Young mortality inequalities worrying

Little if any improvement in low income, 25-44 yrs

11

What have we/NZ done about it? 1-5

1. Income inequality reduced slightly in the 2000’s- but is perhaps now increasing again

2. Social welfare policies have been implemented - E.g. Working for Families (at least partially) pro-equity

Quite a bit in recent decades – mostly around process

3. Intersectoral activities implemented- E.g. retrofitting and insulation of housing stock (energy

efficiency and health benefits)

4. Māori health provider, and Māori development more generally, has been strong:- E.g. ToW and Māori health in Public Health & Disability Act.

5. Increasing focus on the specific needs of Pacific

12

What have we/NZ done about it? 6-10

6. Many policies include equity• has flowed through into programmes, research, health

professional training (e.g. cultural competency), and use of health equity impact tools (e.g. HEAT).

7. Funding of health services by deprivation & ethnicity

Quite a bit in recent decades – mostly around process

7. Funding of health services by deprivation & ethnicity

8. Tailored health promotion and service delivery• E.g. Māori language messages in tobacco control

9. Research and monitoring on health inequalities• has improved our understanding and allowed tracking

10.Targets and performance indicators routinely include metrics by ethnicity and deprivation.

13

Structure


• Background:





– Early childhood and life-course



• Where to next for Aotearoa New Zealand?:

– A possible top-ten list




What is an inequity in health?

Whitehead’s 7 determinants of health inequalities/differences:

1. Natural, biological variation.

2. Health-damaging behaviour if freely chosen (e.g. risky sports).

3. Transient health advantage of one group over another, due to

Guiding principles, but still tricky to decide

one group adopting healthier practises earlier.

4. Health damaging behaviour where the choice of lifestyles is severely limited.

5. Exposure to unhealthy, stressful living and working conditions.

6. Inadequate access to essential health and other public services.

7. Natural selection of health-related social mobility, involving the tendency for sick people to move down the social scale.

15

Early childhood and lifecourse

• Two recent reports:

• PM’s Chief Science Advisor

• ECE Taskforce

• Highlight relevant issues for today:• Evidence on interventions

Research boom → basis for evidence-based policy

• Evidence on interventions

• Efficiency

• Universalism vs targeting

• Pro-equity vs inequity increasing programmes

• Quality

16An Agenda for Amazing Children

Intervening early pays off

• Structured, quality programmes in early childhood have long-reaching pay offs• But a lot of programmes not evidence based, not effective,

and possibly even harmful – reprioritisation needed

• Potential to be pro-equity:

Universal & targeting required; ‘progressive universalism’

• Potential to be pro-equity:• School-based education programmes on drugs tend to be

most effective in low risk children…. but targeted home visiting & parental skills programmes benefit disadvantaged.

• High quality early childhood education can be most effective among disadvantaged (Dearing et al (2009) Child Development)

• “Although all children gain from quality early childhood education, society benefits most from the investment in children from low-income or disadvantaged homes” (p.15, Improving the Transition) 17

But childhood focus no panacea!

Consider alcohol:• Early child programmes and (well conducted) school

education programmes may reduce individuals’alcohol harm in adolescence and older

• But population-wide programmes (e.g. pricing,

Context and ‘period effects’ latter in life matter

• But population-wide programmes (e.g. pricing, availability) reduce overall harm, and inequalities, much more effectively

Consider cardiovascular disease:• Has some causal antecedents in childhood• But population rates peaked in 1970, and have fallen

80% since, for all age groups, indicating importance of population-wide changes effecting all age groups (i.e. period effects as opposed to cohort effects).

18

Can we afford reducing health inequity?

• Cost effectiveness:- Generally agreed that better quality early childhood

interventions return up to $10 to $20 per $1 invested

- Public health prevention programmes – especially population-wide ones such as alcohol tax, salt reformulation

Yes – social investment with major paybacks

population-wide ones such as alcohol tax, salt reformulation in foods – cost saving and likely pro-equity (Vos et al, ACE-Prevention,

2010)

• Redistribution of societal investment is possible:

- For example, consider welfare benefits ….

19

Benefit expenditure over time

$8,000,000

$10,000,000

$12,000,000

$14,000,000

'Other'

Superannuation

Carer’s benefits

By far and away the biggest ‘benefit’ is superannuation

20

$-

$2,000,000

$4,000,000

$6,000,000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Carer’s benefits

Invalid’s Benefits

Sickness-related Benefits

Unemployment-associated Benefits

Source: MSD (2010) The Statistical Report[Note: excludes Working for Families, which in 2008 was about: $2.6 million tax credits; $0.85 million

accommodation supplements; $0.15 childcare assistance.]

Yet we tolerate high child poverty

21

Increasing age of super entitlement

• Age of entitlement set at 65 yrs in 1899. Since then life expectancy has increased by about 25 years!

• Other OECD countries increasing age of entitlement. We should too, so long as living standards of people

Seems only fair, and will free up resources

who cannot work >65 yr are protected• E.g. by having Invalid’s benefit – and indeed all Benefits

including Superannuation – set at an income necessary for healthy living (a.k.a. “Minimum Income for Healthy Living” as recommended in Marmot Review)

• Such redistribution within Welfare would allow shifting of resources to address child poverty.

22

Structure


• Background:





– Early childhood and life-course



• Where to next for Aotearoa New Zealand?:

– A possible top-ten list




What to do next?

1. Equitable and fair fiscal and social welfare policy

2. Maintain and enhance social cohesion

3. Maintaining and enhancing investment in early childhood.

4. Aligning climate change, sustainability and pro-equity policies

5. Health equity needs to be widely understood

Lets debate, improve and then try to act on this list

5. Health equity needs to be widely understood

6. Ill-health prevention that addresses risk factors

7. Ensuring fair employment and safe and healthy workplaces

8. Maintaining and enhancing Māori, Pacific and Asian policies and programmes

9. Ensuring health services are equitable

10. Health equity research to continue and focus on ‘what works’.

24

Blakely T, Simmers D, Sharpe N. Inequities in health and the Marmot Symposia: time for a stocktake. NZ Med J, 8 July 2011

Fact and Action Sheets – in your conference pack

Health care matters

• Consider that:

– Half of the huge reductions in CVD mortality in last 30 years due to improved treatments

– Cancer mortality gaps slowly opening up, and survival worse for Māori (and to some extent lower socio-economic groups)

Treatments improve + costs escalate = inequities likely

for Māori (and to some extent lower socio-economic groups)

• Which makes an equity focus important in:– prioritisation of health resources (new National Health Committee)

– quality of services (Health Quality and Safety Commission)

– information systems:

• recall systems that stop people falling between the gaps

• for monitoring and research

25

Estimating LE by ethnicity in 2040

• If we go smokefree (compared to 2006 smoking rates continuing unchanged into the future), we estimate that by 2040:

• an additional 5 year gain in life expectancy for Māori

Tobacco control eradication matters

26

• an additional 5 year gain in life expectancy for Māori

• an additional 3 year gain for non-Māori

• and therefore a 2 year closing in ethnic inequalities in life expectancy

• Making New Zealand smoke-free is achievable, and worthwhile

Blakely T, Carter K, Wilson N, et al. If nobody smoked tobacco in New Zealand from 2020 onwards, what effect would this have on ethnic inequalities in life expectancy? NZ Med J 2010;123(1320):26-36.

Visioning the end of Māori-nonMāori inequalities in LE

20/20 vision on 204020/20 vision on 2040

60

70

80

90 Non-Mäori (SNZ) Male

Non-Mäori (SNZ)

Female

Māori pre WWII Male

Māori pre WWII

Female

Mäori (SNZ) Male

270

10

20

30

40

50

1840 1860 1880 1900 1920 1940 1960 1980 2000 2020 2040

Mäori (SNZ) Male

Mäori (SNZ) Female

Māori (correcting for

undercount) Male

Māori (correcting for

undercount) Female

Projected non-Māori

2.0% Male


2.0% Female


3.5% Male


3.5% Female

Tobacco eradication is perhaps the single most important thing to do to achieve an end to ethnic

inequalities in health

Back up slides

28

Infectious diseases

• Rheumatic fever very high by international standards among Pacific and Māori – approximately 40 and 20 times the European/Other rates respectively.

• Rheumatic fever is associated with crowding and

A resurgent source of inequalities

• Rheumatic fever is associated with crowding and poverty, and is usually rare in rich countries these days.

• Close contact communicable disease hospitalisation rates not falling over time, and much higher for Māori and Pacific (Baker et al, in progress)

29

Rheumatic fever rates

Perhaps the most prominent health inequality at moment

60

70

80

90

100

Ind

ex

ad

mis

sio

ns

pe

r 1

00

,00

0

Pacific

Māori

European/Other

30

0

10

20

30

40

50

60

Ind

ex

ad

mis

sio

ns

pe

r 1

00

,00

0

Richard Milne, Diana Lennon et al., University of Auckland, 2011

Suicide rates by ethnicity

High youth and Māori rates

31

CVD mortality rates by ethnicity

32Index

35-69 yrs, CVD mortality, Australia www.mortrends.org

33Index

Suicide and injury death rates by ethnicity

34

health equity & social determinants - university of otago

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