Public health on a treadmill of inequality?

IPH Open Conference 14 October 2014

Paul McGill Centre for Ageing Research and Development in Ireland

RoI life expectancy gap at age 20

Least deprived Most deprived Professional Unskilled Third level Primary

58.7

54.6

62.0

55.8

61.3

53.3

Men

Least deprived Most deprived Professional Unskilled Third level Primary

62.8

60.2

66.2

61.2

65.2

59.5

Women

CSO 2010

Relative inequality increases with age

0 20 35 65100

105

110

115

120

125

130

135

116.0

123.0

128.1

133.3

RoI life expectancy of professionals as % of lower SES

Prof as % unskilled, menProf as % unskilled, womenProf as % of 'other' menProf as % of 'other' women

CSO 2010

NI mortality inequality over time

1997-01 1998-02 1999-03 2000-04 2001-05 2002-06 2003-07 2004-08 2005-09 2006-1050%

70%

90%

110%

130%

150%

170%

190%

NI standard mortality gap between most and least deprived

Circulatory U75Respiratory U75Cancer U75Std mortality rateAmenable to healthcare

DHSSPS 2012

Multimorbidity

Mid Low

1.66

2.171

1

1.645

Risk of mid and low SES aged 65+ having 2+ chronic diseases compared with high SES

NIRoI

Savva et al 2011

NI inequalities on range of variables

BMI (kg/m²) CED-S HADS Smokes (%)0

5

10

15

20

25

30

27.1

5.22.7

8

28.1

7.5

3.7

18

All-Ireland health and lifestyle factors aged 65+ by area of deprivation

Least deprivedMost deprived

Age education MMSE Exercisers (%) Never smoked (%)0

10

20

30

40

50

60

70

80

17.8

27.3

80

53

14.8

26.3

70

38Least deprived

Most deprived

McNulty et al (2014)

Why do inequalities persist?

1. Strategies in NI & RoI do not focus on health inequalities? 2. Insufficient priority given to delivery at top level?3. Practice is inadequate or poorly targeted?

Or…looking at the root causesWe haven’t done enough about inequality in wider society. Health services are running fast to stay still. This argument is being expressed by an ever wider group of people – church leaders, economists, academics, international bodies, as well as today’s hosts (IPH).

Academics

‘The Spirit Level’ thesis: …life expectancy, social mobility and educational attainment are lower and physical and mental illness higher in societies with highly unequal income distributions than in those with a greater degree of equality – inequality was a more potent factor than overall low income

- Wilkinson and Pickett (2009)

International bodies

WHO:1. improve daily living conditions2. tackle the inequitable distribution of power, money and resources3. measure and assess the problem and assess the impact of action.

- Marmot, CSDH (2010)

International Monetary Fund

… redistribution appears generally benign in terms of its impact on growth; only in extreme cases is there some evidence that it may have direct negative effects on growth. Thus redistribution — including the growth effects of the resulting lower inequality — is on average pro-growth.

- Ostry et al (2014)

What about Ireland?

RoI incomes, all ages 2006-2012 (€)

1 2 3 4 5 6 7 8 9 10100

200

300

400

500

600

700

800

900

1000

1100

RoI net disposable equivalised weekly income by decile (€)

200620092012

CSO: SILC

RoI impact of recession, all ages (%)

1

2

3

4

5

6

7

8

9

10

-30.0 -25.0 -20.0 -15.0 -10.0 -5.0 0.0

-28.3-17.2

-12.9

-12.3

-14.6

-14.0

-13.2

-12.9

-11.7-16.1

RoI decline in net disposable income by decile 2008-2012 (%)

CSO: SILC

Income of poorest quintile, all agesRoI net disposable equivalised income for 1st decile 2008 & 2012

2008 2012Employee income 33.96 14.98Employer's social insurance contributions 2.43 0.82Cash benefits or losses from self-employment 19.09 9.70Other direct income 9.19 2.17Total direct income 64.67 27.67Unemployment benefits 26.92 38.67Old-age benefits 11.25 7.78Family/children related allowances 45.20 27.98Housing allowances 3.72 6.24Other social transfers 22.78 14.93Total social transfers 109.86 95.60

-------- --------Gross income 174.53 123.27Tax on income and social contributions 3.40 2.76Employer's social insurance contributions 2.43 0.82Regular inter-household cash transfers paid 3.28 1.13Total tax and social contributions 9.11 -4.72Net disposable income 165.42 118.55

-€ 46.87 -28.30%

CSO, SILC

NI weekly pay gap

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013100

200

300

400

500

600

700

800

900

150.0

252.1

251.6

262.7

286.7

402.5

400.3

437.1

437.3

460.0

542.0

844.9

829.1

854.1

NI gross weekly pay of full-time employees 1997-2013

10th

50th

90th

NISRA: ASHE

NI hourly pay gap

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20133

5

7

9

11

13

15

17

19

21

23

3.52

6.006.00

6.256.42

10.00

9.79

10.23

13.77

17.38

20.26

19.98

22.17

21.80

22.56

10th

50th

90th

NISRA: ASHE

NI Low pay and Minimum Wage

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20133

4

5

6

7

NI low pay and the National Minimum Wage (£ per week)

10th20thNMW

NISRA: ASHE

Running hard to stay still?

ReferencesCentral Statistics Office (2010). Mortality Differentials in Ireland. Dublin: CSO.Central Statistics Office (series 2003-2012). Survey on Income and Living Conditions.DHSSPS (2012). NI Health and Social Care Inequalities Monitoring System: Fourth Update Bulletin. Belfast: DHSSPS.Marmot, CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health OrganizationMcGill P (2014). Understanding Socio-economic Inequalities Affecting Older People. Belfast: CARDI.McNulty H, McCann A, Moore A, Hoey L, Molloy A, & Rigby J (forthcoming). Socioeconomic deprivation and risk of age-related cognitive dysfunction: results from the TUDA Ageing Cohort Study. Belfast: CARDI.NISRA (series 1997-2013). Annual Survey on Hours and Earnings. Belfast: NISRA.Ostry, J; Berg, A; Tsangarides, C; Berg (2014). Redistribution, Inequality, and Growth. Washington: IMF Research DepartmentSavva G, Hanley M, McDaid O, Richardson K, Kenny RA and Kee F (2011). Multimorbidity and Disability in the Older Population. Dublin: TCD.Wilkinson R and Pickett K (2006). The Spirit Level: why more equal societies almost always do better. London: Penguin.

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