Mission-oriented policy to address health inequalities

Abstract

In this issue of The Lancet Public Health, Tanith Rose and colleagues present the effects on mental health and wellbeing of an original economic development approach in Preston, UK. The findings offer insight into a new way of making policy in a time of standstill in improving health inequalities. The 10 Years On report to the Fair Society, Healthy Lives Marmot Review on addressing health equalities in England showed a drastic slowdown in increase in life expectancy, which was greatest in the most deprived areas. In several deprived neighbourhoods, the life expectancy had decreased from 2010 to 2020. This decrease coincided with austerity policies, which disproportionately affect household incomes and public funding in the most deprived regions. These policies can affect mortality through increasing exposure to unhealthy environments, including housing, pollution, limited means to invest in health promoting behaviours, and increased stressors, to name a few. Funding cuts could in turn affect spending in care, regulatory services, and prevention. Between 2013 and 2017, research found that funding cuts to local governments were associated with decreased life expectancy and an increase in the life expectancy gap between the most and least deprived regions. Too often portrayed as slow and bureaucratic, with a role to fix, regulate, and redistribute, governments are in fact well placed to orient economies to deliver health for all. In her book Mission Economy: A Moonshot Guide to Changing Capitalism, Mariana Mazzucato references the successful moon landing in 1969 and describes that reaching objective required imagination and a set goal, dynamic and economy-wide interactions to stimulate investment, and innovation for a common purpose. This was achieved by the government's use of its instruments of procurement, price schemes, and grants. Mazzucato proposes this mission-oriented approach for addressing the big issues as outlined in the Sustainable Development Goals, building on the idea that the state can create and shape markets to work for public goods rather than only address market failures. This is a pertinent model when it comes to health—a sector filled with private players, such as private health service providers and pharmaceutical companies, companies with products that stand against health recommendations or contributing to the determinants of health, for instance, by affecting pay, working conditions, and the environment. Community Wealth Building is a people-centred approach to local economic development in which local government shapes and creates markets locally. Some key principles as implemented in the UK are: changing procurement of goods and services to support local supply chains, supporting the development of local enterprises that are accountable and responsive to the local population, and improving recruitment and employment conditions. In their paper, Rose and colleagues evaluated how the introduction of a Community Wealth Building programme in 2015 in Preston affected mental health and welfare indicators. In 2010, Preston was in the top 10% of the most disadvantaged areas in the UK; the Office for National Statistics has estimated that the prevalence of depressive symptoms is more than double in the most deprived regions in England compared with the least deprived. Rose and colleagues found that, compared with areas with similar characteristics to Preston, the introduction of Community Wealth Building was associated with lower antidepressant prescribing and depression prevalence. There was also an increase in life satisfaction and median wages. While mental health indicator improvements were moderate, there might be further effects that the study does not cover, such as health-risk behaviours, living conditions, and access to a better start to life for children. For instance, income changes that could result from wage increases have been associated with improvements in mental health and wellbeing, especially when these can lift individuals out of poverty; the observed increases in wages could therefore have a longer-term positive effect on health outcomes. Reducing health inequalities is a public health cornerstone. Ambitious or even long unthinkable goals can be achieved with a mission-oriented approach that harnesses governments’ tools. Reorienting governments and economies to work for missions that offer public goods for societies will be key to achieving the Sustainable Development Goals and reducing inequalities. The Community Wealth Building in Preston shows the feasibility and effectiveness of such approaches at the local level. The mental health and wellbeing impact of a Community Wealth Building programme in England: a difference-in-differences studyDuring the period in which the Community Wealth Building programme was introduced, there were fewer mental health problems than would have been expected compared with other similar areas, as life satisfaction and economic measures improved. This approach potentially provides an effective model for economic regeneration potentially leading to substantial health benefits. Full-Text PDF Open Access