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Health as if everybody counted blog

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Are social determinants of health moving into the mainstream?

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Monday, 11 February 2013
in CHNET-Works!

In a hard-hitting report, a panel of the US National Research Council and the Institutes of Medicine has addressed the question of why the United States, despite spending far more per person on health care than any other country in the world, is falling behind other high-income countries in health status.  Readers familiar with Evans and Stoddart’s critique of the “thermostat model” will experience a strong sense of déjà vu.

The figures are striking.  For example, relative to the 16 other high-income countries selected for comparison, the United States “had the highest rate of child deaths due to negligence, maltreatment, or physical assault.”  It has the highest average body mass index (BMI) of the 17 countries among people aged 15-44.  And the list goes on.  In the words of the study:  “The U.S. health disadvantage is pervasive: it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries. More specifically, when compared with the average for other high-income countries, the United States fares worse in nine health domains: adverse birth outcomes; injuries, accidents, and homicides; adolescent pregnancy and sexually transmitted infections; HIV and AIDS; drug-related mortality; obesity and diabetes; heart disease; chronic lung disease; and disability.”  

The report’s focus on structural influences and on the life course perspective is notable, and a summary is wroth quoting at length.  “[T]the absence of green space today may be the product of zoning decisions two decades ago. Such influences also extend over a person’s lifetime: that is, the upstream-downstream continuum can also be a temporal experience for an individual. An individual’s struggle through middle age with exertional angina from coronary artery disease may have originated in adolescence with the adoption of cigarette smoking, perhaps as a coping mechanism for a stressful childhood … or simply because the family lived in a poor neighborhood where smoking was the norm. In turn, the family’s move into that poor neighborhood may have resulted from financial setbacks that occurred before the child was born. Health trajectories unfold not only over a lifetime, but also across generations as people are subject to changing health influences stemming from family, neighborhood, and public policies. …. The key dynamic trajectories of health, risk factors, socioeconomic circumstances, and physical and institutional environments are all integrally linked and cannot be decomposed in a reductionist fashion.”   

Texas timesPointing out that the United States has the highest relative poverty rates of the 17 countries, the report notes the accumulation of social disadvantages and their health consequences over an individual’s lifetime and across generations.  Other, more domain-specific explorations include an intriguing comparison between approaches to road traffic safety in the United States and elsewhere in the high-income world and the topical observation that rates of death by homicide involving firearms are an order of magnitude higher than in other OECD countries.  (The accompanying picture, taken at the entrance to a Houston, Texas emergency room, may suggest a partial explanation; the need for such a warning would be almost inconceivable elsewhere in the high-income world.) 

There is no point in trying to provide a more extensive summary of a very long document here; suffice it to say that the report is essential reading for all those concerned with health equity.  A wonderful commentary from the British think tank Chatham House correctly warned that:  “Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if … global trends may soon erode their own hard-earned health gains of past decades.”  Perhaps predictably, the report’s recommendations emphasize the need for further research, and research syntheses.  Nevertheless, there are important steps forward.   On research methods, the report observes:   “The premise that randomized controlled trials are the ‘gold standard’ for establishing causal relationships has put the accumulation of knowledge about the social determinants of health at a distinct disadvantage.”  Numerous earlier papers, including one that colleagues and I published more than a decade ago, have made a similar point, but it has yet to be recognized.  And a key recommendation for further research synthesis emphasizes comparative investigation of the influence of public policy “in one or more health domains.”  Our own health funding agencies would do well to take note.  Social determinants of health may not yet have become mainstream, but there is hope.

Robert G. Evans: An Appreciation

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 01 December 2011
in CHNET-Works!

evans-photo-1Few people who have heard University of British Columbia health economist Bob Evans speak will forget his formidable intellect, ruthless wit and remarkable knowledge of Dickens. A younger generation of population health researchers and practitioners may not realize the extent of his contribution to the study not only of health systems but also of what are now called social determinants of health – notably, as director of the Population Health Program of the Canadian Institute for Advanced Research from 1987 to 1997. (Unfortunately, that program has now been discontinued.)

A classic 1990 article that he wrote with Greg Stoddart – "Producing Health, Consuming Health Care" - contrasted the "reactive" orientation of health care with "the egregious fact that people are suffering, and in some cases dying, as a consequence of processes not directly connected to health care," a fact that "elicits neither rebuttal nor response." Plus ça change, one is tempted to say.

Evans and Stoddart described conventional thinking about health and health care in terms of a model "analogous to a heating system governed by a thermostat." If the room gets cold, or the prevalence of illness and injury increase, we turn up the thermostat or increase the flow of resources to health care. Seldom do we consider the efficiency of the furnace; redesigning the envelope of the building is off the radar (perhaps now even more than when the article appeared). Less frequently cited, but equally important, is their critique of the emphasis on individual risk factors (and on lifestyle change) in the nascent field of health promotion, which they presciently viewed as expanding "the 'product line' of the health care system" and serving "to maintain and protect institutions and ways of thinking about health."

These are gross oversimplifications of nuanced arguments, but they make my point about the importance of this contribution to the literature.

Equally memorable is Evans and colleagues' description of advocates of user charges and other incremental introductions of private finance into the health care system as "zombie masters": people with an interest in resurrecting ideas that "may be intellectually dead but are never buried." User charges under whatever name, they pointed out, "serve primarily to move money from one set of pockets to another" – an application of three axioms that are central to Evans' work, and to understanding the value of a political economy perspective on health policy. (Full disclosure: political economy is my own disciplinary background, and many years of research have strengthened my commitment to following the money as a starting point for social scientific explanation.)

First, health systems can be analyzed in terms of three basic questions: Who pays? Who gets (services)? Who gets paid?

tmc-pictureSecond, and relatedly, as "an accounting identity, expenditure on health care is exactly and precisely equal to incomes earned in health care", whether they are the incomes of care providers, pharmaceutical manufacturers, or insurance company shareholders and employees. In the United States, with the most expensive health care in the world, you can observe the payoffs from a system driven by the economic interests of the health care industry. The glittering towers of medical complexes like the one shown here are almost as tall and shiny as the banks.

Third, decisions about health policy have distributional consequences. Health financing regimes like Canada's that rely mainly on general tax revenues redistribute resources from the relatively healthy and wealthy to the unhealthy and less wealthy, and even if the tax system is only modestly progressive the degree of redistribution can be quite substantial. Critiques of Canada's public health insurance systems as "unsustainable" and arguments that private financing should play a larger role have no basis in actual patterns of expenditure. Rather, Evans sees them as efforts to advance an inegalitarian agenda, based on a sound understanding of the redistributive nature of tax-financed public health insurance: the wealthy aim to reduce the tax burden associated with financing for others the standard of care to which they themselves aspire. He further shows that growth of public spending on health care as a percentage of government budgets cannot be separated from events on the revenue side: tax reductions that have disproportionately benefited the affluent. "Had provincial governments not chosen to use the reviving economy as an opportunity to cut tax rates, the share of aggregate provincial revenues devoted to health care would in 2005/06 have been very slightly below its level in 1982/83, over twenty years previously." At least before the economic crisis of 2008, then, governments were suffering from self-inflicted fiscal wounds. Today's continued reluctance to think about raising taxes on the rich suggests that they are still in denial on that point.

There is more. Evans and colleagues have long challenged the claim that population aging will create unsustainable pressures on health systems, pointing out that aging per se accounts for only a small proportion of increases in health care costs. The Canadian Institute for Health Information recently made this point as well, but without Evans' magnificent image of the zombie of "apocalyptic demography," turned loose as convenient. Perhaps the "natural alliance of economic interest between service providers and upper-income citizens to support shifting health financing from public to private sources" described in one of Evans' most relentless critiques of the thoughtless application of textbook economics to real-world health systems has simply found a new fear-inducer for public relations purposes.

As Canadians watch the negotiation of a new federal-provincial-territorial accord on health financing (someday I will write a posting on getting undergraduate political science students excited about fiscal federalism) while the European Union readies itself for the 2012 Year for Active Ageing and Solidarity between Generations (and yes, solidarity is the word used on the official web site), we would do well to think about the implications.

There is still more. Understanding the politics of social determinants of health means coming to grips with how today's rapid growth in incomes at the top of the economic scale strengthens proponents of the inegalitarian agenda throughout the political process, not only with respect to health systems. Evans wonders: "If we are back to a pre-war income distribution, how much of our post-war policies can survive?" This is the topic of a three-part posting to follow shortly. Meanwhile, readers not yet familiar with Bob Evans' work have a treat in store as they encounter his rare analytical gifts and a style that is the antithesis of the anodyne prose found in much academic writing. So much the better, say I.

See also:

Evans RG. Financing Health Care: Taxation and the Alternatives. Chapter 2 of Mossialos E et al, eds. Funding Health Care: Options for Europe (2002). Buckingham: Open University Press.

Evans RG, Stoddart, GL. Consuming Research, Producing Policy? American Journal of Public Health 93 (2003): 371-379.

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Robert G. Evans: An Appreciation

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Thursday, 01 December 2011
in CHNET-Works!

evans-photo-1Few people who have heard University of British Columbia health economist Bob Evans speak will forget his formidable intellect, ruthless wit and remarkable knowledge of Dickens. A younger generation of population health researchers and practitioners may not realize the extent of his contribution to the study not only of health systems but also of what are now called social determinants of health – notably, as director of the Population Health Program of the Canadian Institute for Advanced Research from 1987 to 1997. (Unfortunately, that program has now been discontinued.)

A classic 1990 article that he wrote with Greg Stoddart – "Producing Health, Consuming Health Care" - contrasted the "reactive" orientation of health care with "the egregious fact that people are suffering, and in some cases dying, as a consequence of processes not directly connected to health care," a fact that "elicits neither rebuttal nor response." Plus ça change, one is tempted to say.

Evans and Stoddart described conventional thinking about health and health care in terms of a model "analogous to a heating system governed by a thermostat." If the room gets cold, or the prevalence of illness and injury increase, we turn up the thermostat or increase the flow of resources to health care. Seldom do we consider the efficiency of the furnace; redesigning the envelope of the building is off the radar (perhaps now even more than when the article appeared). Less frequently cited, but equally important, is their critique of the emphasis on individual risk factors (and on lifestyle change) in the nascent field of health promotion, which they presciently viewed as expanding "the 'product line' of the health care system" and serving "to maintain and protect institutions and ways of thinking about health."

These are gross oversimplifications of nuanced arguments, but they make my point about the importance of this contribution to the literature.

Equally memorable is Evans and colleagues' description of advocates of user charges and other incremental introductions of private finance into the health care system as "zombie masters": people with an interest in resurrecting ideas that "may be intellectually dead but are never buried." User charges under whatever name, they pointed out, "serve primarily to move money from one set of pockets to another" – an application of three axioms that are central to Evans' work, and to understanding the value of a political economy perspective on health policy. (Full disclosure: political economy is my own disciplinary background, and many years of research have strengthened my commitment to following the money as a starting point for social scientific explanation.)

First, health systems can be analyzed in terms of three basic questions: Who pays? Who gets (services)? Who gets paid?

tmc-pictureSecond, and relatedly, as "an accounting identity, expenditure on health care is exactly and precisely equal to incomes earned in health care", whether they are the incomes of care providers, pharmaceutical manufacturers, or insurance company shareholders and employees. In the United States, with the most expensive health care in the world, you can observe the payoffs from a system driven by the economic interests of the health care industry. The glittering towers of medical complexes like the one shown here are almost as tall and shiny as the banks.

Third, decisions about health policy have distributional consequences. Health financing regimes like Canada's that rely mainly on general tax revenues redistribute resources from the relatively healthy and wealthy to the unhealthy and less wealthy, and even if the tax system is only modestly progressive the degree of redistribution can be quite substantial. Critiques of Canada's public health insurance systems as "unsustainable" and arguments that private financing should play a larger role have no basis in actual patterns of expenditure. Rather, Evans sees them as efforts to advance an inegalitarian agenda, based on a sound understanding of the redistributive nature of tax-financed public health insurance: the wealthy aim to reduce the tax burden associated with financing for others the standard of care to which they themselves aspire. He further shows that growth of public spending on health care as a percentage of government budgets cannot be separated from events on the revenue side: tax reductions that have disproportionately benefited the affluent. "Had provincial governments not chosen to use the reviving economy as an opportunity to cut tax rates, the share of aggregate provincial revenues devoted to health care would in 2005/06 have been very slightly below its level in 1982/83, over twenty years previously." At least before the economic crisis of 2008, then, governments were suffering from self-inflicted fiscal wounds. Today's continued reluctance to think about raising taxes on the rich suggests that they are still in denial on that point.

There is more. Evans and colleagues have long challenged the claim that population aging will create unsustainable pressures on health systems, pointing out that aging per se accounts for only a small proportion of increases in health care costs. The Canadian Institute for Health Information recently made this point as well, but without Evans' magnificent image of the zombie of "apocalyptic demography," turned loose as convenient. Perhaps the "natural alliance of economic interest between service providers and upper-income citizens to support shifting health financing from public to private sources" described in one of Evans' most relentless critiques of the thoughtless application of textbook economics to real-world health systems has simply found a new fear-inducer for public relations purposes.

As Canadians watch the negotiation of a new federal-provincial-territorial accord on health financing (someday I will write a posting on getting undergraduate political science students excited about fiscal federalism) while the European Union readies itself for the 2012 Year for Active Ageing and Solidarity between Generations (and yes, solidarity is the word used on the official web site), we would do well to think about the implications.

There is still more. Understanding the politics of social determinants of health means coming to grips with how today's rapid growth in incomes at the top of the economic scale strengthens proponents of the inegalitarian agenda throughout the political process, not only with respect to health systems. Evans wonders: "If we are back to a pre-war income distribution, how much of our post-war policies can survive?" This is the topic of a three-part posting to follow shortly. Meanwhile, readers not yet familiar with Bob Evans' work have a treat in store as they encounter his rare analytical gifts and a style that is the antithesis of the anodyne prose found in much academic writing. So much the better, say I.

See also:

Evans RG. Financing Health Care: Taxation and the Alternatives. Chapter 2 of Mossialos E et al, eds. Funding Health Care: Options for Europe (2002). Buckingham: Open University Press.

Evans RG, Stoddart, GL. Consuming Research, Producing Policy? American Journal of Public Health 93 (2003): 371-379.

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