Social Science & Medicine 101 (2014) 61e69

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Public social monitoring reports and their effect on a policy programme aimed at addressing the social determinants of health to improve health equity in New Zealand Frank Pega a, b, *, Nicole B. Valentine c, Don Matheson d, Kumanan Rasanathan e a

Department of Public Health, University of Otago, PO Box 7343, Wellington, New Zealand Department of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, United States Department of Ethics and Social Determinants of Health, Health Systems and Innovation Cluster, World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland d Centre for Public Health Research, Massey University e Wellington Campus, Private Box 756, Wellington, New Zealand e Health Section, United Nations Children’s Fund (UNICEF), 3 UN Plaza, New York, NY 10022, United States b c

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 15 November 2013

The important role that monitoring plays in advancing global health is well established. However, the role of social monitoring as a tool for addressing social determinants of health (SDH) and health equityfocused policies remains under-researched. This paper assesses the extent and ways in which New Zealand’s (NZ) Social Reports (SRs) supported a SDH- and health equity-oriented policy programme nationally over the 2000e2008 period by documenting the SRs’ history and assessing its impact on policies across sectors in government and civil society. We conducted key-informant interviews with five senior policy-makers and an e-mail survey with 24 government and civil society representatives on SRs’ history and policy impact. We identified common themes across these data and classified them accordingly to assess the intensity of the reports’ use and their impact on SDH- and health equity-focused policies. Bibliometric analyses of government publications and media items were undertaken to empirically assess SRs’ impact on government and civil society. SRs in NZ arose out of the role played by government as the “benevolent social welfare planner” and an understanding of the necessity of economic and social security for “progress”. The SRs were linked to establishing a government-wide programme aimed at reducing inequalities. They have been used moderately to highly in central and local government and in civil society, both within and outside the health sector, but have neither entered public treasury and economic development departments nor the commercial sector. The SRs have not reached the more universal status of economic indicators. However, they have had some success at raising awareness of, and have stimulated isolated action on, SDH. The NZ case suggests that national-level social monitoring provides a valuable tool for raising awareness of SDH across government and civil society. A number of strategies could improve social reports’ effectiveness in stimulating action on SDH. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: New Zealand Health policy Social determinants of health Health equity Social monitoring Social reporting

Introduction To improve health equity, international organizations, governments and civil society need to develop an understanding of health inequities and implement policies leading to action on social determinants of health (SDH) beyond the health sector (CSDH, 2008). The World Health Organization (WHO) Commission on Social Determinants of Health (CSDH) emphasized the vital role that * Corresponding author. PO Box 7343, Wellington, New Zealand. E-mail address: [email protected] (F. Pega). 0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.10.043

monitoring plays in improving health equity with its third overarching recommendation that stressed the need “to measure and understand the problem and to assess the impact of action” (2008, p. 2). Supporting the implementation of the Commission’s recommendations, the Rio Political Declaration on Social Determinants of Health (WHO, 2011) pledged actions “to monitor progress and increase accountability” (p. 6) as one of five action areas. The SixtyFifth World Health Assembly (2012) passed a resolution urging Member States “to implement the pledges made in the Rio Political Declaration on Social Determinants of Health” (p. 2), reiterating the importance of monitoring progress.

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To implement the recommendations of the WHO resolution in all action areas, including monitoring, countries require evidence on policy programmes that tackle SDH and improve health equity (Can health equity become a reality?, 2008; The Sixty-Second World Health Assembly, 2009; WHO, 2011). The Commission’s final report documented the effectiveness of several monitoring tools in supporting a SDH- and health equity-focused policy program (CSDH, 2008). Experience on global and national monitoring of health equity (CSDH, 2008) and the realization of the right to health (Backman et al., 2008; UN, 2006) is increasing. Policy-makers are becoming more interested in monitoring SDH. One aspect of monitoring that has received comparatively little attention in the framework of monitoring SDH is social monitoring. Social monitoring is “the production and provision of socially relevant information including their presentation” (Habich & Noll, 1994), generally relating to the “economic, political, cultural and socio-psychological aspects of human actors and systems” (Lass & Reusswig, 2002, p. 5). Monitoring SDH, health equity and the realization of the right to health therefore falls within the scope of social monitoring. Social reporting is a social monitoring tool that aims to provide “information on social structures and processes and on preconditions and consequences of social policy, regularly, in time, systematically, and autonomously” (Zapf, 1977, p. 11). Since the introduction of social reporting in the 1960s as part of the social indicator movement (Bauer, 1960), numerous international organizations and governments have produced global and national social reports such as the United Nations (UN) the Human Development Report and United Kingdom the Social Trends reports (Noll, 1996). Social reporting is generally guided by internationally ratified definitions and measurements of social conditions, processes, determinants and outcomes (UN, 1954, 1989). In recent times, social indicators and broader indicators of development have been harmonized and integrated across international organizations’ and states’ mandates, such as in the Millennium Development Goals (UN, 2001, 2003). They have also received more prominence in the Report of the Commission on the Measurement of Economic Performance and Social Progress (Stiglitz, Sen, & Fitoussi, 2009), which debated the inappropriate use of some national income metrics and the potential for use of different metrics to enhance understanding of quality of life. Whitehead’s (1998) Action spectrum on inequities in health theorizes that evidence (e.g., from social reports) translates into comprehensive coordinated policy action via recognition, followed by awareness-raising, will to take action, isolated initiatives and more structured developments, but can also fail to generate action through mental block or denial/indifference. Professional, political and organizational divisions within and between policy institutions are also theorized to hinder translation of evidence into action (Smith & Joyce, 2012). Literature on the impact of social monitoring and reporting on health policy development suggests that social indicators inform health policy development and service planning (Gorman & Labouvie, 2000; Herman-Stahl et al., 2001; Sherman, Gillespie, & Diaz, 1996; Steinmeyer, 2001). The up-take of social report findings is most widespread among organizations involved in producing the reports (Wong et al., 2000). Despite the broader literature affirming the role of social reports, little research exists on their application in the context of SDH- and health equityfocused intersectoral policy programmes. This paper explores the extent and ways in which the annual Social Reports (SRs; Ministry of Social Development [MSD], 2001) supported a policy programme aimed at addressing SDH to improve health equity in New Zealand (NZ) in 2000e2008. The underlying research questions were To which degree does social monitoring contribute to action on health inequities at the national

level? and How must such information be presented and disseminated to catalyse action? To address these questions, the paper documents the history of SRs with a particular emphasis on their inclusion within intersectoral health policy initiatives oriented towards SDH and health equity. The policy impact of SRs is assessed by examining both their general use and explicit focus on SDH- and health equity policy programming in government and civil society. Lastly, the lessons learned from the NZ experience are considered in terms of their relevance to similar efforts taking place in other countries. Methods Describing SRs’ political history Ethical consent for the study was granted by the World Health Organization (Contract ID: OD/AP-08-01583). We searched scientific databases (Academic Search Complete, MEDLINE, Social Sciences Citation Index) for literature on SRs’ political history in December 2012. We were particularly interested in how SRs were initially introduced and what major changes they underwent throughout their development and up until, 2008. Drawing on the literature on SRs’ history in relation to SDH and health equity policy development, we wrote a draft description of the SRs’ evolution within policy programming in NZ. To validate our description, we conducted five key-informant interviews with senior managers in the NZ Ministry of Health (MoH) and MSD (where SRs are produced). We designed individual questionnaires for each key informant to cover their area of expertise and institutional knowledge about SRs (available from the authors on request). The first questionnaire section focused on the reports’ history and relation to health policy. We briefed key-informants about all aspects of the study and interview. All key-informants granted written informed consent to participate in the study. We conducted semi-structured, face-to-face interviews between 45 and 90 min in duration between February and March, 2008. The interviews were audio-taped and transcribed verbatim. Drawing from the information provided in the interviews, we validated and refined our description of SRs’ political history. Finally, three experts on SRs and health equity policy reviewed and further validated our description. Assessing SRs’ policy impact Assessing general use The first step to assess impact on policy was to examine how intensely SRs have been used across sectors and organizations in government and civil society. This initial examination enabled us to identify sectors and organizations in which SRs were not used, which therefore could be excluded from policy-impact analysis. We collected information on how SRs were used by policy-makers across sectors and organizations in government during the keyinformant interviews, as described above, under the second section of the questionnaire. To inform our assessment of SRs’ use among those relevant government departments that we had not gathered sufficient information about in key-informant interviews (treasury and economic development departments and local government) and in civil society, we conducted an email survey with potential SRs users from these groups. We designed and pre-tested a nine-item questionnaire. In our selection of survey participants, we sought potential SRs users at the senior level of their organization. We ensured that our sample of civil society participants was representative across community, health, social and commercial sectors within NZ society. We selected and distributed the email survey to thirty-two eligible participants in May, 2008. Of these, twenty-four

F. Pega et al. / Social Science & Medicine 101 (2014) 61e69

participated in the study. Table 1 presents the sample by sector and organizational affiliation. We conducted a thematic analysis (Daly, Kellehear, & Gliksman, 1997) of interview and survey data to assess the intensity of SRs’ use in policy-making. We applied Braun and Clarke’s (2006) approach and guidelines for thematic analysis and adhered to Seal and Silverman’s (1997) guidelines for ensuring rigour in qualitative public health research. Our thematic analysis was datadriven, semantic and realist, whereby events were reported as they were experienced by the participants themselves. At an early stage of the data analysis, we developed basic classification criteria according to the themes identified from the data (Fig. 1). These criteria align with the SRs’ objective “to help identify key issues and areas where action is needed, which can in turn help with planning and decision-making” (p. 7, MSD, 2001). We then systematically applied these criteria to the data to assess the intensity of general use of SRs across sectors and organizations. We also conducted bibliometric analyses as a way to infer impact through changes in policy outcomes. These analyses were based on the rationale that SRs’ impact on a respective department or sector could be gauged by the frequency with which SRs were cited in government publications and media items. We searched web pages of five key NZ central government departments (that is, Department of Prime Minister and Cabinet, The Treasury, and Ministries of Economic Development, Health and Social Development), as well as local governments, including 21 district health boards (local health authorities responsible for ensuring the provision of health and disability services to populations within a defined geographical area) and 72 local authorities (11 regional, 50 district and 11 city councils). Search parameters were set to include any 2000e2008 publications (briefing papers, discussion papers, white papers, media releases) that contained the words ‘social report’. We determined bi-annual publication numbers of the identified publications per department or sector. We then searched the Factiva database for 2001e2008 media items referring to ‘social report’. We determined the bi-annual number of sources quoted from different sectors (government ministers, academics/researchers, businesses, community organizations, health advocacy organizations) of the items citing SRs. Assessing impact on a SDH- and an intersectoral health equityfocused policy programme We collected information from the key-informant interviews (third questionnaire section) and from the email-survey (questions 1e3) about the extent and ways in which SRs had raised awareness and stimulated action on SDH and health equity across government

Table 1 Sector and organizational affiliation of email survey participants. Sector Community

Health

Social Commercial Central Government Local Government TOTAL

Organizations ori Iwi (tribes), urban Ma Pacific Islanders People living with disability Health advocacy District Health Boards Public health research Welfare service providers Social policy research Business associations Chamber of commerce The Treasury, Ministry of Economic Development City council District councils

Number of participants 3 1 1 3 2 1 2 3 2 1 2

Intensity

63

Criterion

of use No use

Reports were not used

Low use

Reports were used in a minor way in relation to the core business of the organization (e.g., in policy organizations: Reports were used for ad-hoc statistical reference, but not for strategic planning and budget decisions)

Medium

Reports were used sporadically in the core business of the organization

use

(e.g., in policy organizations: Reports were used sporadically in strategic planning and budget decisions)

High use

Reports were an integral part of the core business of the organization (e.g., in policy organizations: Reports were an integral part of strategic planning and budget decisions)

Fig. 1. Classification of intensity of general use of the social reports.

and in civil society. We used Whitehead’s (1998) theoretical framework described above to assess the intensity of SRs’ support of SDH and health equity policies. This framework was selected as it describes distinct stages from generating awareness to health equity to developing a comprehensive and coordinated health equity-focused policy programme. It has previously been used to assess progress of a health equity policy programme in Norway (Strand, Brown, Torgersen, & Giæver, 2010). Based on Whitehead’s model, we developed a classification scheme for assessing the intensity of policy impact of SRs on SDH- and health equity-focused policies (Fig. 2). Again, these criteria align with SRs’ objective of providing a basis for strategic planning and decision-making (MSD, 2001). We then systematically applied the classification criteria to the data. We further report factors that participants identified as limiting SRs’ impact on SDH- and health equity-focused policy-making. To infer SRs’ impact on a SDH- and health equity-focused policy programme in the media, we determined the proportion of the Factiva-indexed media items referring to SRs that reported health inequalities. Results The SRs’ political history The SRs’ history can be divided into three phases: Growing interest and support for social reporting (1970se1990s); establishment of SRs (2001); and refinement and consolidation of SRs (2002e2008). Building momentum NZ has a history of strong social welfare policy (McClurke, 1998). The interest in the establishment of SRs was publicly documented

Intensity of policy

Criterion

impact Low impact

Reports were not used to generate awareness or stimulate action on the SDH to achieve health equity

Medium impact

Reports raised awareness to health-equity or raised political will

High impact

Reports stimulated action in the form of isolated initiatives to

to take action

address the SDH to achieve health equity Very high impact

Reports stimulated action in the form of significant and structured initiatives

1 2 24

Fig. 2. Classification of intensity of impact of the social reports on a SDH- and health equity-focused policy program.

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in the early 1970s. In 1972, a report by the Royal Commission on Social Security defined what social well-being meant for NZers. In 1974, the Social Development Council developed and published a set of eight objectives that focused on increasing social well-being and quality of life, urging the government to establish a social indicator system to monitor social outcomes. In 1976, the government responded by setting up the Social Indicator Unit in the Department of Statistics. This unit developed an interim list of social indicators aligned with the social objectives of the Social Development Council and social indicator sets developed by the Organization for Economic Co-Operation and Development (OECD) (Department of Statistics, 1978, 1980). In 1979, the Department of Statistics convened a two-day workshop on social indicators for development in collaboration with the National Commission for the UNESCO, which provided a link to research on international social indicators. This workshop culminated in a proposed collection of key indicators for the eight objectives put forward by the Social Development Council (Cant, Hill, & Watson, 1979). In 1988, the Royal Commission on Social Policy updated definitions of social well-being and reiterated earlier calls for systematic national social reporting. These early endeavours were interrupted in the 1980s and 1990s by successive governments aiming at social welfare reform aligned to neo-liberal economic policy (Crothers, 2006; Evans, Grimes, Wilkinson, & Teece, 1996). The 1998 Code of Social Responsibility that advocated a pledge of “personal responsibility” marked the peak of this trend of moving away from social welfare approaches (Davey, 2000). These reforms were associated with increased health inequities such as widening ethnic and socio-economic disparities in mortality (Tobias, Blakely, Matheson, Rasanathan, & Atkinson, 2009). Crothers (2006) has argued that social indicator work languished during this period as government “actively endeavoured to suppress any systematic information about the social consequences of its economic policies” (p. 3). Establishing the SRs The Labour-led Government elected in 1999 reshaped the dominant focus on economic growth as a measure of progress to include the achievement of social outcomes. Reducing inequities became a central policy concern, and the MSD was established. As part of this policy reorientation, the government enacted the government-wide “Closing the Gaps” initiative (later called “Reducing Inequalities”), which was initially led by the Department of the Prime Minister and Cabinet and eventually the MSD (Minister of Social Development and Employment, 2003). In NZ’s public health sector, the initiative manifested in the MoH’s “Reducing Inequalities in Health” strategy (2002a), which aimed “to assist the health sector to implement a population health approach that will improve the overall health of the population and ori Health” strategy reduce health inequalities” (p. 2), and the “Ma ori are the Indigenous people of NZ; 2002b), which aimed for (Ma “M aori families [to be] supported to achieve their maximum health and wellbeing” (p. 1). Both strategies understood health disparities as caused by the unequal distribution of SDH and were implemented widely across the public health sector. In 2001, the MSD was charged with leading the development of a social reporting scheme (Cotterell & Crothers, 2011; Crothers, 2006). The ministry developed (with the help of many other government departments) and launched the first SR within a few months (Cotterell & Crothers, 2011; Crothers, 2006). The SR was conceptually grounded in findings from the two previous national Royal Commissions on Social Security and Social Policy (MSD, 2001). It detailed, over time and in comparison with OECD reference populations, 43 indicators spread over ten social well-being domains (Web Appendix 1), including health (MSD, 2001).

Refining the SRs Following the release of the first SR, the reporting scheme underwent a two-year phase of development and evaluation informed by nationwide public and stakeholder consultations (MSD, 2002). The evaluation found that SRs were almost universally supported, but identified the need to continue them as a regular series, linking them directly to regional information and integrating them more explicitly into policy and action. Major improvements to SRs followed the evaluation, with the government committing to annually publishing SRs in 2003 and regional-level SRs in 2005 (MSD, 2005). Between 2003 and 2008, the reports were refined and updated, while retaining their overall structure. Social indicator measures were refined, and new data sources were incorporated. Attempts were made to include compulsory reporting mechanisms for these social indicators within formal government accountability systems (MSD, 2002), but proved unsuccessful. The reports continued to monitor trends in social well-being for the populations mainly targeted by the “Reducing Inequalities” policy. By 2008, the government-wide “Reducing Inequalities” initiative had mostly been abandoned, with several equity-focused policy groups dismantled, including in the MoH. Over the course of the implementation of the “Reducing Inequalities in Health” strategy, health ori (and Pacific respectively) and noninequalities between Ma ori, non-Pacific New Zealanders initially widened and then Ma started to close (Tobias et al., 2009). The SRs’ policy impact Use of the Social Reports In government. Two key informants reported that Cabinet and the Department of the Prime Minister and Cabinet used SRs extensively for strategic purposes and decision-making (high use). For example, key informant 4 noted the important role that SRs had played in Cabinet meetings, “where Ministers need to look across the whole area of social policy and indeed beyond that to integrate what is happening in society, the economy and the environment”. Moreover, Cabinet Ministers were quoted eighty-four times, as sources in Factiva-indexed media items citing SRs, comprising onefifth of all sources quoted. Ministers having cited SRs included the Prime Minister (eight times) and Ministers of Social Development ori Affairs (seven), Pacific Island Affairs and Employment (55), Ma (seven), Health (three), Finance (three) and Housing (one). However, no concrete examples of policies influenced by SR use were reported. Three key informants reported that the MSD used the reports for strategic planning and decision-making, as well as for monitoring progress on the “Reducing Inequalities” initiative (high use). The MSD published the largest number of reports referring to SRs among the studied central government departments in 2007 and 2008 (Fig. 3). The three key informants from the MoH reported that the ministry valued SRs for providing information on SDH, but used them only moderately, mostly to access reference information on SDH and seldom for strategic planning and decision-making (medium use). Several survey participants commonly (four times) listed local government as a sector in which SRs were most current. Additionally, one key informant and two participants from local government reported that local governments regularly used SRs to support strategic development and planning (high use). The high use of SRs resulted from statutory requirements for local governments to use social indicators in their planning (Informant 3). Local government organizations published the largest number of reports citing SRs in 2007 and 2008. Two participants from DHBs reported

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Fig. 3. Bi-annual number of government publications citing social reports, 2001e2008.

that DHBs used SRs to inform needs assessments and service planning, although generally to a limited extent and often as reference information only (medium use). Four key informants expected treasury and economic development departments to use SRs. This expectation is highlighted in the perspective from Informant 4 who stated: They [The Treasury and Ministry of Economic Development] fully recognize that the purpose of the markets is to produce wellbeing in the end and that if you don’t have a healthy, educated population, you are not going to have much in the way of international competition. (text in brackets added by authors) However, two survey participants from these departments reported that SRs were used for ad-hoc statistical reference only (low use). As Participant 23 stated: The greatest value of the Social Report is that it creates an opportunity for formalizing the use of indicators and developing a more systematic tool for assessing the impact of social policy.

In civil society. Civil society sources comprised 43% of all sources of 2001e2008 media items indexed in Factiva and citing SRs. Survey participants most often (six times) listed health advocacy organizations as civil society groups most commonly using SRs. The three participants from such organizations reported using SRs to inform advocacy activities, such as influencing SDH at central and local government levels, and international reporting (high use). However, health advocacy organizations did not feature prominently as sources in Factiva-indexed media items citing SRs (Fig. 4). Survey participants also commonly (six times) listed universities and research organizations as SR users. All five academics and researchers who participated in the survey reported regularly using SRs for teaching, research and publicly raising awareness (high use). According to four key informants and one survey participant, media covered SRs widely (high use). Media coverage increased from radio only initially to extensive television coverage (Informant 3). Confirming study participants’ assessment, the Factiva database search identified 122 articles from major NZ newspapers citing SRs over the 2000e2008 period. The number of media items citing SRs tended to increase over time. A MSD key informant concluded: We are in the niche we wanted to be positioned in: One of those slightly boring, but worthy things that the news feels like they have to report on, like the Reserve Bank lifting interest rates.

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Fig. 4. Bi-annual number of sources of Factiva-indexed media items citing social reports, 2001e2008.

Four survey participants from community organizations knew ori tribal) authorities had of SRs, but only the two from Iwi (Ma used them for tribal, strategic and service planning (medium use). ori community health organizations made little use of SRs Ma (Informant 5). However, community organizations were a prominent source of Factiva-indexed media items citing SRs. Only 5% of 2001e2008 media items indexed in Factiva and citing SRs were published in business-focused newspapers, and businesses comprised only 3% of sources for these media items. None of the three survey participants from chambers of commerce and business associations had used SRs (no use). When asked how prominent SRs were in the business community, one of the participants representing a business association responded: “It has little influence”. Twelve survey participants answering the question, whether SRs had achieved equal status as prominent economic indicators, reported that they had not. For example, Participant 3 answered: The Social Report does not appear to have gained significant traction in shifting the paradigm from fiscal reporting to a greater emphasis on social reporting. Four participants expressed a contrary view. For example, Participant 22 said that SRs have “helped reset the balance enormously”. In summary (Fig. 5), SRs use was medium to high across organizations and sectors; however, SRs have neither entered treasury and economic development departments, nor the commercial sector.

Limitations. Study participants identified four factors as limiting the use of SRs. Firstly, SRs findings are not sufficiently linked to and transferred into policy and action, possibly due to lack of ownership and accountability for the different social domains. For example, Informant 1 said: If you come up with an indicator for a Social Report, who is responsible for it, who is actually accountable for it? That is one of the major disadvantages of the Social Reports. Secondly, SRs do not clearly indicate the inter-linkage and cause-effect relationships between their domains and indicators. This view was expressed by Informant 4: There is no sense of dynamics and there is certainly no sense of how the one domain interrelates quantitatively to other domains. [.] You still don’t actually have any direct, explicit information about

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Intensity of general use of the Social Reports No use

Low use

Medium use

High use

(not used for core business)

(used in a minor way)

(used sporadically)

(integral part of core business)

Ministry of Health

Cabinet

Government Ministry of Economic Development The Treasury

District Health Boards Department of the Prime Minister and Cabinet Ministry of Social Development

Civil society

Business Roundtables

Community organizations

Health advocacy organizations

Chamber of Commerce

Social service organizations

Researchers and academics Media

Fig. 5. Intensity of general use of the social reports in government and civil society.

the prospect. If you press this button at this point, precisely what will happen? Thirdly, SRs do not provide data about key target populations ori tribal) and disabled populations. such as DHB-area, Iwi (Ma Finally, SRs’ domains and indicators are still siloed, rather than synthesized into one index or a few more manageable indices. By what means and how much did SRs support a SDH and health equity policy programme? In government. Two key informants reported that SRs had increased the visibility of SDH and health inequities in Cabinet, Department of the Prime Minister and Cabinet and the MSD, motivating these users to consider how their policy-making influenced SDH and health equity (medium impact). The three MoH key informants reported that within the ministry SRs had validated and strengthened an intersectoral, SDH approach and refocused public health discourse to the root causes of health inequalities, rather than health care access inequalities alone (medium impact). They welcomed that another government department (MSD) took ownership of and promoted a determinants- and equity-based policy approach, thereby raising awareness to SDH in non-health sectors. As Informant 5 noted: It [the SR] is useful for [the Ministry of] Health because [the Ministry of] Health, especially [the] Public Health [Directorate], has always talked about the determinants of health and it is useful for us to have another agency actually owning their own activity and getting a better understanding about how that influences outcomes within our directorate. It has always been hard to have a conversation with another sector and say: ‘You are doing this and thereby impacting on our outcomes.’. Two key informants and one survey participant from local government reported that local governments had used SRs to stimulate isolated policy initiatives such as “focussing our organization’s interventions on the biggest gaps” (Participant 7; high impact). However, according to two DHB survey participants, SRs had not raised SDH and health equity concerns in DHBs, nor had they stimulated action (low impact). Two survey participants from treasury and economic development departments reported that SRs had not raised awareness of or stimulated action on SDH and health equity in these departments (low impact). In civil society. The three survey participants from health advocacy organizations reported that SRs had not raised SDH and health equity

concerns within their organizations, because “we have got the concerns already” (Participant 2). They had used SRs, which they saw as an important source of official statistics on SDH, to inform SDHfocused advocacy at local and central government levels (high impact). For example, Participant 8 had used SRs “to oppose various Council proposals to eliminate Council housing programmes” and “to argue for health impact assessment of significant government policies such as those involved in budget commitments”. Three participants from community organizations who knew of SRs said that SRs had not commonly increased awareness or stimulated action on SDH and health equity among community organizations (low impact). All five researchers and academics reported using SRs to raise public and academic awareness and encourage debate of SDH and health equity (medium impact). According to the three participants representing businesses, SRs had not raised such awareness among businesses (low impact). Nearly half of the Factiva-indexed media items published between 2001 and 2008 and citing SRs raised health equity concerns, suggesting that SRs raised awareness of health equity concerns among media workers (medium impact). In summary (Fig. 6), among their users, SRs have been successful at raising awareness and have stimulated some, albeit isolated, action on SDH and health equity. Limitations. Survey participants identified two ways in which SRs could limit efforts to improve SDH and health equity. Firstly, political interference could lead to misreporting of SDH and health equity data, with four key informants reporting cases of attempted ministerial interference in SRs. Secondly, extenuating reporting of positive trends could limit political will to improve health equity. For example, Informant 5 recalled concerns about reporting of ori/non-Ma ori inequalities in life expectancy improvements in Ma in a SR and explained: The reason why we were keen not to paint too rosy a picture, as was the concern that it had been painted too rosy a picture, was that we then had only just started the journey to improving or addressing inequalities. If the report said: ‘Well, we are doing fantastically’, now they could say to anybody else: ‘Well, we can take our foot off the accelerator.’

Discussion Our findings suggest that social reporting supported a policy programme aimed at addressing SDH to improve health equity in NZ. Establishing social reporting was related to a political climate in which social progress mattered and was closely linked to establishing a government-wide programme aimed at reducing inequities. Use of

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Impact of the Social Reports on the SDH and health equity-focused policy program Low impact

Medium impact

High impact

(did not raise awareness)

(raised awareness)

(stimulated isolated action)

Cabinet

Local governments

Government The Treasury

Ministry of Economic Development Department of the Prime Minister and Cabinet District Health Boards

Ministry of Health Ministry of Social Development

Civil society

Business Roundtables

Media

Chamber of Commerce

Health advocacy organizations Researchers and academics

Community organizations

Fig. 6. Intensity of impact of the social reports on a SDH and health equity-focused policy programme in government and civil society.

SRs was medium to high across organizations and sectors, but SRs had neither entered treasury and economic development departments, nor the commercial sector. Among their users, SRs were successful at raising awareness and stimulated limited action on SDH and health equity. However, the study also identifies several limitations of social reports that need to be overcome for them to better function as health equity policy tools. The study has several limitations. First, the key-informant interviews and email survey collected qualitative data on the perceived (not actual) policy impact of the SRs. However, these data are supplemented by bibliometric analyses seeking to quantify the SRs’ impact empirically, and findings from the qualitative and quantitative analyses support the same conclusions regarding policy impact. Second, the key informants, senior policy staff of some ministries centrally involved in establishing and developing the SRs, may have been interested in presenting the SRs’ impact overly positively. However, several key informants provided critical analysis and explicitly drew attention to several imitations of the SRs. Moreover, to balance the potentially biased accounts of key informants, the email survey provided data from several non-government sources (including civil society and businesses). The study finds that social reporting can be used to measure and understand the problem and to assess the impact of action (third overarching recommendation, CSDH, 2008) and monitor progress and increase accountability (fifth action area, Rio Political Declaration on Social Determinants of Health; WHO, 2011). Since social reports are established instruments and standardized across many countries (Noll, 1996), they present readily available, cost-effective tools for basic SDH and health equity monitoring. International harmonization and rationalization of social indicators in recent years will ensure across-country comparability of social report findings on SDH and health equity. In summary, social reports present an additional tool in countries with, and a useful monitoring tool in countries without, other SDH- and health equitymonitoring devices. For countries interested in investing in social reporting specifically for monitoring SDH and health equity, the description of the political systems, conditions and processes that produced social reports in NZ can be informative. Centrally, the NZ experience suggests that social reports can be established well when the political climate is supportive, but are not necessarily transformative instruments if the political landscape affords a low priority to equity and lines of accountability are not clearly articulated. To implement the CSDH’s (2008) recommendation to “place responsibility for action on health and health equity at the highest level of government and ensure its coherent consideration across

all ministerial and departmental policy-making” (p. 11), WHO Member States have committed to promoting better governance for health and development (Sixty-Fifth Health Assembly, 2012). This approach is known as health-in-all-policies or health-equity-in-allpolicies. The current study shows that SRs in NZ influenced the Cabinet and several governmental departments to consider SDH and health equity. This suggests that social reporting is a tool that government and civil society can use to work towards achieving SDH and health equity-focused policy-making. This study identified the need to develop social reports that have the potential to influence economic development and treasury departments, the commercial sector and budget allocations. Social inequities, under certain circumstances, constrain economic development (Commission on Macroeconomics and Health, 2001; Epstein, Jimenez-Rubio, Smith, & Suhrcke, 2009; Mackenbach, Meerding, & Kunst, 2007; McAdams, 2007; Suhrcke, Nugent, Stuckler, & Rocco, 2006). Consequently, improving SDH and health equity, for example, by creating more equitably distributed economic gain and health outcomes, can lead to improved economic performance. Explicitly drawing upon this link provides an opportunity to increase the perceived relevance of SRs to the economic and commercial sectors, thereby reducing professional and political divisions preventing evidence from SRs to stimulate action (Smith & Joyce, 2012; Whitehead, 1998). For example, reporting the links between comprehensive early childhood education and economic benefit or budget allocations and social outcomes could contribute to the emerging evidence base on the interplay of social and economic factors and outcomes. Producing empirical research that further establishes these direct links could also have a positive influence on political will for addressing SDH. A third principal finding is that social reporting in NZ stimulated limited SDH- and health equity-focused action. Several study participants wanted SRs to be more closely linked to policy and action, which was echoed from MSD’s public and stakeholder consultation in 2002. Drawing on the international evidence and suggestions from key informants, we recommend seven strategies for ensuring that social reports effectively stimulate SDH- and health equityfocused action. First, a conceptual framework could be developed and included in social reports on the interrelationship and cause-effect relationship between social indicators and domains, and specifically the cross-links between health indicators and inequities. This framework would provide policy-makers with the rationale and guidance for targeted intersectoral policy and action. It could prevent the denial, indifference or mental block arising from professional, political and organizational divisions potentially preventing translation of SRs evidence into action (Smith & Joyce, 2012;

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Whitehead, 1998). We believe that the existing evidence is comprehensive enough to develop such a framework. However, initiatives such as the general social surveys of the NZ and Canadian governments will further grow the current body of evidence on the links between social indicators and domains. Second, social reports could be developed to include a small number of more manageable composite indices of the report’s social indicators. We endorse La Rosa, Dubois and Tonnellier’s (2007) claim that social indices are vital for raising awareness about the social responsibility for health. While composite indices are sometimes criticized as inaccurate or misleading, the widespread use of gross domestic product as a measure for economic progress, despite the indicator’s increasingly recognized limitations in scope and accuracy, shows the appeal of single indicators (Stiglitz et al., 2009). The social index that the German Federal State of Brandenburg has developed for its social and health reporting provides a timely precedent and confirms the technical feasibility of composite social indices (Bohm, Ellsasser, & Ludecke, 2007). Third, social reports could be more closely linked to public management accountability to stimulate greater action towards SDH and health equity. Based on experiences in NZ, Norway (Torgersen, Giæver, & Stigen, 2007) and Canada (Wong et al., 2000), we recommend making relevant agencies responsible for reporting on social indicators. We also recommend a parallel process by which relevant agencies are responsible for setting goals for their social indicators and then undergoing regular public consultation to review progress towards these goals. A case study from the United Kingdom showed that this second accountability step is crucial for the success of this strategy, whereby determinants targets were introduced across sectors, but were neither linked to an outcomes-framework nor publicly consulted on and therefore received no follow-up (Wanless, 2002, 2004). When social reporting is established, efforts should be made to ensure that performance indicators of chief executives, annual reports to parliament and statements of intent by different departments are required to specifically refer to social outcomes and reports. Fourth, legal instruments that require governments to use social indicators could be established to ensure accountability. This study found that legislation requiring local governments to plan, monitor and report on social indicators motivated the use of social reports and, in turn, to improve SDH and health equity at the local level. Further examples of potentially vital and prominent legal instruments requiring social indicators are statutory environmental and health impact assessments. Evidence for the effectiveness of these tools in changing policies is mixed (Wismar, Blau, Ernst, & Figueras, 2007). Arguably, legal requirements for health equity impact assessments are required to stimulate SDH and health equity-focused action. Fifth, social reports could be produced by departments with statutory independence (e.g., statistics departments), as suggested in an earlier SRs review (MSD, 2002), or by non-governmental organizations. Key informants of this study reported attempted political interference in social reporting. They identified this as a threat for SDH and health equity-focused policy-making, which echoed concerns also expressed by the public and stakeholders (MSD, 2002). Sixth, social indicators could be given higher status around joint or whole-of-government strategic plans. Specific incentives within cabinets could be created to promote specific social (non-financial) targets. For example, the Scottish Government’s (2009) national planning framework talks about a ‘wealthier and fairer, greener, smarter, safer and stronger and healthier’ Scotland. These types of development frameworks may be effective, but need leadership and continuous promotion. Similarly, the premier of South

Australia has set a series of targets to actively promote action on several key health determinants. The Norwegian (Torgersen et al., 2007) and South Australian (Kickbusch & Buckett, 2010) experiences show that the health sector needs to caste a health lens over these goals and assist other sectors in reaching them. Seventh, as a final, overriding strategy we recommend that countries work towards a joint government structure that can deliver on complex problems such as health inequity, in line with the 2010 Adelaide Statement on Health in All Policies (WHO). The NZ experience suggests, in line with Smith and Joyce’s theory (2012), that while social reports can present a whole-of-government view of social progress, action resulting from social indictors will remain weak, when government departments contributing to them remain fragmented. In NZ, each department has a single focus that is strongly reinforced by the incentives and power of the chief executives through the 1988 State Sector Act. The Scottish Government’s (2010) Equally Well outcomes framework sets joint goals across departments, showing a potential way forward in accountability for joint targets. The social reports are thus leading the concept of joint government action, although how different parts of government will operate still needs to be outlined. The question of developing a comprehensive social indicator needs to be accompanied by a similar riding instruction to the public sector to work towards the attainment of complex integrated social goals, across all spheres of government. Conclusions In NZ, the establishment of SRs was related to a political ideology focused on social progress, alongside economic development and linked to the establishment of a government-wide programme aimed at reducing inequities. SRs were used moderately to highly in central and local government and in civil society, but did not enter treasury and economic development departments, or the commercial sector. Among their users, SRs had success at raising awareness of, but stimulated limited action on the SDH and health equity. Acknowledgements We thank the key informants from the New Zealand Ministries of Health and Social Development and the survey participants for generously contributing their time and knowledge to this study. Professor Tony Blakely, Dr Kristie Carter, Professor Charles Crothers, Professor Peter Davis, Professor Philippa Howden-Chapman, Professor Ichiro Kawachi, Katelyn Merritt and Dr Orielle Solar provided feedback on drafts of this paper. Frith Williams and Katelyn Merritt provided assistance with editing the manuscript. This study was supported by the World Health Organization through a research grant (Contract ID: OD/AP-08-01583); the Royal Society of New Zealand through an International Travel Scholarship (grant no: ITF08-01); and Fulbright New Zealand through a Fulbright - Ministry of Science and Innovation Graduate Award (grant no: 15120390) to Pega. Appendix 1. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.socscimed.2013.10.043. References Backman, G., Hunt, P., Khosla, R., Jaramillo-Strouss, C., Fikre, B. M., Rumble, C., et al. (2008). Health systems and the right to health: an assessment of 194 countries. Lancet, 372(9655), 2047e2085.

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