SECOND OPINION:Health spending has little relationship with mortality rates
THE NEWS last week that Ireland is the most efficient country at reducing mortality per euro spent on health was greeted with surprise by many commentators. Death rates among Irish adults, aged 15-74, dropped from 10,374 per million to 5,433 between 1979 and 2005, an astonishing reduction of 48 per cent. This means that Ireland went from having the highest mortality rate among 19 Western countries to seventh place, and achieved this while spending the least on health services.
No one seemed to question the thinking behind the Bournemouth cost effectiveness study, which links GDP health expenditure with mortality rates. The theory is that the amount spent on health services correlates with death rates. This seems reasonable given that reducing mortality is one of the goals of all health systems.
The problem with this simplistic theory is that expenditure on health services has little or no relationship with mortality rates, which are hugely influenced by factors outside the health system. It is estimated that health services determine about 10 per cent of health status and the other 90 per cent is created by factors such as education, social status, employment and income.
These are exactly what influenced health in Ireland during the years covered by the Bournemouth study. Statistics from the CSO show that between the years 1979 and 2005 educational attainment and employment levels increased dramatically. Percentages of people with a primary school education only, dropped from 64 to 15. Unemployment rates reduced from 14 to 4 per cent between 1983 and 2003.
Nearly 40 years ago, the Lalonde report confirmed the major influence of the social determinants on health, and challenged the view that “medicine is the fount from which all improvements in health have flowed and popular belief equates the level of health with the quality of medicine”.
A more recent report from the WHO, Closing the Gap in a Generation, shows quite conclusively that the huge differences in health between and within countries are matters of social justice. For example, a girl born in Lesotho will die 42 years earlier than a girl born in Japan. The risk of dying in childbirth in Sweden is one in 174,000 whereas it is one in eight in Afghanistan.
New research by the same Bournemouth researchers shows no relationship between GDP health expenditure and child mortality (0-14 years), but a highly significant correlation between child death rates and income inequalities in 20 Western countries. The four countries with the narrowest gap between the top and bottom 20 per cent of income had the fewest child deaths.
This is very bad news for the Irish taxpayer as children’s health in Ireland is almost exclusively provided by the HSE and the amount we spend makes no difference to child mortality.
Since mortality and health status differences result from the social environments where people live, work, play and age, why bother having health services other than emergency departments? The answer is simple. We need health services to treat the ill health resulting from a toxic mixture of bad policies, unfair economic arrangements and bad politics.
The main reason why GDP health expenditure contributes so little to health creation is that the health system is busy picking up the pieces left behind by other sectors, which is where most of the money goes.
Mortality statistics should not blind us to the burden of non-fatal diseases which cause much suffering. Depression is the second most common chronic disease in adults aged 15-59. Mental health is particularly relevant in today’s Ireland as stress can have a powerful and detrimental effect on health, according to a 2008 report from the Combat Poverty Agency.
Stress can result from financial strain, debt and unemployment, and future health studies will surely show that the health of Irish people has deteriorated since 2005.
Of particular relevance to Ireland are the structural adjustment policies pursued by the IMF, which do not benefit disadvantaged people. I dread to think what Irish health status and mortality rates will be for 2011 given that unemployment is once again at 14 per cent and school class sizes are increasing, which will lead to lower educational attainment.
The next budget needs to dramatically narrow the gap between rich and poor people in Ireland or we can expect truly awful health statistics that cannot be laid at the door of the HSE.
Dr Jacky Jones is a former regional manager of health promotion with the HSE