Kumanan Rasanathan

Changing trends in indigenous inequalities in mortality: lessons from New Zealand

BACKGROUND We describe trends from 1951 to 2006 in inequalities in mortality between the indigenous (Māori) and non-indigenous (non-Māori, mainly European-descended) populations of New Zealand. We relate these trends to the historical context in which they occurred, including major structural adjustment of the economy from the mid 1980s to the mid 1990s, followed by a retreat from neoliberal social and economic policies from the late 1990s onwards. This was accompanied by economic recovery and the introduction of health reforms, including a reorientation of the health system towards primary health care. METHODS Abridged period lifetables for Māori and non-Māori from 1951 to 2006 were constructed using standard demographic methods. Absolute [standardized rate difference (SRD)] and relative [standardized rate ratio (SRR)] mortality inequalities for Māori compared with European/Other ethnic groups (aged 1-74 years) were measured using the New Zealand Census-Mortality Study (an ongoing data linkage study that links mortality to census records) from 1981-84 to 2001-04. The SRDs were decomposed into their contributions from major causes of death. Poisson regression modelling was used to estimate the extent of socio-economic mediation of the ethnic mortality inequality over time. RESULTS Life expectancy gaps and relative inequalities in mortality rates (aged 1-74 years) widened and then narrowed again, in tandem with the trends in social inequalities (allowing for a short lag). Among females, the contribution of cardiovascular disease to absolute mortality inequalities steadily decreased, but was partly offset by an increasing contribution from cancer. Among males, the contribution of CVD increased from the early 1980s to the 1990s, then decreased again. The extent of socio-economic mediation of the ethnic mortality inequality peaked in 1991-94, again more notably among males. CONCLUSION Our results are consistent with a causal association between changing economic inequalities and changing health inequalities between ethnic groups. However, causality cannot be established from a historical analysis alone. Three lessons nevertheless emerge from the New Zealand experience: the lag between changes in ethnic social inequality and ethnic health inequality may be short (<5 years); both changes in the distribution of the social determinants of health and an appropriate health system response may be required to address ethnic health inequalities; and timely monitoring of ethnic health inequalities, based on high-quality ethnicity data, may help to sustain political commitment to pro-equity health and social policies.

Primary health care and the social determinants of health: essential and complementary approaches for reducing inequities in health

Increasing focus on health inequities has brought renewed attention to two related policy discourses - primary health care and the social determinants of health. Both prioritise health equity and also promote a broad view of health, multisectoral action and the participation of empowered communities. Differences arise in the lens each applies to the health sector, with resultant tensions around their mutual ability to reform health systems and address the social determinants. However, pitting them against each is unproductive. Health services that do not consciously address social determinants exacerbate health inequities. If a revitalised primary health care is to be the key approach to organise society to minimise health inequities, action on social determinants has to be a major constituent strategy. Success in reducing health inequities will require ensuring that the broad focus of primary health care and the social determinants is kept foremost in policy - instead of the common historical experience of efforts being limited to a part of the health sector.

Innovation and participation for healthy public policy: the first National Health Assembly in Thailand.

Aim  This paper aims to describe and disseminate the process and initial outcomes of the first National Health Assembly (NHA) in Thailand, as an innovative example of health policy making.

Action on social determinants of health is essential to tackle noncommunicable diseases.

Noncommunicable diseases cannot be effectively addressed without action on social determinants of health. Without addressing social inequalities and the conditions in which people are born, grow, live, work and age, along with the reasons that health systems work better for some population groups than for others – that is, adopting a social determinants approach – prospects for reversing the noncommunicable diseases epidemics are poor.1 This year’s United Nations General Assembly High-Level Meeting on Prevention and Control of Noncommunicable Diseases (in New York) and the World Conference on Social Determinants of Health (in Rio de Janeiro) provide a unique opportunity for progress. There may never be a better global platform for countries, civil society and international organizations to commit to a coherent social determinants approach to tackling noncommunicable diseases and other global priorities at local, national and global levels. In this context, we explain why a social determinants approach is essential for combating noncommunicable diseases, discuss what such an approach entails, and identify priority actions for the global community.

Natural and unnatural synergies: climate change policy and health equity

Climate change and health inequities represent two of the greatest challenges to human development in the 21st century. As the Copenhagen summit on climate change planned for December 2009 approaches, there are opportuni-ties to use the political momentum of climate change to promote health equity. The broad-ranging policies re-quired to address climate change have both positive and negative implications for health and health equity.

Cash transfer schemes and the health sector: making the case for greater involvement

Cash transfer schemes can be important contributors to human development and social protection. Although they have significant health benefits, they have rarely been considered an integral part of the health policy portfolio. We believe that a case can be made for greater health sector involvement in the design, implementation and evaluation of such schemes. Cash transfers (CTs) are attracting increasing interest as effective and ac ceptable means of improving the welfare of disadvantaged households in low- and middle-income countries. They give households regular, predictable amounts of money in the form of pensions, child benefits or regular household grants. Although such social protection mechanisms are often the norm in highincome countries, CTs have historically been rare in low- and middle-income countries. Instead, governments and donors have typically preferred supplyside interventions (expanding health care coverage, for example) or in-kind transfers of goods or food. Financial shocks during the late 1990s, however, triggered a global shift towards social protection schemes more closely resembling European models (emphasizing social security rather than assistance as a last resort). This shift also reflected a desire to correct shortcomings associated with reforms advocated under the Washington consensus, characterized by the dismantling of State services and their replacement with segmented private services.

The Need to Monitor Actions on the Social Determinants of Health

Intersectoral actions, defined as the alignment of strategies and resources between actors from two or more policy sectors to achieve complementary objectives,1 are central to the health-related sustainable development goals (SDGs).2 The World Health Organization’s (WHO) Commission on Social Determinants of Health recommended a subset of intersectoral actions to improve health equity in 2008.3 Intersectoral actions address the social, commercial, cultural, economic, environmental and political determinants of health. Without intersectoral actions, the health sector will probably not achieve SDG 3, that is, ensuring healthy lives and promoting well-being for all at all ages.4 National governments have committed to and implemented several of these intersectoral actions through multisectoral development and health policy frameworks, including the 2030 agenda for sustainable development,4 the Rio Political Declaration on Social Determinants of Health,5 the New Urban Agenda6 and the Marrakech Ministerial Declaration on Health, Environment and Climate Change.7 We argue for monitoring intersectoral actions because such assessment draws attention to those government interventions that improve living conditions, but are outside the immediate control of the health sector. These interventions often have established co-benefits across multiple policy sectors (for instance, emission-free public transport systems improve air quality, transport and health). Action monitoring can also strengthen coherence and efficiency across sectors. The SDGs’ extensive multisectoral indicator framework8 offers health policy-makers the opportunity to link action monitoring to the SDGs, as national governments begin their SDG implementation.4 In particular, actions taken in the context of policy frameworks that address the social determinants of health, such as those in the five action areas of the Rio Political Declaration,5 need to be monitored. Therefore, we define and categorize indicators for intersectoral actions on social determinants of health that improve health equity. If these indicators are drawn from the SDG indicator system,8 they will enable policy-makers to link intersectoral actions to sustainable development.9 For social determinants of health, we use WHO commission’s definitions,3 which refer to the wider set of social, commercial, cultural, economic, environmental and political determinants that drive patterns of health inequalities. These determinants are the daily conditions in which people grow, live, work and age; they are the forces and systems shaping living conditions. Determinants include population exposure to the physical environment; occupational hazards, housing, chemicals, air and water quality, sanitation and hygiene, and climate change. The determinants converge and accumulate over time to shape the health of population groups according to their social status. This is defined by, for example, education, ethnicity including indigeneity and migrant status, gender, gender identity, income, occupation and sexual orientation. Hence, changes in health equity that result from specific interventions or policy frameworks aimed to improve social determinants of health may take time to show. Using the commission’s evidencebased recommendations for intersectoral action,3 we offer a classification of three groups of intersectoral interventions that focus on the determinants and are relevant to the SDGs’ equity and sustainable development foci.4 The first group includes governance interventions, defined as political and decisionmaking structures and processes that improve health equity, such as wholeof-government or multisectoral committees, funds or plans, or human rights legislation. The second group consists of socioeconomic interventions, defined as those policies and programmes that allocate social and or financial resources to improve health equity. Such interventions could improve early child development, education, living wage, pay equity and social protection. The third group includes environmental interventions, defined as policies or programmes for the built or natural environment that improve health equity. Examples of such interventions are slum upgrading, air and drinking water quality improvement, sanitation and hygiene improvement and climate change mitigations and adaptations. Of the commission’s 39 intersectoral action recommendations,3 17 are for governance interventions, 16 for socioeconomic interventions and 6 for environmental interventions (Box 1). Effective action monitoring requires valid, sensitive and reliable indicators drawn from a solid evidence base on intervention effectiveness. Theoretical evidence suggests that interventions focussed on social determinants of health could be used as action indicators, since they are theorized to improve these determinants, health service use, health The need to monitor actions on the social determinants of health Frank Pega, Nicole B Valentine, Kumanan Rasanathan, Ahmad Reza Hosseinpoor, Tone P Torgersen, Veerabhadran Ramanathan, Tipicha Posayanonda, Nathalie Röbbel, Yassine Kalboussi, David H Rehkopf, Carlos Dora, Eugenio R Villar Montesinos & Maria P Neira