TASC is happy to host a space for alternative viewpoints. The views expressed in TASC Thinkpieces are those of the authors.

Thinkpieces

by Nigel Ryan

December 2010Thinkpieces

The Socio-EconomicRealities of Health in Ireland

Justin Frewen &Anna Datta

The Socio-Economic Realities of Health in Ireland | December 2010

Thinkpiece

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Preamble to Constitution of WHO Public health is what we, as a society do collectively to ensure the conditions in which people can be healthy. US National Institute of Medicine Authors Justin Frewen has worked for the UN since 1997 in Asia, the Middle East, Africa and the US. He is a member of the Board of Comhlámh and is completing a PhD in Political Science at NUI Galway. Dr Anna Datta is a Speciality Doctor in Psychiatry at the East London NHS Foundation Trust and is completing an International Masters in Mental Health Policy and Services (World Health Organization/New University of Lisbon). This Thinkpiece builds on the arguments made in a recent Thinkpiece co-authored by Justin Frewen and Dr. Anna Datta - The Socio-Economic Realities of Mental Health in Ireland - published by TASC earlier this year. Introduction The issue of the economic cost of health has come ever more to the fore. One of the principle concerns raised has been the failure to effectively target health concerns can lead to significant economic costs in the longer term. These costs include not only direct expenditure on health treatment and care but also lost economic productivity and output as a result of ill health. It is imperative therefore that states ensure they develop and implement the required policies, programmes and actions to optimise the overall health prospects of their populations. However, maximising the overall level of health and well-being of the general population requires an holistic approach; one which moves beyond the mindset that the only way to improve health standards is true investing in public health service accessibility and delivery. Although the public health services are, of course, the critical component in any health system, there is an urgent need to involve those socio-economic sectors, which directly impact on health. Of particular importance is the identification of the negative social-determinants which lead to health inequalities and inequities, that result in certain socio-economic groups having far higher incidences of ill health, stress and other medical problems. This paper will briefly outline the economic burden of bad health to society. This will be followed by an examination of the role of social determinants in influencing health prospects, paying particular attention to the issue of health inequities. Emphasis will be placed on highlighting the role negative social determinants play in producing health inequities between different social groups, the urgent need to address them and how best this might be done. This paper´s major argument is that in order to improve on the current levels of health in Ireland and work towards a maximum positive health and well-being status for all our citizens, it will be

Justin Frewen & Anna Datta

necessary to devise and deliver coordinated programmes and actions across a broad range of socio-economic spheres in addition to the health sector. In effect, although an effective, well-resourced, flexible and accessible is essential, more is needed. Public Health and `Economic Costs´ While an efficiently run public health service is evidently important in ensuring optimal service delivery and the cost effectiveness of its operations, the current attack on health funding risks debilitating it significantly. While the prognosis for the public health service is extremely negative, the outlook is little better for those of us forced to use the declining facilities. Even if the economic situation in Ireland should improve, the damage done to the public health services will make it far more difficult and costly to repair the damage done. Therefore, given the current and almost unanimous political party predilection to slash costs in the public service to pay for the economic mess the financial sector has placed us in, it is imperative to develop solid economic explanations to help demonstrate the importance of investment in the public health sector. Economic arguments help clarify the importance of allocating sufficient financing to the health sector in terms of cost outcomes. As Brid O’Connor, CEO of the Mental Health Commission, explains. Resources are not infinite, so choices must be made between alternative uses of the same resource or service… ’economic analysis is therefore a crucial aid to decision making on resource allocation and on priority setting’. While decisions on resource allocation are grounded in values, economics is a central tool in the making of these decisions.1 Economic assessments of the cost of health issues can help advance the argument for at the very least maintaining – if not actually increasing – investment in the public health sector. Evaluating the economic cost of health, though, requires more than simply totalling the funds allocated to public health service delivery. This is not to deny the importance of a transparent and accountable system for monitoring health service expenses or that an upgrading of the current system would be beneficial. However, this is insufficient in itself. To undertake a serious economic analysis of the costs of health to the state, the wider economic impact and outcomes of ill health, such as any resulting decline in economic productivity, must be taken into consideration. For instance, as Doyle et al argue: Being employed is better for health than being unemployed... A healthier workforce will also pay economic dividends in terms of reduced absenteeism and increased productivity.2 There are four major areas where good public health can benefit economic performance, both at the personal and national level, namely higher productivity, higher labour supply, higher skills as a result of greater education and training, and more savings available for investment in physical and intellectual capital. The 2001 WHO Commission on Macroeconomics and Health argued that there are significant economic rewards to be obtained through improving the overall level of health in a country. Although this report concentrates on `developing´ countries, the results have relevance for states irrespective of their overall level of development. The Commission estimated that

1 O’Shea, E. & Kennelly, B., 2008 2 Doyle, C. et al, 2005

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diverging economic growth rates can be explained to a large extent by population health status, even taking standard macroeconomic variables into account. For instance, up to 50% of the growth differential between wealthier and poorer nations could be explained by the contrasting incidence of ill health and varying lifespans.3 In a 2005 study, Suhrcke et al found there were “significant economic benefits” to be obtained by “improving health”. These benefits would occur through an increase in the availability of labour, higher productivity and improved levels of education, training uptake and completion of courses. At the same time, this would lead to an increased availability of funding to be invested in physical and intellectual capital.4 The European Commission emphasises the crucial contribution a good level of public health can make in improving economic output and prosperity. Not only will average life expectancy increase but most importantly so too will `healthy´ life expectancy, which can have a highly positive impact on overall economic productivity and output.5 Research conducted in several European countries found that over the period 1970 to 2003, there had been significant welfare benefits ranging from 29-38% of gross domestic product (GDP) linked to increases in life expectancy. These gains far exceeded the total expenditure in each of these states on national health.6 O´Shea and Kennelly estimated that the economic cost of mental health associated issues alone was €3 billion or just over 2% of Ireland´s GNP. One third of this figure or €1 billion approximately was made of up healthcare related costs while the remaining €2 billion resulted from lost economic output.7 A further study by Behan et al put the cost of schizophrenia to Ireland in 2006 alone at €46.6 million. The results of the O´Shea and Kennelly research were mirrored in this analysis with the indirect costs of schizophrenia far outweighing those of direct care at €343 million €117.5 million respectively.8 The more recent attempts to try and provide an economic weighting for human and social costs, which do not come under the headings of either healthcare or lost economic output costs, are also worthy of mention. These human and social costs refer to the reduced quality of human life, resulting from mental health problems. In a follow up to a similar 2002/2003 study,9 the Sainsbury Centre for Mental Health (SCMH) estimated that mental health issues costs the UK £105.2 billion10 in 2009/10. Of this human and social costs made up just over half the costs at 51% (£53.6 billion), economic output losses 28.8% (£30.3 billion) and health care costs 20.2% (£21.3 billion).11 Such calculations can be very effective in highlighting the economic folly in not paying greater attention to ensuring a high level of good public health. For instance, in their 2003 study, the SCMH pointed out the cost of mental health to the UK exceeded that of crime.12 Furthermore,

3 WHO, 2001 4 Suhrcke, M. et al, 2005 5 EC, 2007 6 Suhrcke et al, 2008 7 O’Shea, E. & Kennelly, B., ibid 8 Behan, C., et al, 2008 9 SCMH, 2003 10 €120 billion approx – 4 November 2010 11 SCMH, 2010 12 SCMH, 2003

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given the falling crime rates since then, they argue that this would remain the case today.13 In a collaborative analysis with the Northern Ireland Association for Mental Health (NIAMH), the SMCH found the total 2002/3 cost of mental health issues in Northern Ireland was £3 billion, more than the total expenditure on health and social care for all health conditions.14 Despite this growing body of evidence highlighting the economic cost of health problems and the consequent urgent need to improve the general level of health, there still appears little political will or desire to implement the required reforms in policy, planning and practice. The current recession has further aggravated this situation as the pressure on politicians by various interest groups and lobbyists hoping to access the rapidly dwindling resource base has become ever more intense. A common finding in the above reports concerns the fact that the major costs associated with health problems are not those allocated to providing health services. These costs are dwarfed by the costs of lost economic output and even more so by the attendant human and social costs. There is therefore an urgent need for increased investment in health. However, it is important that other relevant economic and social sectors are encouraged to introduce the required reforms and policies to promote health and well-being. In addition, Ireland needs to invest in social and economic programmes which will, for example, facilitate the incorporation of people with a health problem into the workforce. Failure to adopt such an approach risks diminishing our long-term economic potential. In this context, it is imperative that advocates for better health avail of economic arguments to further their case not only in terms of the present costs of bad health but also on how the state risks even greater expenditure on health care treatment as well as increased lost economic output in the future. Additional Benefits of Economic Cost Analysis Before proceeding to the impact of social determinants on health prospects and why they must be tackled to improve overall health and well-being as well as reducing the economic burden of health related problems on the state, we shall outline some of the other benefits of Economic Cost Analysis (ECA): ECA helps places a focus on the importance and relative priority of various health issues

by providing an economic measure of their importance. This enables the making of economic comparisons between various potential interventions in terms of cost effectiveness and optimal allocation of resources. Although it should be noted that this does not remove the need for each proposed intervention to be justified independently.

Such analysis could assist decision-makers on how best to allocate available health

funding and resources. Although there is a good deal of evidence, which shows that well-funded and appropriately targeted investment in the health services can pay for itself several times over, ECA would enable greater understanding of the exact costs involved. This would help enhance health policy and planning decisions.

The information gleaned from ECA can also be used to calculate the costs required in

different budget periods, which can prove critical for the implementation of selected cost-effective interventions.

13 SCMH, 2010 14 NIAMH/SCMH, 2003

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ECA facilitate the estimation of the real costs of health, as they relate to different social

groupings in society. The results obtained would facilitate a clearer understanding as to the relative impact of health policy and service decisions on different socio-economic groups.

Health policy should be based on the best available data, information and evidence, adduced from experience and relevant research. In this respect, ECA can greatly contribute to the design and implementation of successful and cost-effective health policies.

Social Determinants, Health Inequalities and Policy Implications Social Determinants Given the significant costs entailed in providing health services and treatments together with the lost economic output and productivity arising from health problems, the importance of an effective health policy is clear. While prompt, targeted and patient-centred treatment will continue to be an important component in any health policy, it is through prevention involving the reduction of negative social determinants that the greatest impact can be made. As the WHO argue: The new discoveries on the human genome are exciting in the promise they hold for advances in the understanding and treatment of specific diseases. But however important individual genetic susceptibilities to disease may be, the common causes of the ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live.15 Biological or genetic predispositions may, of course, be extremely important in determining dissimilar health prospects at the level of the individual. However, in the broader context when examining the health risks of social groups they fail to adequately explain larger scale variations between these groupings. Furthermore, although genetic factors can help us understand and treat certain health issues, they do not account for the rapid changes in the health prospects and healthy life expectancies of differing social groups over comparatively brief periods. Health is not just the outcome of genetic or biological processes but is also influenced by the social and economic conditions in which we live. These influences have become known as the ‘social determinants of health’. Inequalities in social conditions give rise to unequal and unjust health outcomes for different social groups.16 Therefore, good health is determined by a multitude of factors outside the direct influence of the healthcare sector. It should also be noted that social determinants are relevant to both communicable and non-communicable maladies.17 The rise in recognition of the impact of social determinants on the overall level of health in society first came to prominence in the 1970s. The 1974 Canadian Lalonde report – A New Perspective on the Health of Canadians –was one of the first by a major industrialised country to acknowledge that biomedical interventions were not primarily responsible for improvements in

15 WHO, 2003 16 Farrell, C. et al, ibid 17 Metcalfe et al, 2009

Justin Frewen & Anna Datta

health. The Lalonde report advocated for a public health policy that would concentrate preventative, ‘upstream’ determinants rather than medical solutions. Half a decade later in 1979, the Labour Government of the day commissioned a study on the impact of the health inequalities. The resulting Black Report argued that policies that tackled the material causes of health inequities could have the greatest benefit in improving general public health. More recently, The Tallinn Charter, which was agreed at the WHO European Ministerial Conference on Health Systems in June 2008, included a commitment from member states to“…invest in health systems and foster investment across sectors that influence health, using evidence on the links between socioeconomic development and health.”18 In The Solid Facts, the WHO outlined ten “principal socio-economic determinants of health and well-being” including Health follows a social gradient deteriorating the worse one´s socio-economic conditions are; Stress is a predictor of ill health; Future health depends on early life influences; Social exclusion affects the poor and is a powerful predictor of ill health; Work and health are closely linked; Unemployment and premature death are inextricably linked; Social support supports health; Addiction is associated with and increases health and social inequalities; Food and health are very closely bound and; Transport influences health.19 People who are less well off or who belong to socially excluded groups tend to fare badly in relation to these social determinants. For example they may have lower incomes, poorer education, fewer or more precarious employment opportunities and/or more dangerous working conditions or they may live in poorer housing or less healthy environments with access to poorer services or amenities than those who are better off – all of which are linked to poorer health.20 Perhaps the most widely recognised social determinant is that of economic insecurity and its most obvious consequent, poverty. As the WHO Regional Committee for Europe highlights: Widening disparities in society or economic changes in individuals’ life courses seem to be of particular importance here. Whether defined by income, socioeconomic status, living conditions or educational level, poverty is an important determinant of mental disability and is associated with lower life expectancy and increased prevalence of alcohol and drug abuse, depression, suicide, antisocial behaviour and violence.21 The average health expectancies of people in any society are not primarily determined by the accessibility and availability of appropriate health services, although they are of course essential in the treatment of illnesses and disease. Negative social determinants such as poverty, gender inequalities and ethnicity have a detrimental impact not only in provoking health problems but also in terms of access to services and recovery rates.22 It is therefore critical they are tackled in a sustained and targeted manner. Health Inequity/Inequality The varying levels of health risks and expectations between different socio-economic groups is known as health inequity/inequality. This contrasts starkly with the random and non-systematic variance in health prospects at the level of the individual. As Metcalfe et al explain:

18 WHO, 2008 19 WHO, 2003 20 Farrell, C et al, ibid 21 Schizophrenia Ireland, 2005 22 MIND, 2002

The Socio-Economic Realities of Health in Ireland | December 2010

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Health inequalities refer to the avoidable and unjust gap in health outcomes between those at the top and bottom ends of the social scale. People in higher socioeconomic groups are more likely to live longer and enjoy more years of good health than those in lower socioeconomic groups. There are also notable differences in the health experiences of men and women. As health inequalities often mirror social inequalities, addressing the social determinants of health can impact positively on health inequalities.23 Health inequalities, emanating from negative social determinants, are estimated to reduce average life expectancy across the EU25 by 1.84 years or a total of approximately 11.4 million life years lost per annum. At the same time, healthy life expectancy is reduced due to the existence of inequalities by an average of 5.14 years or an approximate yearly loss of 33 million healthy life years. Over 700,000 deaths and 33 million healthy years were lost annually due to health inequities. In terms of economic costs, these negative social determinant derived health inequalities incurred a massive economic cost equivalent to some 20% of all health care costs and 15% of social security benefits.24 When valued as a capital good – “an important component of the value of human beings as means of production” - the economic losses resulting from inequality related health problems were estimated at around €141 billion in 2004 or 1.4% of EU25 GDP. If regarded as a consumption good – “health directly contributes to an individual’s ‘happiness’ or ‘satisfaction’” - the economic cost soared to €1,000 billion or 9.5% of GDP.25 Health and health inequalities are largely determined by factors outside the reach of the healthcare sector, including low income, unemployment, poor environment, poor education and sub-standard housing. Improving health and reducing health inequalities therefore requires action and investment across government to tackle these root causes. A report released in early 2010 - Fair Society, Healthy Lives – calculated that health inequality led to between 1.3 and 2.5 million years being lost annually through premature mortality. A further 2.8 million years were affected by limiting illness or disability. In economic terms the annual costs were considerable with productivity losses estimated at between £31-33 billion, higher welfare payments and lost taxes at £20-32 billion and additional NHS healthcare costs of over £5.5 billion. Most importantly, failure to adopt the corrective policies to tackle health inequality will see these costs continue to rise in relative terms.26 Strengthening health equity – globally and within countries – means going beyond contemporary concentration on the immediate causes of disease. More than any other global health endeavour, the Commission focuses on the ‘causes of the causes’ – the fundamental global and national structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age.27 Social Determinants and Health Inequality There are a number ways in which social determinants interact with and can contribute to health inequity including, inter alia, the following:

23 Metcalfe et al, 2009 24 Mackenback et al, 2007 25 Ibid 26 Marmot Review, 2010 27 CSDH, 2008

Justin Frewen & Anna Datta

(i) Social determinants contribute to health inequalities between social groups. This is because the effects of social determinants of health are not distributed equally or fairly across society. (ii) Social determinants can influence health both directly and indirectly. For example damp housing can directly contribute to respiratory disorders, while educational disadvantage can limit access to employment, raising the risk of poverty and its adverse impact on health. (iii) Social determinants of health are interconnected. For example poverty is linked to poor housing, access to health services or diet, all of which are in turn linked to health. (iv) Social determinants operate at different levels. Structural issues, such as socioeconomic policies or income inequality, are often termed ‘upstream’ factors. While ‘downstream’ factors like smoking or stress operate at an individual level – and can be influenced by upstream factors. A Social Determinants of Health (SDH) perspective focuses on the link between the socio-economic conditions in which people exist and their health. By combining this concept with that of Health Inequalities - the differing levels of health at the population level according to social and economic status - with that of SDH, it is possible to arrive at a substantial tool, the Social Determinants of Health Inequalities (SDHI), which places an emphasis on the role of social and economic conditions in people´s different rates of health and illness.28 The important and intrinsic connection between social determinants and health inequities have been increasingly acknowledged over the past couple of decades. This has led to organisations such as the WHO Commission on Social Determinants of Health in their report - Closing the gap in a generation - calling upon all member states “…to take into account health equity in all national policies that address social determinants of health.”29 Negative social determinants can also potentially impact upon the entire life span of an individual. Not only can health inequities impact upon individuals irrespective of where they are in their personal life cycle but they can also have detrimental effects on their later health prospects even if their overall quality of life and circumstances improve. As the WHO warns: Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Nor are the effects confined to the poor: the social gradient in health runs right across society, so that even among middle-class office workers, lower ranking staff suffer much more disease and earlier death than higher ranking staff.30 A Recent EU Survey on Income and Living Conditions (EU-SILC) has confirmed the importance of social determinants with respect to health inequalities, finding that

28 Determine, 2008 29 CSDH, 2008 30 WHO, 2003

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“being unemployed, retired, disable (sic), housewife or inactive is positively associated with suffering health limitations... Those employed part-time are also more likely to report health limitations than those working fulltime... In terms of the ability of individuals to make ends meet, in general it is possible to see a gradient, with individuals more likely to report health limitations as they make ends meet with any difficulty.” 31 Vicious Circle?32 At this point, it is necessary to briefly address the argument that the correlation between higher poverty levels and health ailments might more correctly be attributed to a decrease in the employment prospects and earning power of health services users. There is doubtlessly some truth in the contestation that a certain degree of poverty can be attributed to a deterioration in one´s health. Long term sufferers from bad health frequently see their economic position deteriorate due to enforced absences from work, reduced employment capabilities and so forth. This is often referred to as the vicious circle, which is experienced by many health service users. Certain commentators go further with this argument and claim the reason there is a higher incidence of people with a health problem amongst the lower socio-economic groups is a consequence of their particular health issue. However, the declining economic prospects of a certain number of people with a health problem can in no way adequately account for the higher incidence levels of ill health amongst larger social groups suffering from negative social determinants. Policy Implications Accepting the important and centrality of social determinants in contributing to health risks has significant policy implications. By broadening the scope of what is meant by health policy, it will be possible to make the greatest impact. Whereas health policy has generally been regarded as an effort to provide guidelines on how the health sector might best provide medical care at an optimal cost, it now needs to be understood that good health is an issue that involves a panoply of social and economic sectors and actors. Above all, it means that policy makers must recognise the importance of looking at health in an holistic manner and address the social and economic factors influencing the health prospects of the various socio-economic groups in our society.33 Such an acknowledgement will necessitate the development of a health policy that both incorporates and coordinates closely with the relevant socio-economic sectors and institutions to minimise those conditions which increase health risks and damage the health prospects of particular social groups. The health sector needs to take the lead in not only delivering an effective, universal and equitable public health system and services but in identifying, diagnosing and targeting upstream factors such as the socio-economic environment and background which militate against the health prospects of many of our fellow citizens. Just as, noted above, health ailments incur economic costs that extend beyond expenditure directly on healthcare services and treatment, the improvement of general public health and prevention of health problems will entail the reduction of health inequities. Promoting good health should therefore not be seen as the exclusive domain and responsibility of the health care system. The public health sector will also need to take on the role of advocating and

31 Hernández-Quevedo, C. et al, 2010 32 See related Thinkpiece for TASC - The Socio-Economic Realities of Mental Health in Ireland -

for an expanded and more detailed discussion of this argument. 33 Determine, 2008

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assisting other social and economic sectors to enable them contribute towards improved public health. Similarly policy measures and the ensuing programmes and actions will need to be co-ordinated as far as possible with partners in the relevant sectors throughout society, so that negative social determinants creating increased health risks can be successfully tackled. In this respect, the development and implementation of inter-departmental policies and programmes will play an essential part in eradicating structural inequality and endemic poverty. This is not to deny the crucial role of the Department of Health, HSE and so forth in working towards greater health equity. Indeed, the provision of an equitable and universal health care would be a positive social determinant in itself. However, it is not enough on its own. A determinants approach to health promotion requires action across the entirety of our society and economy, one which emphasises “coherent action” to minimise negative social determinants and foster positive ones for all our population. This will be no easy task as there are many who would prefer the current inequitable distribution of resources and privilege in our society to continue as is. Concerted action and advocacy is therefore required to ensure that we are all aware of our common responsibility for the health of our fellow citizens. As Dr. Margaret Chan, the director-general of the WHO explains, Health inequity really is a matter of life and death... health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health.34 The Commission on the Social Determinants of Health (CSDH) emphasises the necessity of involving the entire “government, civil society and local communities, business and international agencies” and provides three overarching guidelines to close the gap in health inequalities improving daily living conditions, this is, housing, early child development, health care and social protection; tackling the unequal distribution of resources; and finally, measuring and understanding the problem.35 In the short run, we need to work towards ensuring that at the very least the social and economic status of all our citizens meets certain minimum standards. The Founder President of the Candidate Institute for Research, J. Fraser Mustard, explains that: If we want to produce health—and I deliberately use an economic term—we have to work on reducing poverty and socio-economic inequality. The levelling out of such inequality and the uneven distribution of wealth is an important factor if we want to continue to improve health and make wise economic choices in our investments.36 Tackling the social determinants that contribute to health problems will also potentially encapsulate benefits in a wider range of areas ... by tackling some of the material and social injustices, policy will not only improve health and well-being, but may also reduce a range of other social problems that flourish alongside ill health and are rooted in some of the same socioeconomic processes.37

34 WHO, 2008 35 Hernández-Quevedo, C. et al, 2010 36 Mustard, J. F, 2008 37 WHO, 2003

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Furthermore, this new approach to policy would be significantly facilitated by the systematic and systemic nature of social determinants and their interrelationship with health inequities. Conclusion For those of us who aspire to living in a just society, the provision of an essential public good such as universal and equitable healthcare is surely a prerequisite. However, not only is an approach to health based on tackling negative social determinants and health inequalities the ethically correct manner in which to proceed, it also makes sound economic sense. Targeted investment to address health inequalities by action on social determinants of health is more cost effective than paying later for the consequences of these inequalities. It follows then that addressing health inequalities is not only a matter of social justice but also contributes to economic growth. Furthermore, there appears to be a distinct willingness on the part of the Irish population to invest in such policies. As the 2010 TASC issue of `The Solidarity Factor´ notes, there is an overwhelming majority (91%) of the Irish population that either strongly agreed or agreed there is a pressing need for a redistribution of resources to address the issue of inequality, which lies at the heart of so many health problems. In contrast only 4% felt strongly or disagreed with this proposition.38 Such an approach is imperative if we wish to reduce negative social determinants such as absolute and relative poverty/inequality. The failure to do so will greatly reduce the health prospects of large sections of our community and militate against the introduction, implementation and propagation of universally accessible, targeted and responsive health policies and programmes. As Fran Baum points out of course “the exact process” by which governments commit to improving the social determinants in a society to tackle health inequalities will differ “from one context to another”.39 While Ireland can and should learn from the experiences and best practices of other states, it would be wrong to engage in rote imitation of the public health policies and practices of others. The promotion of public health must therefore be taken forward in the context of the political, social, economic and institutional context of individual societies and the life circumstances in which countries find themselves, and in which their people actually live. Understanding these factors is fundamental to analysing the many differences in population health experience across and within societies.40 In essence what is needed is a Health in All Policies (HIAP) approach, which promotes an explicit recognition by non-health sectors of the effect of their policies and actions on the health and well-being of all our citizens. This should be supported by an emphasis on Social Inclusion and Poverty Exclusion through which all relevant socio-economic and political sectors and institutions ensure their policies and actions have a beneficial impact on these areas. HIAP would be highly beneficial in helping minimise the negative social determinants which can lead to

38 TASC, 2010 39 Baum. F., 2007 40 Aldersdale, R., 2001

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increased health inequalities and higher rates of sickness amongst certain disadvantaged social groupings in society.41 Of course such an approach will demand a long term outlook. While there are immediate measures that can be introduced to alleviate the impact of negative social determinants, it is in the long run that the real benefits will become evident. Most of all we need to overcome the current rigid adherence to socio-economic policies which have left so many of our society unable to participate in any kind of equitable manner. In effect, we need a radical overhaul of our current approach to social policies, economic structures and systems as well as political action.42 A failure to do so will condemn a sizable section of our fellow citizens to lives blighted by illness and bad health that could otherwise have been avoided, not to mention create a significant future drain on our economic resources. However, as Aldersdale correctly points out: Such an approach is much easier to define and describe than to deliver. Creating the political, administrative and managerial dimensions of public health policy, and securing the necessary commitment and accountability from multiple actors at the various levels, are difficult challenges to us all. Many who need to be convinced may not see the relevance of their activities to health, or may not wish to take responsibility and be accountable for their health consequences. 43 Health should be placed at the centre of any effort to improve our socio-economic development, so that our public policy brings together and unites the “determinants of health, human development and sustainable economic development.”44 In the final analysis the issue of equitable health and well-being for all members of our society is one of social justice. This preparation of this paper has been animated by this belief in accordance with the definition of social justice by the Commission on Social Determinants of Health. Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death.45 It is indeed time to `claim our future´ and ensure that we move away from, as Sara Burke so accurately terms it, the current system of Irish health apartheid46

41 Determine, 2009 42 CSDH, 2008 43 Alderslade, R., 2001 44 Alderslade, R., 2001 45 CSDH, 2008 46 Burke, S., 2009

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Justin Frewen & Anna Datta

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Thinkpiece

WHO (2001) Report of the Commission on Macroeconomics and Health. World Health Organization: Geneva