Education as a tool for health policy making


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Education as a tool for health policy making

  1. 1. CJ  Regazzoni,  Health  Policy  Proposal   1   EDUCATION AS A TOOL FOR HEALTH POLICY MAKING   Dr.  Regazzoni  Carlos  Javier,  MD,  PhD   Buenos  Aires,  November  2005   A B S T R A C T . There is growing evidence that public health is strongly related to educational background. Moreover, educational interventions have proved to be strong boosters of a community’s health. It is mandatory to explore the best-evidence-based government policy tools available to integrate education and health in a concerted effort towards public health improvement. In order to accomplish this goal, first, a critical appraisal of existing medical literature on this subject must be undertaken by local governments, in an effort to determine the most relevant evidence-based associations between education and a population’s health outcomes. Subsequently, an analysis of existing policies should be undertaken, and finally, the strategies able to improve health throughout education policies would be proposed, based on solid scientific foundations. I. IN T R O D U C T I O N . Latin America in general and Argentina in particular need more innovative and broaden view policies to improve health. In the most inequitable region in the world (Morley SA, 2001), health is poor and unequally distributed (Suárez-Berenguela RM, 2000). Furthermore, evidence suggests (Baird M, 2004) that most regions of the developing world will not, at the current pace, reach the Millennium Development Goals (MDGs) for health by 2015— including reducing child and maternal mortality, primarily because improving health outcomes is linked not only to the provision of health services, but also to interventions outside the health sector like behavioral changes and other societal factors. While education differentials are a key factor in income inequalities, poor health is a considerable contributor to the problem. Income explains a good portion of health status; in addition, good health by itself, is an essential pre-requisite for economic development (Bloom DE, 2004). On the other hand, both education capital and health capital are strongly interrelated (Baldacci E, 2004): health capital contributes to the accumulation of education capital, and education is also associated with health capital. More importantly, education is a strong determinant of mortality and disease at all ages (Matthews RJ, 2005). At present, investment in health promotion has been inefficient, and higher public spending on health as a share of GDP is shown to be tenuously related to improved health status (Filmer D, 1997) or to greater health equality (Isaacs SL, 2004). Afore-mentioned evidence urges towards combined and specific goal oriented actions (Morrisson C, 2002) instead of uncoordinated measures, a typical problem of government programs in Latin America. In this regard, it seems reasonable to think about education policy as part of a grand strategy to improve health (Goldman D, 2001). Unfortunately, proposals of this sort are scarce and mostly based on traditional medical policies like vaccination, hygiene teaching, etc., while education and health policies remain largely disengaged from each other. II. LI T E R A T U R E RE V I E W . Social factors are critical for health (Kaplan GA, 1993); as a matter of fact, people in upper classes live longer and healthier lives than do people in lower classes (Mathews RJ, 2005), and education seems critical among these class inequality determinants (Marmot M, 1999). II.A . E ducational attainm ent influences m ortality. There is an inverse association of education with all cause and specific disease mortality. Kitagawa and
  2. 2. CJ  Regazzoni,  Health  Policy  Proposal   2   Hauser (Kitagawa EM, 1969) found that 1960 educational attainment, as assessed by years of school completed, and income, were both inversely related to mortality in the white population especially prior to age 65; but education was stronger predictor of death than income. Later, Pappas et al. (Pappas G, 1993) showed that for persons 25 to 64 years old, those who had not graduated from high school had a death rate two to three times higher than those who had graduated from college, a gap larger than that due to many other well-known risk factors including cigarette smoking. At the age of 65 (Guralnik JM, 1993), those with 12 or more years of education have an active life expectancy 2.4 to 3.9 years longer than those with less education; that is an influence even stronger than race. Preston and Elo (Preston SH, 1994) confirmed and improved definition of afore-mentioned trends in educational mortality differentials. More recently (Elo IT, 1996), it has been reported that college graduates tend to have lower mortality rates than high school graduates, and people who do not attend high school tend to have even higher mortality rates, especially at working age. Despite the fact that lower levels of education are also associated with higher incidence of cigarette smoking, systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol levels (Wickleby MA, 1992), educational differentials in mortality persist, albeit attenuated, when controlled for risk factors and other individual’s characteristics like income or behavior. In a study of more than two million people, who were followed for twenty years (Steeland K, 2002), lower education was associated with higher death rates even after adjustment for six risk factors (smoking, body-mass-index, menopausal status, diet, alcohol, and hypertension) in addition to age. Life expectancy was decreased by 4.8 and 2.7 years for men and women respectively, for the lowest versus the highest educational group. The same trends have been found in South Korea (Khang YH, 2005), Lithuania (Kalediene R, 2005), and other countries. Striking differences in stroke mortality according to maximal school or university degree achieved have been demonstrated in Europe (Avendaño M, 2004). Education also affects cancer mortality (Fernandez E, 1999); for all malignancies, both sexes in the lowest educational level showed a greater risk of death compared with men with a university degree. In general, researchers (Wong MD, 2002) have estimated that ischemic heart disease contributed 11.7 percent to the educational disparity in life-years lost, followed by lung cancer (7.7 percent), stroke (5.8 percent), congestive heart failure (5.1 percent), pneumonia (5.1 percent), and lung disease (5.0 percent). In the elderly (Bassuk SS, 2002), education was inversely associated with mortality despite adjustment for behaviour, actual health status, and income. Women are another particularly vulnerable group (Lee JR, 2005): the risk of death owing to cardiovascular disease (CVD) among women with established CVD was more than twice greater among non– high school graduates than that of high school graduates at age 60, independent of other risk factors. This study emphasizes the urgency of educational efforts among women (only 5% of Argentine women 30 years or older hold a university degree1). In addition to educational level, the closely related IQ, appears to affect health too. In a 1970 Scottish cohort followed for 25 years for hospital admissions and mortality (Harta CL, 2004), childhood IQ was associated with cardiovascular risk factors, myocardial infarction, and stroke occurrence. People with higher Intelligence Coefficient in childhood live longer (Kuh D, 2004; Batty D, 2004). Finally, there is an impressive array of associations between mothers’ educational level and children’s health status (Filmer D, 1997), and educational attainments of both spouses have resulted to be significant predictors of one’s own overall mortality (Jaffe DH, 2005) in couples. II.B . E ducation as a tool for health policies. Better access to preventive and early care doesn’t explain the better health status of the more privileged; in the United Kingdom, for instance, similar disparities in health among socioeconomic classes persist despite presumably universal health access (Marmot MG, 1987); it urges in favor of an independent “health effect”. Policymakers frequently search for ways to improve both education and health, but they rarely appreciate the relationship between the two. In 1995, the World Health Organization launched “WHO's Global School Health Initiative”, which was designed to improve the health of students and community lives through "Health-Promoting Schools" -a healthy setting for living, learning and working- (WHO, 2005). This initiative, 1 Calculation based on 2001 National Census. Data available at:
  3. 3. CJ  Regazzoni,  Health  Policy  Proposal   3   however, focuses largely on the convenience of schools as means of implementation of specific health education and promotion activities. Health literacy—the degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions—is just another example of intersection between both fields (Parker RM, 2003). Research on new policy tools to incorporate health and formal education into an integrated strategy for development would be a challenging innovative way to improve health. Moreover, this approach should set the health problem in the broad perspective of “social class inequalities” (Isaacs SL, 2004). III. PR O P O S E D W A Y O F A C T I O N . An innovative approach, intended to promote educational strategies in order to improve health status of the population should bare two main objectives in mind. First, it is mandatory to determine, what are, at present, the best scientifically established links between education and a population’s health outcomes, and the previous experience with integrated policies. Secondly, it is recommended to derive a list of well-grounded recommendations, anticipated to integrate education and health in a concerted effort oriented towards public health improvement. Education attainment, in this case, is understood as the maximal degree achieved within the formal education system. Education policy in this case is defined as any policy based on formal educational system intended to promote new quantitative or qualitative educational goals. Health outcome, in this case, is defined as disease occurrence or mortality. The working questions for the researcher could be stated as follow: 1-What are the established links between education attainment and health outcomes? 2-What is the quality of the available evidence in this regard? 3-What recommendations derive from this evidence? 4- What health outcomes might be expected from the application of these recommendations? Is there any model in this regard? 5-When and where have education policies been applied in order to advance health outcomes? 6-Is there any additional evidence of health outcome changes presumably derived from innovative education policies (Plan “Borsa schola” in Brazil, for instance)? 7-What conclusions can be derived from these experiences? 8-What is the perspective of the experts about scientific evidence and previous experiences of education policies to improve health? Finally-What policies could be recommended for Argentina in particular and Latin America in general, as an interrelated education and health strategy to improve public health? Is it necessary to create a specific office of coordination, any specific body of norms, or new research? The aim of the work must be a detailed description of the state-of-the-art of links between education attainment and health outcomes, a reassessment of previous experience with joined policies of this sort, and a list of reasonable recommendations for education policies to be implemented in order to improve health. IV. EX P E C T E D C O N C L U S I O N S A N D F U T U R E I M P L I C A T I O N S . With the research, the scholar expect to perform an extensive review of up-to-date published data on the relationships between health and education, as well as a collection of the trials carried out elsewhere in order to test the hypothesis that interventions on general education are useful and cost-effective measures for population’s health improvement. This work should allow us to make recommendations about the implementation of educational policies intended to improve health. Although there is still much to learn about the relative contributions of education, income, and occupation to health, the fact that they do have an influence means that policies affecting these areas must be examined for their effects on health (Isaacs SL, 2004). This requires broadening the concept of health policy to include areas not normally considered when thinking about health (Tarlov AR, 1999). Investments in social and economic policy made upstream can pay health dividends downstream. Policies regarding education cannot be divorced from their effects on health. Experts (Hurowitz JC, 1993) caution against expecting too much from reform of the health care system without more fundamental social and economic reform; issues like child mortality or heart attack aren’t purely medical matters; otherwise, it would be an approach expensive and ineffective. It may be time to regard medical illness as the result --
  4. 4. CJ  Regazzoni,  Health  Policy  Proposal   4   direct or indirect -- of social factors, and to treat it as such. Health reform, to date, has focused primarily on health financing and medical assistance; but it is worth considering that ensuring adequate medical care for all will have only a limited effect on Latin America’s health. More important is enabling people, in the lower economic classes, to adopt healthier behaviors and skills. Two main reasons make this approach to health policy critical: firstly, it could serve to implement new combined policies. The combined policies should imply new assignments and budget distributions, which implies that money traditionally earmarked for health care should be diverged to education, but at least part of the results could be measured as health gains (for instance: to lower child mortality or mother mortality through a plan mainly based on educational strategies). The same should be taken into account when assuming decisions about human resources, infrastructure, and others. Secondly, it could serve as a primer for research and innovation in an area relatively unexplored in the region, as it is the case for the implementation of coordinated health and education policies in order to achieve a mutual benefit of both fields. It ultimately should result in a more integral achievement of human development in a region that worth deserves it. V. BI B L I O G R A P H Y . 1. Angell M (1993). Privilege and Health -- What Is the Connection? New England Journal of Medicine, volume 329, p.:126- 127 2. Avendaño M, Kunst AE, Huisman M, et al (2004). Educational Level and Stroke Mortality. A Comparison of 10 European populations during the 1990s. Stroke, volume 35, p.:432-437 3. Baird M, Shetty S (2004). Getting There -How to accelerate progress toward the Millennium Development Goals-. In: Jeremy Clift (Ed.). International Monetary Fund. Healthand & Development. Washington, DC 4. Baldacci E, Clements B, Gupta S, and Cui Q (2004). Social Spending, Human Capital, and Growth in Developing Countries: Implications for Achieving the MDGs. International Monetary Fund Working Paper, WP/04/217 5. Batty GD, Deary IJ (2004). Early life intelligence and adult health. British Medical Journal, volume 329, p.: 585-586 6. Bassuk SS, Berkman LF, and Amick BC (2002). Socioeconomic Status and Mortality among the Elderly: Findings from Four US Communities. American Journal of Epidemiology, volume 155, p.: 520–33 7. Bloom DE, Canning D, Jamison DT (2004). Health, Wealth, and Welfare. In: Jeremy Clift (Ed.). International Monetary Fund. Health and & Development. Washington, DC. 8. Elo IT, Preston SH (1996). Educational differentials in mortality: united states, 1979-85. Social Sciences Medicine, volume 42, p.: 47-57. 9. Fernandez E, Borrell C (1999). Cancer mortality by educational level in the city of Barcelona. British Journal of Cancer, volume 79, p.: 684-689 10. Filmer D, Pritchett L (1997). Child mortality and public spending on health: how much does money matter? World Bank, Working paper No.: 1864 11. Goldman D, Lakdawalla D (2001). Understanding health disparities across education groups. National Bureau of Econimic Research Working Paper No. w8328. http://www. 12. Guralnik JM, Land KC, Blazer D, Fillenbaum GG, Branch LG (1993). Educational status and active life expectancy among older blacks and whites. New England Journal of Medicine, volume 329, p.:110-116 13. Hart C.L., Taylor MD, Smith GD, et al (2004). Childhood IQ and cardiovascular disease in adulthood: prospective observational study linking the Scottish Mental Survey 1932 and the Midspan studies. Social Science & Medicine, volume 59, p.: 2131–2138 14. Hurowitz JC (1993). Toward a social policy for health. New England Journal of Medicine, volume 329, p.:130-133 15. Isaacs SL, and Schroeder SA (2004). Class — the ignored determinant of the nation’s health. New England Journal of Medicine, volume 351, p.: 1137-1142 16. Jaffe DH, Eisenbach Z, Neumark YD, Manor O (2005). Effects of husbands’ and wives’ education on each other’s mortality. Social Science & Medicine, In press. 17. Kalediene R, Petrauskiene J (2005). Inequalities in mortality by education and socio-economic transition in Lithuania: equal opportunities? Public Health, volume 119, p.: 808–815 18. Kaplan GA, Keil JE (1993). Special report: socioeconomic factors and cardiovascular disease: a review of the literature. Circulation, volume 88, p.: 1973-1998 19. Khang YH, Kim HR (2005). Relationship of education, occupation, and income with mortality in a representative longitudinal study of South Korea. European Journal of Epidemiology, volume 20, p.: 217–220 20. Kitagawa EM, Hauser PM (1969). Review of 1960 matching study of deaths and census records. In: U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. Public Health Service, Health Services and Mental Health Administration. The 1970 Census and Vital and Health Statistics. A Study Group Report of the Public Health Conference on Records and Statistics. Public Health Service Publication No. 1000-Series 4-No. 10, Washington, D.C. 21. Kuh D, Richards M, Hardy R, Butterworth S, and Wadsworth MEJ (2004). Childhood cognitive ability and deaths up until middle age: a post-war birth cohort study. International Journal of Epidemiology, volume 33, p.:408-413 22. Lee JR, Paultre F, and Mosca L (2005). The association between educational level and risk of cardiovascular disease fatality among women with cardiovascular disease. Women’s Health Issues, volume 15, p.: 80–88 23. Marmot M (1999). Epidemiology of Socioeconomic Status and Health: Are Determinants Within Countries the Same as Between Countries? Annals of the New York Academy of Sciences, volume 896, p.: 16-29 24. Marmot MG, Kogevinas M, Elston MA (1987). 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