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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
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

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




“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

national goal realistic timeframe
National Goal- Realistic Timeframe

in a generation

“Achieve Health Equity”

First nation on earth

to achieve health equity

The First Nation to Achieve Health Equity

The Marmot Cup

2030 New Zealand

replace gdp as the main indicator of societal progress
Replace GDP as the main indicator of societal progress


Cited in Human Development Report, 2007

colonial views

Colonial Views

Marmot Symposium, Wellington

Wednesday 13th July 2011

re presented1

Percentage of the 2006 Population by NZ Deprivation Decile


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



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.


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.
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
Heart health equity

What prospects?

Norman Sharpe

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

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

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

Inequality of Access to Health Services

Hospital Discharges in 2009 with an Angiography Procedure

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

New Zealand Medical Students’ [email protected]

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