Tackling health inequities can reduce pressure on healthcare systems

Health equity means fair opportunity to live a long, healthy life and inequities in health are not inevitable or necessary, but unjust and the product of unfair social, economic and political arrangements, Ms. Suzanne Costello, Chief Executive, Institute of Public Health in Ireland told the Conference.

Ms. Suzanne Costello, Chief Executive, Institute of Public Health in Ireland
Ms. Suzanne Costello, Chief Executive, Institute of Public Health in Ireland

Ms. Costello, who took up the role of CEO at the Institute of Public Health in Ireland ten months ago, was speaking on “Preventing the future…reducing health inequalities to build healthier societies on the island of Ireland.”

She said health was normally viewed as health care and public heath as disease control – the Institute of Public Health occupied a space in the less well known middle – prevention, promotion, with a particular focus on achieving health equity.

“We work on addressing the causes of and solutions to health inequity through research, evidence review, and policy analysis, using health and wellbeing impact assessment and creating partnerships to share knowledge, with the aim of optimising population health on the island of Ireland.

“We work on a North South basis, with offices based in Dublin and Belfast and a staff team of about 20.

“What that all means is that we seek policy solutions to help everyone to reach their potential to live as healthily as possible, for as long possible. And in doing so, we hope we help in some way to reduce the pressure on healthcare systems, you and your staff teams in delivering care.”

Ms. Costello said that currently their work was mainly informed by the key preventative health strategies on the island of Ireland, Healthy Ireland in the Republic of Ireland and Making Life Better in Northern Ireland.

Across Europe preventative health frameworks were being implemented in almost every Western country where many of the health issues were the same – to help societies meet the challenges of ‘lifestyle’ diseases and that of living well for longer.

“While there is near universal recognition of the importance of a healthier society and most of us value our own health highly, we do tend to act in ways that undermine it and we don’t always welcome the messages and information that flow from the preventative health approach.

“Undoubtedly, personal responsibility has a part to play, but in our view there is a disproportionate emphasis on the individual as the locus of change. Change is also required at the social and structural level of society – broadly referred to as the social determinants of our health.

“WHO defines and recognises the role of social determinants in shaping population health – as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

we seek policy solutions to help everyone to reach their potential to live as healthily as possible, for as long possible. 

“So, income, access to public services, education, psychosocial factors like stress, isolation and environmental factors, access to good nutrition and good health information and advice, all contribute to our health, good or bad, throughout our lives.

“Equally commercial determinants impact health behaviours and influence policy responses, particularly to ‘lifestyle’ diseases. Transnational corporations are often more powerful than states and when they seek legitimately to shape policy to protect their interests – this can have detrimental effects on the health of individuals – individuals who have less influence and power.

“These factors shape health outcomes throughout society but have the biggest impact on poor communities. This is not just a case of poor countries versus affluent countries – we know there is health inequity in affluent countries, including Ireland.

“A CSO research paper published earlier this year indicated that people in most deprived areas of Ireland have lowest life expectancy.

“And although it came with some health warnings, it is aligned with the internationally recognised phenomenon whereby people who are less advantaged in terms of socioeconomic position have worse health (and shorter lives) than those who are more advantaged.

“The social gradient in health is a term used to describe the phenomenon whereby people who are less advantaged in terms of socioeconomic position have worse health (and shorter lives) than those who are more advantaged.

“It should be shocking that people die earlier and live with more ill health than they need to – this should motivate us all in itself. But for those who need a further reason, health and equity are not only important in themselves, but also make good economic sense, stimulating people’s ability to achieve their potential and optimise their economic and social productivity.

“People in the highest social strata live longer and have better health than those in the strata just below them who, in turn, live longer than those just below them and so on in a downward gradient until the bottom of the social ladder is reached.”

Ms. Costello said Marmot suggested the following key aims to address this inequity:

  1. Give every child the best start in life.
  2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.
  3. Create fair employment and good work for all.
  4. Ensure healthy standard of living for all.
  5. Create and develop healthy and sustainable places and communities.
  6. Strengthen the role and impact of ill-health prevention.

On a wider level, other factors must be considered. They included:

  • The role of the health and public health professionals and other workforce
  • Health systems, governance and delivery
  • Global and macro level factors

The Marmot principles emphasised prevention and health care professionals and prescribed proportionate universalism intervention to target the greatest areas of need, to level the gradient.

This is not just a case of poor countries versus affluent countries – we know there is health inequity in affluent countries, including Ireland.

The problem appeared to be that people did not disagree with preventative actions but rather that they did not seem to address the issue at hand – the present was much more pressing than the future.

In healthcare terms – the action and drama was in treatment – it was lifesaving and life changing in a way that engaged everyone, so engaging people in prevention was difficult.

“This is a huge challenge for society, but US researchers have identified six points which could work to motivate us:

  1. “Actively connect actions now with outcomes later – what we do now will impact positively later.
  2. “Legacy thinking- we know people are motivated around future generations. Keeping family healthy, and staying healthy for children, is a key motivator.
  3. Focus on solutions – that are reachable, take a daily 20 min walk.
  4. “No one understands statistics– the use and misunderstanding of absolute and relative risk alone has undermined the credibility of health messaging. How often have we heard ‘everything gives you cancer’. Clearly everything doesn’t give you cancer, but that approach can quickly undermine important health messages.
  5. “We think in stories and we act on emotion. The context and stories of how people live their lives can mitigate the lack of connection.
  6. “Remember this is unseen work -prevented ill health is an invisible win, you will rarely get attention for this success. We need KPIs to illustrate it.

“But, the key in all of this is the trusted voice – and healthcare professionals remain trusted voices in our society. This trusted role remains crucial in influencing and changing attitudes, be it as advocates, in your communities or in your work, your voices and influence have become more important than ever in a crowded, confused world of health and wellbeing and wellness.

“The challenge of achieving the large scale behaviour change in a world that doesn’t yet encourage health, and where some face greater challenges than others is significant. It requires large scale structural, political and social change. We need not only health in all policies, but health equity in all policies. I fully appreciate the pressure and intensity of healthcare and how annoying it can be to be asked to do yet more with every new plan and strategy and initiative. But this is an enormous task, and as we try to meet this challenge, we value your contribution enormously.”