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E conomic & Social Determinants. Philippa Howden-Chapman He Kainga Oranga/ Housing and Health Research Programme www.healthyhousing.org.nz New Zealand Centre for Sustainable Cities www.sustainablecities.org.nz University of Otago, Wellington. The importance of e mpathy.

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E conomic & Social Determinants

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E conomic social determinants

Economic & Social Determinants

Philippa Howden-Chapman

He Kainga Oranga/Housing and Health Research Programme


New Zealand Centre for Sustainable Cities


University of Otago, Wellington

The importance of e mpathy

The importance of empathy

Most respondents in the NZ Values Survey were prepared to pay increased taxes to provide better health services and a better standard of living for the elderly and the disabled.

Carroll et al, THE WIDENING GAP, Social Policy Journal, 2011

Waitangi tribunal truth reconciliation and compensation

Waitangi Tribunal: truth, reconciliation, and compensation

Newsp e ak


  • Current HNZ tenants most deprived 5% of households

  • Healthy Housing Programme

    • 27% fall in the total number of acute and arranged hospitalisations of year

    • 61% fall in hospitalisations after crowding reduction

  • Excluding 55 % of applicants is a faster path to overcrowding, infectious disease (25% of acute hospitalisations) + homelessness

  • Unfair to reduce small stock of social housing when private rental properties unregulated +

  • some landlord’s discriminatory




E nergy poverty

Energy poverty

E conomic social determinants

“Any one who has ever struggled with poverty knows how extremely expensive it is to be poor”

James Baldwin, Nobody Knows My Name, 1961.

Built e nvironment

Built Environment

-- Private rental housing stock requirements extremely limited

Boarding houses and camping grounds increasingly housing of last resort

Insecurity of tenure -> residential mobility -> irregular primary care -> school attendance



Evidence based policies

Evidence-based policies

+ Government funding– underpinned by research – has led to step change in retrofitting insulation and heaters for home-owners

co-benefits: health, education, energy + climate change

+ Experimentwithmixed-tenure, low carbon urban houses with low operating costs

Develop economies of scale

+ Social Inclusion

Marmot symposium achieving health equity

Marmot SymposiumAchieving Health Equity

Prof Don Matheson

National goal realistic timeframe

National Goal- Realistic Timeframe

in a generation

“Achieve Health Equity”

E conomic social determinants


E conomic social determinants

First nation on earth

to achieve health equity

The First Nation to Achieve Health Equity

The Marmot Cup

2030 New Zealand

All maori to experience the rights and opportunities it promised

All Maori to experience the rights and opportunities it promised.

Replace gdp as the main indicator of societal progress

Replace GDP as the main indicator of societal progress


Cited in Human Development Report, 2007

Scrap comparisons with australia as the bench mark for our society s progress

Scrap comparisons with Australia as the bench mark for our society’s progress.

Resist marginalisation and ostracism of non conformists

Resist marginalisationand ostracism of non conformists.

Free health care for children 24 7

Free Health Care for Children 24/7


Colonial views

Colonial Views

Marmot Symposium, Wellington

Wednesday 13th July 2011

Re presented


Re presented1


Percentage of the 2006 Population by NZ Deprivation Decile

E conomic social determinants


Source - Hauora IV p38

Re presented2


1 Eliminating child abuse and neglect


It’s a journey not a destination

Re presented3


2 Eliminate childhood poverty

Welfare Working Party

Working for Families

Father not known


Re presented4


3 Protect & expand early childhood education

Evidence based

Cost effective

Needs training support


Re presented5


4 Live gently on our planet

Global warming

Population size



E conomic social determinants

Pacific people in New zealandDebbie Ryan and Ineke MeredithMarmot symposiumWellington13 july 2011

Pacific people in nz 2011

Pacific people in nz 2011

  • Pacific peoples constitute 6.9% of NZ population (2006 Census)

  • 38% Pacific population under 15yr of age

  • By 2051, NZ student population will rise from 1 in 10 as it is currently to 1 in 5

  • Poorer life expectancy

  • Highest mortality rate for cerebrovascular disease

  • Mortality rate for cardiovascular disease higher than that for non-Maori non-Pacific People

  • Diabetes

  • Obesity

  • Amenable mortality

Pacific child health in nz

Pacific Child Health in NZ

  • 85% Pacific children completely immunised by age 2

  • Highest failure rates new entrant hearing tests

  • At 5yr of age, only 32% Pacific children caries free

  • Pacific children aged 5-14yr are 6x more likely to be obese than other children in NZ

  • Unintended pregnancy and longtermconsequences: poor antenatal care, obstetric complications, low birth weight infants, poor educational attainment and child abuse (The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, 2005)

  • Rheumatic Fever

  • Rheumatic Heart Disease

  • Meningitis

  • Highest hospitalisations for asthma

Acute rheumatic fever in nz

Acute rheumatic fever in nz

Acute Fever Rheumatic Admissions in 0-24 Year Olds by Ethnicity, New Zealand 1996-2007

Source: New Zealand Child and Youth Epidemiology Service

Serious skin infections

Serious skin infections

Hospital Admissions due to Serious Skin infections in Children and Young People 0-24 years by

Ethnicity, New Zealand 1996-2006

Source: New Zealand Child and Youth Epidemiology Service

Avoidable hospitalisations

Avoidable hospitalisations

  • NZHS 2006: Decreasing unmet need

  • Pharmaceutical expenditure approximates that expected based on health need

  • Increasing rates of emergency care self-presentation for less urgent conditions

ASH rates per 1000 for Counties Manukau 0-74 year olds, by ethnicity 2001-2009



non-Maori non-Pacific

Source: CMDHB: Changes in Primary Health Care 2001 - 2009

Focus on youth

Focus on youth

  • Disadvantage at different stages of life affects adult health (Power and Kuh 2006)

  • Are there circumstances which make inequality later in life more likely?

  • “Although all children gain from quality early childhood education, society benefits most from the investment in children from low-income or disadvantaged homes” (Improving the Transition, May 2011)

A focus on reducing inequalities for pacific peoples system response

A Focus on Reducing inequalities For Pacific Peoples System Response

  • Legislation NZ Public Health and Disability Act 2000 – “...to reduce health disparities by improving the health outcomes of Maori and other population groups...”

  • National strategies

    • New Zealand Health Strategy 2000

    • Primary Health Care Strategy 2001

    • Public Health

    • Pacific Health and Disability Action Plan 2002 and Pacific Provider Development Fund

  • Quality focus

    • Evidence based guidelines

    • Primary health care accreditation

    • Performance management

  • Research and evaluation

  • Workforce development

  • Determinants of health and empowerment

    Determinants of health and Empowerment

    • DHB Pacific community and church based programmes

      • Enua Ola

      • LotuMoui

      • Health Village Action Zones

    • HEHA

    • Housing programmes

    • Anti-smoking

    • Health prevention- immunisation (MenzB, childhood, Influenza, HPV), cancer screening, early childhood health checks

    • Pacific unemployment rate in was 4.7%, (3.4%) in December 2007 compared with 26.1% (10.6%) in 1992.

    A new approach understanding adaptive challenges

    A new approach – understanding “adaptive challenges”



    Russell Wills FRACP, MPH

    Community and General Paediatrician, HBDHB

    Children’s Commissioner

    Why should we care about children

    Why should we care about children?

    • The foundations of adult health are laid in childhood.

    • Children are vulnerable.

    • Children are 25%

    • of our population.

    • Children have no

      political power.

    • Evidence base.

    • UNCROC.

    Lessons and opportunities

    Lessons and opportunities

    Big problems require a plan

    Local solutions to local issues, with national standards

    • Immunisations, B4SC, FVIP, ASH…

    • Can reduce inequalities

      National solutions

    • PSNZ clinical networks

    • Annual “State of the Nation’s Children Report”

    • Scorecard

    • Green Paper

      • Difficult choices with uncertain answers

        • Universal entitlement vs targeted to guarantee needs met?

        • Parents’ rights vs state’s right to require behaviours?

      • Engage media to discuss the issues, c.f. conflict

      • Opinion pieces, public debates & presentations

    E conomic social determinants

    Heart health equity

    What prospects?

    Norman Sharpe

    Disproportionate universalism cvd mortality

    Disproportionate universalism: CVD mortality

    An increasing burden for m ori

    An increasing burden for Māori

    IHD Mortality in NZ Trends and Projections

    Tobias et al NZMedJ April 2006

    For Māori, an actual increase in the absolute number of deaths is projected for males and a relatively stable number for females

    Cigarette smoking obesity prevalence and nz dep nz health survey 2006 7

    Poverty and health risk in New Zealand

    Cigarette smoking, obesity prevalence and NZ Dep NZ Health Survey 2006-7

    E conomic social determinants

    Risk Factors for Acute Rheumatic Fever 0-24 years New Zealand 2002-2006

    Maori 23 times and Pacific ~50 times more affected


    Maori (29/100,000) 22.97Pacific (62/100,000) 48.62

    European (1.3/100,000) 1.00Asian/Indian (1.3/100,000) 0.99

    E conomic social determinants

    Life expectancy and health inequalities in NZ

    Variation amongst DHB areas

    Smaller health inequalities











    S Canty

    Shorter life expectancy

    Longer life expectancy



    W Coast


    H Bay



    “Health inequality” = variation in life expectancy within each DHB’s area.


    Counties M


    Greater health inequalities

    E conomic social determinants

    Inequality of Access to Health Services

    Hospital Discharges in 2009 with an Angiography Procedure

    E conomic social determinants

    Acute Coronary Syndrome Revascularisation Cohort Study5,456 Māori and 62,294 non-Māori 1st acute admissions 2000-2008 with ACS

    E conomic social determinants

    Michael Chen-Xu

    New Zealand Medical Students’ Associationwww.nzmsa.org.nznzmsa@nzmsa.org.nz

    We are nz s future health professionals

    We are NZ’s future health professionals

    • Increasing costs of healthcare

      • Ageing population, new technology, obesity

    • Significant inequalities in social determinants of health

    • Health inequities – ethnic, SES, children

      • Double burden of infectious and chronic diseases

    • Climate change

      • “The biggest global health threat of the 21st century…”1

    1 Costello et al. Managing the health effects of climate change. Lancet. 2009;373:1693-733



    A paradigm shift:

    Encouraging health, rather than simply treating disease


    • Addressing social determinants of health

    • Abandoning the patriarchal paradigm

      • Becoming advocates for change

    Who definition of health

    WHO definition of Health

    • Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity2

    2 World Health Organization. 1946. WHO definition of Health, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States and entered into force on 7 April 1948.

    How to get there

    How to get there?

    • Challenge of communicating this vision

    • Enhancing social cohesion

      Integration of addressing social determinants of health as doctors, particularly in primary care

    • Alma Ata Declaration

    • Ottawa Charter

    How to get there1

    How to get there?

    Source: Rasanthan et al. Primary healthcare and the social determinants of health: essential and complementary approaches for reducing inequities in health. J Epidemiol Community Health 2011

    Health professionals for a new century

    Health Professionals for a New Century

    • Empowerment of young professionals

      • Tangible research opportunities in the community; making that difference quantifiable

      • Supporting student/young person advocacy: IFMSA projects, P3 foundation, NZMSA

    • Developing social accountability in education3

      • Integrating clinical presentations with public health, equity vs. equality, cultural competency

    3Wen LS et al. Social accountability in health professionals’ training. Lancet. 2011

    A call to action

    A “call to action”

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