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Policies to tackle inequalities in child health: why haven't they worked (better)?
  1. Catherine Law,
  2. Chloe Parkin,
  3. Hannah Lewis
  1. MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK
  1. Correspondence to Catherine Law, MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK; Catherine.Law{at}ucl.ac.uk

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The UK Labour Government that came to power in 1997 had issued a pre-election promise to investigate and tackle inequalities in health.1 The new government also championed policies to promote children's well-being and life chances. Both policy stances were in stark contrast to those of the preceding administration, under whom child poverty had risen to record levels2 and inequalities in mortality had widened.3 Such stated commitments to both children and equity were unprecedented and so it is particularly important to assess whether these commitments, and the policies which flowed from them, resulted in a reduction in child health inequalities, and if not, why not.

The new direction in policy for health inequalities stimulated commentary and analysis.4,,7 Recently, Johan Mackenbach, a respected Dutch commentator on health inequalities, has analysed the overall strategy to reduce inequalities under the Labour Government (1997–2010). He argues that, despite being the first European country to adopt a ‘systematic policy’ to reduce health inequalities, England's strategy did not succeed, and he offers a number of explanations for this.8 9 In this paper we focus on how the Labour Government's strategies for children, as well as health inequalities, impacted on child health inequalities.

Health inequalities are the “virtually universal phenomenon of variation in health indicators (eg, mortality rates…) in association with socioeconomic status and ethnicity”.10 (Such variation can also occur by other characteristics such as gender, age and disability, but the focus of this paper is socioeconomic inequalities, reflecting that of the Labour Government.) Inequalities in health are largely preventable, and therefore, unfair.11 They are particularly unjust for children, to whom any emphasis on individual responsibility for health (as opposed to a social determinants approach) should not apply. Children cannot, for instance, exercise personal responsibility for their own birth weights, choose whether or not to live with a parent who smokes, or take action to alleviate their families' poverty. That health inequalities vary between otherwise comparable countries indicates they are responsive to social, cultural and policy differences. For example, Sweden has almost eliminated inequalities in infant mortality through policy intervention, while inequalities persist in other European countries with similar economic development.12

At the beginning of the Labour administration, child health inequalities were pervasive. For example, in 1995 the incidence of breastfeeding in all manual occupational groups was 60% compared to 80% in non-manual groups.13 In 1998 road traffic casualties among children under 15 years of age were 447 per 100 000 in the most disadvantaged fifth of areas compared to only 307 per 100 000 in the least disadvantaged.14 Furthermore, differences were seen not just between the best and the worst off but across the whole distribution of advantage. For many measures of morbidity, mortality and health-related behaviours there was a gradient of risk, such that rates of adverse measures increased with disadvantage.3 The social determinants of health were also a cause for concern. In 1996/97, 26% of children lived in relative poverty,15 34% lived in poor housing16 and 8% of pupils obtained no GCSE high school examination passes or equivalent.17 Health inequalities had effectively been off the political agenda for 18 years.

The new Labour Government of 1997 set about trying to tackle health inequalities. It commissioned an independent scientific inquiry,3 created inequalities in health targets18 and put in place a wide range of policies, brought together in 2003 under ‘A Programme for Action’.19 At the same time it prioritised promoting children's life chances, ‘Every Child Matters’ subsequently becoming the main ‘umbrella’ under which policies for children were collated.20 Some policies tried to tackle the health inequalities themselves. For example, there were initiatives to increase immunisation rates and early antenatal care for disadvantaged groups in an attempt to reduce inequalities in infant health.21 Other policies addressed the determinants of poor child health, such as obesity22 or parental smoking.23 There were also policies to improve the social determinants of health, the so-called ‘causes of the causes’. These included making hitherto unprecedented commitments to eradicate child poverty24 and to raise educational standards.25 Taken individually and as a whole there was much in these policies to commend. There was a life-course approach to tackling health inequalities, commitment to the evidence base and the social determinants of health, and recognition of the gradient in health and disadvantage. The policies featured cross-government commitments and inter-sectoral working at local level. Policies were both ‘horizontal’ (across sectors) and ‘vertical’ (addressing different levels of influence).

So, after 13 years of policy effort, did health inequalities reduce? Disappointingly, the answer is not an unequivocal yes. Some inequalities reduced, some widened and some stayed the same. For some indicators, relative inequalities widened but absolute inequalities decreased. In their review of progress published in 2009, the Department of Health noted that most of the policy commitments had been implemented. However, while there had been “significant improvements in… health… over the last 10 years… Health inequalities between different groups and areas… persist”. Child health inequalities generally mirrored this pattern.15 So why did these policies not work better?

First, perhaps the target was wrong. The main target for child health inequalities was to reduce the difference in infant mortality rates between jointly registered infants as a whole and those from manual classes.18 This difference was already quite small, and the target excluded groups such as infants registered by only one parent or those whose parents' occupations were classified as ‘other’ (largely those who had been long term unemployed), who had far higher mortality rates and who were reasonably the focus of public health and clinical practice.5 Over the period of the last government infant mortality inequalities as measured by the target widened, before narrowing to levels similar to those in 1997.26 However, some other measures of child health and well-being also showed persisting inequalities over 1997–2010,15 so it is unlikely that the apparent failure of policy was simply failing to pick the best overall measure of it.

Second, perhaps the wrong policies or the wrong entry points for policies were chosen.8 For example, it was assumed that reducing child poverty through any means would reduce child health inequalities, without a clear articulation of the mechanisms through which this would be achieved. The main policy chosen to reduce family poverty was to encourage one or both parents into paid employment.24 If parents, particularly mothers, return to work when their children are small, their children's health might benefit from increased income from employment and high quality day care (if affordable and accessible). However, there are also potential health disbenefits from reduced time for parenting, such as lower chances of breastfeeding and possible exposure to poor quality child care.27

Third, the balance of policies to tackle social determinants of health and those to tackle individual behaviour may have been suboptimal. As progress on health inequalities remained difficult, the Department of Health focused increasingly on interventions where it could have direct control, such as health services and social marketing.21 This had the effect of prioritising interventions directed at individuals such as ‘Change 4 Life’,22 rather than tackling the disadvantaged environments which shape families' behavioural choices.

Fourth, many policies aimed primarily to raise standards for the whole population rather than particularly raise standards for children living in disadvantage. While taking a progressive universalism approach in specific cases, ‘Every Child Matters’, as its name signified, sought to promote the life chances of all children. Educational achievement, for example, increased for all children over the decade from 1999, including in marginalised groups such as looked after children. However, although absolute inequalities in educational achievement between looked after children and the population as a whole decreased over this decade, relative inequalities increased.28

Fifth, the scale and the timescale of the policy effort, although unprecedented, may have been insufficient.9 For example, by 2010 there was meant to be a Sure Start Children's Centre in every community (3500), but in 2005 there were only 350, and they were not systematically reaching the children who were most vulnerable.29 ‘Every Child Matters’ and ‘A Programme for Action’ were published well into Labour's second term of office, so many of the policies they set out were implemented over only a few years, not over the entire Labour administration. Linked to this, it was perhaps over-optimistic to think that intergenerational cycles of problems with complex aetiology such as low birth weight, smoking and unemployment, could be broken in a few years. Early intervention is crucial to addressing both child and adult health inequalities, but it is likely to require sustained action over time, and some effects (such as those on adult chronic disease) would not be expected for many years.3

Sixth, perhaps the context was wrong. Income inequalities, which are associated (although not necessarily causally) with health inequalities, were not the subject of policy action and were unchanged or even widened over the period Labour were in power.8 Finally, underpinning these problems was the weakness of the evidence base, particularly on how to tackle the gradient of health inequalities across the whole population.11

Mackenbach has concluded that “reducing inequalities in overall health is currently beyond our means”.8 He argues that it would take a greater redistribution of resources than the UK population would be prepared to tolerate, and so is politically untenable.9 However, many child health professionals believe that doing nothing is not an option. What action would be helpful?

First, child health professionals can make health services part of the solution, not part of the problem, by ensuring that services are accessible and equitable. Second, they can ensure that the education and training of staff includes understanding the causes of and solutions to child health inequalities. Third, they can build the evidence base, by taking part in or facilitating information gathering and research which addresses the extent of, and trends in, child health inequalities, tests how to reduce them, or seeks to understand the complex causes. Fourth, they can be advocates, both in their workplaces and society more generally, to change the culture in which inequalities in children's health are accepted as inevitable or even normal.30 31

In the UK, health for children has improved, but it has not become more fairly distributed. Inequalities in health have complex causal pathways and changes in health outcomes can rarely be attributed to specific policies. Over the last decade or so, the wrong policies – often focusing too much on overall health improvement rather than reduction of inequalities – implemented on an inadequate scale for insufficient time periods all may have contributed to the persistence of child health inequalities. Unfair enough in themselves, child health inequalities also reflect wider inequalities in children's life chances which jeopardise their futures. Learning from the past may enable fairer lives for all children in the future.

References

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Footnotes

  • Competing interests None.

  • Funding The Centre for Paediatric Epidemiology and Biostatistics was supported in part by the Medical Research Council in its capacity as the MRC Centre of Epidemiology for Child Health. Research at the University College London Institute of Child Health and Great Ormond Street Hospital for Children receives a proportion of funding from the Department of Health's National Institute for Health Research Biomedical Research Centres funding scheme.

  • Provenance and peer review Commissioned; externally peer reviewed.

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