Economic development and health policy

Report to the Public Health Advisory Committee, National Health Committee

 

Associate Professor Philippa Howden-Chapman and Dr Ralph Chapman,

Maarama Consulting[1]

 

February 2004

 

Table of Contents

 

1      Introduction. 2

1.1       Background. 2

1.2       Approach. 3

1.3       Structure of the report 4

2      A model of economic development and health. 5

2.1       Introduction: definitions and caveats. 5

2.2       A simple model 6

3      Analysis of relevant economic development frameworks. 9

3.1       Introduction. 9

3.2       The Growth and Innovation Framework. 9

3.2.1         Information and Communication Technology. 10

3.2.2         Biotechnology. 11

3.2.3         Employment and health/well-being. 13

3.3       ‘The Inclusive Economy’ 15

3.4       The Sustainable Development Programme of Action. 18

3.4.1         Sustainable Cities. 19

3.4.2         Energy. 20

3.5       The New Zealand Transport Strategy. 22

4      Conclusion. 26

References. 27


1    Introduction

 

1.1     Background

 

While the Public Health Advisory Committee of the National Health Committee has commissioned a number of reports looking at aspects of the social and economic determinants of health, the role of economic development issues and policies has not been considered in detail in relation to health.  Moreover, although the NHC has supported the use of frameworks for more careful evaluation of the health effects of proposed policy (‘health impact assessment’)[2], some of the policy linkages between economic development and health remain relatively unexplored.[3]

 

This can leave health policy analysts at a disadvantage in terms of engaging with emerging economic policy discussions, and less able to take advantage of strategic opportunities to influence policy development in a way which advances health outcomes.

 

The recent Sustainable Development Programme of Action (POA) published by the New Zealand Government is a major step forward in explicitly calling for improved policy integration.  Two of the principles of the POA stand out in this context:

 

·        Seek innovative solutions that are mutually reinforcing

·        Use the best information available to support decision making.

 

The first suggests that economic development policies which advance or reinforce desired health outcomes should be given greater impetus and prominence (e.g. transport or other economic development policies supporting healthier and more ‘livable’ cities), and are of special interest, as are policy approaches which avoid or minimise trade-offs.  The second implies, in the present context, that economic development policies should be analysed comprehensively, using the best possible information about impacts on health and well-being.  For example policy decisions about infrastructure; about occupational health and safety; about policies which impinge on lifestyle choices; and about policies which influence the environment should all be considered for their health impacts. This analysis should ideally include assessment of the intangible impacts of system design.  Examples of this might be the intangible impacts of transport and education strategies on lifestyle and consumption habits.[4]

However, such comprehensive aspirations may provide limited immediate help.  It is necessary to be selective in order to make progress within the constraints of the practical policy world.  Accordingly, this paper steps back from the wide scope of interactions between economic development and health, and asks where policy development resources (such as background analysis of policy) might be best allocated in order to take advantage of opportunities currently or prospectively arising.[5]  Some simple criteria for focusing our gaze are suggested in the next section.

 

1.2     Approach

 

The question we focus on in this paper is what current and developing strategic frameworks are being used to steer economic development, and how might those frameworks be shaped to include important health impacts.  This is an aspect of the larger policy debate about what economic development factors most contribute to improving outcomes in terms of health and well-being. 

 

Accordingly, an assessment is made of the key current areas of debate (in New Zealand) in relation to economic development and health, and the magnitude of health impacts.  Aspects of economic policy frameworks and decisions of little significance for health, either short or long-term, are set aside.

To provide an underpinning to such analysis of health impacts, and guide the conceptualisation of these impacts, this paper sketches (in section 2) a simple model of the main ways in which economic factors interact with health and well-being outcomes. 

 

Second, this paper provides an outline analysis of where the main economic development frameworks being used at present within government may have significant health outcome implications, and where they might therefore be better linked to health gains. 

To focus the scope, the role of health services is excluded.  However, a broad view of health is employed. 

 

At any time, there are numerous initiatives within government aimed at advancing economic development in various ways, so it is necessary to be selective.  In particular, frameworks such as the Programme of Action for Sustainable Development have major implications for health which we sketch.  The analysis includes policies flowing from these strategies, in areas such as urban sustainability and infrastructure development.  The aim is to guide analysis towards the principal “currently active” areas where policy development could generate significant gains in terms of health outcomes, including some shorter-term policy priorities.  

 

1.3     Structure of the report

 

Section 2 of this report defines health for the purposes of this report, and provides an outline model of how key aspects of economic development impact on health.

 

Section 3 provides an exploratory analysis of the several key policy frameworks being used and refined within government, in relation to economic development, which have implications for health outcomes, including a summary of the health implications of recent key ‘think-pieces’ or strategies (including the Growth and Innovation Framework; the Treasury’s ‘Inclusive Economy’; and the Programme of Action for Sustainable Development).

 

Section 4 sets out brief recommendations as to key policy areas to be further explored, which are likely to generate health gains.

 

2     A model of economic development and health

 

2.1     Introduction: definitions and caveats

 

In this section we first characterise health and economic development policy for current purposes, and then identify, and sketch the principal interlinkages between, the various economic development influences on health. 

 

Health can be interpreted as a state of physical, mental and social well-being.  This broad view is consistent with that outlined by Mason Durie[6], as Te Pae Mahutonga.[7]  However, people outside the health area often see health as one element of well-being, connected to other elements.  Well-being in this sense is akin to the economists’ notion of welfare.[8]  For example, the authors of the Six Cities report, and more recently the Eight Cities report, stress the interconnectedness of health and other social, economic, environmental and economic factors affecting citizens’ quality of life,[9] and others have seen well-being as including elements such as consumption of goods and services, security and community.[10]

In the policy context, use of a broader notion of well-being tends to be more useful in tracing connections and improving understanding on which to base policy.  Such a broader view is consistent with a ‘sustainable development’ approach to policy.

 

Economic development is a very wide canvas so, for practicality, this paper focuses on the subset of aspects of economic development given weight in current government development strategies.   In practice, this essentially means that economic development policy can be interpreted as aspects of micro-economic policy (including policy relating to natural and human-made capital) contributing to New Zealand’s economic development.  Macro-economic policy issues of monetary and fiscal management, taxation, globalisation and trade are excluded, as they can affect health and well-being outcomes (indirectly) but raise complex issues which go beyond the scope of this project.  Also beyond the scope of this project are social and human capital development policies[11], and research and development policy.  However, economic development policy frameworks relating to employment, infrastructure development, transport and energy are covered.  We have drawn the line to exclude narrower economic development policy frameworks such as the Biosecurity Strategy.[12]

2.2     A simple model

 

Figure 1 below presents a simplified model of how various forces impact on well-being, including personal health.  It makes (implicitly or explicitly) the following points:

 

Some elaboration of and comment on this highly simplified model is necessary:

 

 

 

 

 

There continues to be a range of views on the extent of the significance of inequalities for health.[21]  Recent economic debate around the World Development Report (2000) has focused on the evidence about the impact of inequality within countries.  In New Zealand the debate about income inequality has also focused on the degree to which this is confounded by the interaction between economic position and ethnicity.[22] Nonetheless, at a macroeconomic level, it appears that the distributional and other impacts of trade, employment and related policies remain very important influences on health.[23] 

 

3     Analysis of relevant economic development frameworks

 

3.1     Introduction

 

This section examines the following principal economic development frameworks of relevance to health outcomes, and which are currently being used to guide public sector policy development in New Zealand, are:

 

3.2     The Growth and Innovation Framework

 

The 2002 Growth and Innovation Framework (GIF) represents the Government’s primary statement of economic strategy.  At a high level, the GIF takes social and environmental goals explicitly into account.  It states that “the government does not believe we can put on hold social and environmental progress” and “Not only will social and environmental policy continue to be given high priority in their own right, but the choice of economic policy instruments will be influenced by their interaction with social and environmental factors.  Sustainability will be paramount”[25] (emphasis added).

 

This is a clear statement that the Government does not see economic development as preceding, or being a precondition for, or being more important than, social or cultural development or environmental protection.  The dimensions should, implicitly, all be advanced together. Where economic development encounters short-term tensions between dimensions of well-being (e.g. between health outcomes and economic development), there is no presumption that economic development should have priority.

 

In effect, the GIF points to an interest in and emphasis on complementarities between social and economic policies (and outcomes).   A major complementarity is between income growth and social development – prosperity which facilitates a higher quality of life, for example.  At the same time, there are also less obvious ways in which complementarities emerge from the GIF’s priorities, and which might therefore represent opportunities to be identified and taken up when policy in these areas is being developed.  

 

In particular, we examine (below) issues in two of the three “enabling sectors critical to New Zealand’s future” - the areas of information and communication technology (ICT), and biotechnology.   Before doing so, however, it is worth noting that the GIF itself is almost silent on the links between economic development and health and well-being.  However, a passage does note some linkages in one direction – namely that a healthy population is an important foundation for sustaining our economy.[26]  It notes that the key priorities (as of 2002) are re-establishing community involvement in health decision making, introducing a new primary care strategy, and taking other actions relating to health services (such as investing heavily in mental health).  

 

The GIF also focuses on developing skills as the primary mechanism to contribute to economic development.  A strong case can be made for effective employment policies – which include skill development policies – because of the beneficial impact of employment on health.  While a comprehensive analysis of the literature on this topic is beyond the scope of this project (and, we understand, is partly covered elsewhere in NHC work), we sketch below the nature of some important links between employment and health and well-being, especially the linkages between employment of the most vulnerable and health outcomes for this group.

 

3.2.1   Information and Communication Technology

 

ICT has some potential to contribute to health and well-being outcomes through social inclusion and opportunity, especially if it can contribute to employment in rural and disadvantaged areas.  ICT can contribute substantially to innovation and economic development[27] and may also contribute to social connectedness, although the international evidence on this is less clear, and is likely to depend on policy actions.[28]   While ICT contributes to productivity across all sectors, there is some Australian evidence that ICT can make a particularly positive contribution to multifactor productivity growth in the cultural and recreational services sector; this may be of particular value in the New Zealand context, given the emergence and potential of our creative and tourism industries.[29]

 

In terms of social inclusion, an important issue is access by a range of groups in the community to ICT, to enable fuller social participation.  This includes both low-income groups and some ethnic groups in urban areas,[30] and rural groups, such as farmers and small-town communities, for whom the tyranny of distance can be mitigated to an extent by ICT.   For many in rural communities, ICT links may enable the use of e-commerce options to increase diversity, and contain costs, of supplies, and to access wider markets.  It may help rural communities to remain sustainable in an economic sense, as e-commerce and teleworking arrangements underpin employment (e.g. through internet marketing and facilitation of local eco-tourism).  These opportunities depend on adequate infrastructure supporting affordable internet access.   Even if e-commerce does not reverse the movement of skilled people to urban centres, and enrich rural communities again,[31] ICT investment may help maintain the viability of regional communities and be a significant issue for the health of otherwise declining rural communities and inhabitants. 

 

The Government’s ‘Connecting Communities’ strategy supports communities’ access to ICT. The vision of the Government is that “all New Zealanders, either as individuals or as members of communities, have the opportunity to access and efficiently use current and emerging information and communications technologies.”  This initiative is potentially useful, for example, in facilitating job placement and skills development, so it is appropriate that the Government’s Employment Strategy stocktake notes its contribution.[32]

 

While there are some specific environmental health issues relating to ICT infrastructure, in particular the possible health implications of the location of cellphone towers in urban areas, the magnitude of these health implications is likely to be small.

 

 

3.2.2   Biotechnology

 

Biotechnology has aptly been described as a horizontal technology[33], or series of technologies – it has applications across many other sectors, such as forestry, agriculture, specialist food production and pharmaceuticals.  It goes well beyond genetic modification, for example, and includes areas such as microbiology and biochemical engineering.  Its breadth means that it has a variety of implications for health and well-being, although these implications are so diverse as to impede easy characterisation.

 

A first general question to be posed of biotechnology investment is what is the nature of the expected benefit to the health and well-being of New Zealanders, what are the associated risks, and how might the benefits and risks be managed to New Zealanders’ overall advantage? 

 

The Government’s Biotechnology Strategy was released in May 2003, and begins to address these questions.   It vision is that “New Zealand responsibly develops and applies our world-class biological knowledge, skills, innovation and technologies to benefit the wealth, health and environment of New Zealanders, now and in the future.”  The principles of the strategy include commitments to focus on outcomes which benefit the wealth, health and environment of New Zealanders, and safeguard our well-being through identification and management of the risks and uncertainty.  Effective regulation and public consultation – conducted in a manner which builds trust but does not stifle innovation - are identified as critical requirements.

 

From a policy viewpoint, while both the benefits and risks of biotechnology need to be recognised, it is not clear that the potential health benefits of biotechnology regularly warrant special government intervention on public good grounds (to a greater extent than, say, general medical research investment).  Within an effective legal framework encompassing intellectual capital protection, the companies undertaking biotechnology research can generally be expected to be able to gain a return from their investments, whether they generate health or other benefits.  An exception to this can occur where there is demonstrated public good health benefit arising in promising lines of research, and in such cases, there may be a public benefit arising from taxpayer support.  This does not constitute a case for special treatment of biotechnology firms, including pharmaceutical companies, however.[34]  To ensure that health and well-being benefits are captured and supported requires that health agencies track and evaluate developments in the biotechnology ‘sector’, while maintaining rigorous independence from the sector.

 

On the other side, the longer-term health risks associated with some forms of biotechnology require consistent and long-sighted policy attention, as part of the portfolio of social research which should accompany any radical new technology.  Many risks and uncertainties may not emerge into sharp relief without investment in their careful consideration.  An eminent international scholar on these issues, Wynne (2003), has noted:

 

“…New Zealand appears to suffer some similar blind-spots to most other international partners. Thus for example with the exception of the UK’s recent investments, very little research has yet been funded anywhere on the social, ethical and cultural implications of current scientific knowledge-production processes such as the new disciplines of proteomics, metabolomics and their connections with genomics and with ‘whole -organism’ and environmental behaviours. These become interesting for social research on the ways in which their intellectual culture may become inadvertently too narrow to be able properly to address environmental (and even whole-organism) questions and uncertainties, and to integrate effectively with salient ecological and social knowledge.”

 

Debate on the Biotechnology Strategy points to a need for greater trust in a rigorous regulatory system and opportunities for input into public policy issues, cultural and ethical matters, with use of a precautionary approach.[35] At the same time, it is important that the regulatory regime is not unduly complex.

 

At an institutional level, and looking beyond the building blocks such as the effective operation and updating of the HSNO Act, and maintaining public trust in agencies such as ERMA,[36] a critical element of this process is to ensure that health agencies participate in the coordination of policy regulation and ethical standards relevant to biotechnology, including working with agencies such as MfE, which is also responsible for supporting Toi te Taiao, The Bioethics Council, and overseeing ERMA; MAF, MoRST, and DOC.  There is an important role for health agencies to liaise closely with MORST in its regulatory oversight role with respect to biotechnology.

 

Food biotechnology development illustrates some of these implications. The WHO is currently conducting a study[37] of the implications of modern food biotechnology for health and development.  Key issues include:

This agenda lists some of the issues which New Zealand regulatory authorities are likely to need to have clear answers on in years to come, not only to be able to demonstrate that New Zealand food consumers are being protected, but also to be able to demonstrate that New Zealand food products are able to meet forthcoming international scrutiny, whether ‘legitimate’ (in terms of, for example, health and environmental risk) or ‘artificial’ (for example, disguised barriers to trade). 

 

3.2.3   Employment and health/well-being

 

Evidence has been emerging for some time that there are strong and diverse linkages between employment on the one hand, and health and well-being on the other.  This does not imply, of course, that there is necessarily good evidence in respect of the efficacy of policy interventions, for example youth apprenticeships and other active labour market programmes.  A recent OECD study of active labour market programmes, for instance, pointed out that:

“ …‘outcomes’, in the [active labour market policy] evaluation literature, are invariably expressed in terms of program impacts on future earnings and/or re-employment prospects of participants, and this stress is reflected in this paper.  There is little or no evidence available on social benefits such as reduced crime, less drug abuse or better health.”[38]

 

This lack of published evidence on social benefits appears also to hold for New Zealand employment programme evaluation.[39]

 

The GIF places emphasis on various programmes, particularly under the headings of:

It would be desirable if provision is made, as the “Growing more talent” investment programmes are further developed, for their outcomes to be comprehensively evaluated, and – where appropriate - health and well-being gains associated with improved employment patterns to be included in the evaluations.  This also holds for other initiatives under the Government’s 2000 Employment Strategy, in particular the “Work-Life Balance Project”, and actions towards Goals 6- 8 (which all relate to social exclusion through lack of employment).  Wider well-being is an obvious objective in respect of all these programmes.[40]  A further refinement would be research to evaluate aspects of employment quality which may be associated with health outcomes, including work-related health problems, such as work stress.[41]

 

There are good reasons to believe that enhancement of employment prospects, however achieved, is generally important and positive for health and well-being.  This relationship is acknowledged by New Zealand policy agencies.[42] As a background to the consideration of effective policy, the following paragraphs review some key findings on the linkages between employment and health outcomes.

 

Employment security and related factors have long been seen to have an impact on health:

 

“Economic instability and insecurity increase the likelihood of immoderate and unstable life habits, disruption of basic social networks, and major life stresses - in other words, the relative lack of financial and employment security of lower socio-economic groups is a major source of their higher mortality rates.”[43]

 

The question of causation is, however, problematic.  There is considerable recent debate about the meaning of the association between unemployment and health and the possible causal pathways.[44]  Unemployment could be a direct result of ill health among the unemployed.  It may be the result of the higher levels of disease in those who lose their jobs and, once having been made unemployed, find it difficult to regain secure employment.  Or it could be an indicator of an indirect selection effect, whereby a single spell of unemployment signals an insecure work history.  This in turn is more likely to be associated with lower levels of educational attainment and perhaps relatively poor working conditions and low pay.  These conditions are independently associated with health risks or lifestyle risks such as heavy alcohol consumption and smoking and are likely to be cumulative over a lifetime.

 

Nonetheless, studies tend to show higher rates of ill health, both psychological[45] and physical, in women and men who are in insecure work[46] or are unemployed.[47] Several studies in Scandinavia and New Zealand have shown that the mortality of the unemployed is higher than that of employed persons,[48]even if they are later re-employed.[49] During economic recessions, when more people are unemployed, the health effects are less marked (the unemployed stand out less) than in more prosperous times when unemployment levels are low.  A protracted period of unemployment at a young age seems to have a particularly deleterious effect on the mental health of young men, regardless of their social background.[50] This suggests, for example, that policies which maximise employment opportunities for, and minimise social exclusion of, young men may be particularly valuable in terms of health impacts.

 

3.3     ‘The Inclusive Economy’

The 2001 Treasury report, ‘The Inclusive Economy,’ focuses on improving well-being and argues that the “overriding objective” of government in an inclusive economy is to enhance well-being by directing policy to ensure that there are broad-based opportunities to participate in society and economy.[51]  While the report is light on the link from economic development to health outcomes (or what role health policies, rather than education and labour market policies, might have in expanding such opportunities), it does point to some conclusions in relation to health outcomes that policy advisers could usefully give greater prominence.

 

The report’s key conclusions indirectly relevant to health (defined as an element of well-being) are as follows:

 

The report also makes two important points about health and well-being: one relates to assessment of the impacts of growth and economic liberalisation; the other concerns the health of the disadvantaged.

 

In relation to growth and liberalisation, a strong finding relevant to health and well-being is that growth usually creates winners and losers, as resources shift from declining to expanding sectors, skill categories or regions.  The report notes that this means that the fruits of growth can turn out to be unevenly distributed, with particular individuals and groups suffering relative or absolute losses alongside others who experience improving fortunes. This can cause social tensions and divisions.[52]  

 

Globalisation and greater openness can also place strains on the social fabric.  Thus, it is important to consider, in policy discussion of the factors that influence economic performance, those factors’ positive and negative impacts on social capability.  These points service as ‘health’ illustrations of a more general conclusion the report reaches – which is that the need for social cohesion requires that the social consequences of economic growth should be predicted and built into policy thinking.

 

In relation to the health of the disadvantaged, the report makes the point that effective health-promoting policy should focus at least as much on the material living standards

of the least well off, particularly their children, their level of educational attainment and the social networks and supports present in communities, as on health services.[53] The report draws on some international evidence to explain how providing effective public services and infrastructure to, and job opportunities for, the poor can enhance their health and well-being.

 

In a more recent follow-up of the Inclusive Economy work, Treasury[54] has produced an evaluation of initiatives aimed at “Investing in Well-being.”  They note that:

 

“This paper represents a preliminary overview of issues at the heart of the well-being of children and young adults in New Zealand. It has only begun to bring together the evidence and insights necessary to operationalise a social investment framework. Much remains to be done to strengthen and deepen understanding of the causal relationships between childhood and adulthood, and, in particular, the factors underlying poor states of well-being in New Zealand; and the evidence from both New Zealand and elsewhere of the effectiveness of interventions.”

 

Despite this, the report does point to some further evidence relating to the benefits of investing in disadvantaged children.[55]  In this, it reinforces the conclusion of the Inclusive Economy report that there is a continuing need for effective policies – both targeted and universal – which work for the least well off, particularly at-risk children.

 

Some policy initiatives may work from health and employment factors to better social and economic outcomes which in turn improve health outcomes.   One important mechanism is social exclusion.  There is evidence that there is an interaction between education and qualification levels, and exclusion from the labour market at times of recession, a mechanism which can contribute to social exclusion.[56] This matters particularly where unemployment reduces eligibility for various forms of social assistance.

 

Recently, government initiatives have been announced which are aimed at increasing the participation of women in the workforce.  The Prime Minister stated in her 10 February Statement to Parliament that raising women’s participation could increase incomes significantly (although it may reduce welfare from ‘home production’ and other activities).[57]  A closely parallel situation arises with health- and disability-related barriers to participation in the workforce – these too can constrain opportunities and reduce income levels and standards of living.  For example, where primary care availability and effectiveness for disadvantaged groups has a positive impact on employment outcomes, there is likely to be a wider gain in terms of health and well-being outcomes.

 

3.4     The Sustainable Development Programme of Action

 

The Government has stated its commitment to sustainable development, described in its 2003 Programme of Action (POA) as a different way of working which involves looking after people, taking a long term view, taking account of economic, environmental, social and cultural impacts and encouraging participation and partnerships.  More recently this has been summarised as seeking progress across a quadruple bottom line – with economic, social, cultural and environmental dimensions – in which none takes precedence over the others.[58] 

 

An important part of the POA is working in partnership with local government, and working in a transparent and participatory manner.  Under the Local Government Act 2002, local authorities have clear and overarching sustainable development responsibilities.[59]  Local government also has obligations under the Resource Management Act to promote sustainable management and avoid, remedy or mitigate adverse effects.  In general, sustainability requires the active input and support of local communities of interest, and attitudinal changes to accompany behaviour more consistent with sustainable outcomes.   

 

There are three key issues identified in the POA which constitute aspects of economic development – sustainable cities, energy, and freshwater quality and allocation. All three have important implications for health. 

 

We examine two of them here.  Water is not covered, given that it has been the subject of another recent NHC investigation.  Suffice it to say here that important health and sustainability-related questions arise in respect of urban water systems including the issue of how well community water supplies meet drinking water standards, and environmental issues with longer-term health impacts such as how the abstraction of water affects critical catchments and aquifers; and in respect of sewerage and wastewater treatment (where significant environmental impacts can occur, with a risk that certain economic and socio-cultural activities may be compromised by pollution from wastewater facilities).

 

3.4.1   Sustainable Cities

 

The overarching goal set out in the POA for sustainable cities is that “our cities are healthy, safe and attractive places where business, social and cultural life can flourish.”[60]

 

The sustainable cities work within government is at an important formative stage at present.  It principally comprises work on:

The Urban Affairs Strategy,[61] currently being developed, will set out the Government’s view on the priority urban issues and actions and the management arrangements for central government – i.e. it will be a strategy for the ‘whole of government’ management and coordination of urban affairs.  It will be focused on implementation and governance at a national government level.  The aim is to have the strategy adopted by June 2004, following consultation across the whole of government and with key stakeholders.

The Urban Design Protocol[62] work aims to promote discussion and agreement at a national level about ways to improve the urban design of our cities and towns.  It aims to provide a high level framework for identifying and addressing the most effective outcomes for New Zealand cities and towns.  Thus, it will not be a planning guide or a series of regulations focusing on detailed design issues but instead will focus on “developing broader objectives that set desirable outcomes for the way New Zealand urban areas should be designed and the methods for realising them.”

The sustainable cities regional programme focuses so far on the Auckland region as the first candidate for action, and is a joint undertaking between government agencies and local government in Auckland.  The programme identifies a joint action plan and a series of projects over a three year period, covering principally:

 

Again, it is a ‘whole of government’ programme involving a range of agencies. Overall responsibility rests with the Department of Prime Minister and Cabinet, the Ministry of Economic Development and the Ministry for the Environment.

 

Current policy development work on sustainable cities has a number of important implications for health outcomes – especially in relation to sustainable transport, sustainable buildings and sustainable urban design.   Sustainable transport is discussed in section 3.5 below. 

 

To illustrate some of these connections, consider the links between sustainable urban design and form, on the one hand, and health outcomes on the other.  Internationally there is a rapidly growing body of evidence on this relationship.[63] One of the most interesting conclusions emerging is that peripheral urban development may be associated with increasing rates of physical inactivity and (hence) increasing obesity.[64]

 

Work on ‘sustainable buildings’ (buildings consciously designed to be more energy-efficient and more comfortable environments) has recently accelerated in the US and other countries, with more work also taking place to quantify the variety of benefits which accrue - including savings form distributed energy (heat, power and cooling) generation; reduced waste, and water costs, lower environmental and emissions costs, lower operations and maintenance costs, and savings from increased productivity and health.[65]  In fact, it is likely that the sheer diversity of benefits of such building design, along with inevitable uncertainties in the health and productivity benefit estimates, are major reasons for the slow take-up of such designs. It is only when the whole range of benefits is considered, and a dollar value range estimated for benefits, that the case for ‘greener’ buildings tends to become persuasive.  Lovins (1999) notes that “the 6 to 16 percent labor productivity gains in efficient buildings -- due to their superior visual, acoustic and thermal comfort—are typically worth at least ten times more than the energy savings themselves, but are absent from all economic models of whether building proprietors will improve their energy efficiency.”[66]

 

Similar considerations apply in respect of ‘green housing’ – i.e. more environmentally sustainable housing design.  Indeed, green housing can be thought of as a subset of green building, albeit an important subset given that people spend 90% of their lives indoors. 

 

3.4.2   Energy

 

Energy is clearly an important component of economic development, and has significant implications for health outcomes.  Energy is not prominent in the GIF, but is identified as an important element of the Sustainable Development Programme of Action principally because of the long-term environmental and social impacts of energy production and use. 

 

Globally, the most important connection between energy and health is via climate change.  The International Energy Agency projects a 57% increase in the predominantly fossil fuel based global energy demand over the next 20 years.[67] New Zealand contributes – to a small extent – to the production of energy-based greenhouse gas (GHG) emissions: our per capita emissions were in 2000 just over 8 tonnes per capita of CO2 per year (dramatically less than, for example, the USA’s, at over 20 tonnes, or even Australia’s, at 17 tonnes, but more than some Scandinavian countries such as Sweden, at 6 tonnes).[68] 

 

There is not a direct link between New Zealand’s emissions and New Zealanders’ health, since GHGs are not a local but entirely a global atmospheric pollutant.  That is, effects felt in New Zealand are largely due to emissions from other countries. For this reason, although New Zealand is a participant in international efforts to stabilise the climate by reducing GHG emissions, climate change mitigation cannot be argued to be an immediate health policy issue at the domestic level within New Zealand.  In the medium term, however, and perhaps sooner rather than later, adaptation issues are likely to arise in New Zealand.[69]  That is, there are likely to become evident increasing health and safety issues around the impacts of climate change on New Zealand, and strategies for adapting to that impact – for example through flood protection.  Liaison between health agencies and the Climate Change Office, and ongoing assessment of impacts and the effectiveness of adaptation policies, will be important as an adaptation strategy is developed and the first stages are implemented over the next few years.

 

Probably the most important aspect of energy production and use with a bearing on health outcomes, and which is also subject to active policy development in New Zealand, is the use of energy in transport systems.  This is addressed below (section 3.5). 

 

In addition, however, non-transport energy production can have localised health impacts, particularly where air quality is affected.  Effects may also extend to loss of amenity (e.g. visual or noise-related).  These are handled under the provisions of the Resource Management Act, which requires local authorities considering resource consents to ensure that adverse environmental impacts are avoided, remedied or mitigated.  

 

A significant further issue, associated with energy use patterns, with implications for health and well-being is ‘fuel poverty’.  So far, little work has been carried out on this in New Zealand, and there is a case for it being given greater policy attention, for example along the lines of the UK’s approach.[70] 

 

Fuel poverty can be defined as arising where households spend more than a reasonable proportion of their incomes (say 10%) to heat their homes adequately and affordably.  This is caused by a number of factors including fuel costs, low earnings, and the energy efficiency of the dwellings involved.   More work is needed on the extent of this problem in New Zealand, the mechanisms for addressing it, and the extent of the benefits (including health and social inclusion benefits) from solving it.  

 

In the UK, the 2003 Energy White Paper, which sets out an energy strategy, identifies addressing fuel poverty – “ensuring that every home is adequately and affordably heated” – as one of four energy goals for the UK.  This is premised on the view that “policies should take account of impacts on all sectors of society. Specific measures are needed for particular groups of people (for example to support those for whom energy bills form a disproportionate burden).”   Clearly, fuel poverty is not exclusively a health issue, and there are inevitably debates about what agencies are best placed to address it.  In the UK, the conclusion to date has been that work across a number of government agencies – together with energy suppliers and local government - is necessary to ensure that national and local policies on benefits, health and housing, and appropriate implementation efforts, can succeed in alleviating fuel poverty.[71]

 

3.5     The New Zealand Transport Strategy

 

The Minister of Transport placed considerable emphasis on sustainable development in his foreword to the Government’s transport strategy (December 2002): 

 

            “[The strategy] is about creating a sustainable transport system that is also affordable, integrated, safe and responsive to our needs.” [72]

           

The strategy’s statement of principles lists sustainability and safety (alongside the principles of integration and responsiveness), with prominent themes being resilience/ flexibility:

 

·                    “Sustainability: To ensure that transport is underpinned by the principles of sustainability and integration, transport policy will need to focus on improving the transport system in ways that enhance economic, social and environmental well-being, and that promote resilience and flexibility. It will also need to take account of the needs of future generations, and be guided by medium- and long-term costs and benefits.”

·                    “Safety: To ensure that transport is underpinned by the principles of safety and responsiveness, policy will need to ensure high standards of health, safety and personal security for all people, including users, workers, and operators.  It will also need to ensure there is a robust health and safety framework, complemented by an emphasis on individual and business responsibility.”

 

Significantly, the transport strategy notes that the changes of recent decades, while increasing efficiency, “by and large ignored the broader linkages between transport and other issues such as regional development, urban form and social cohesion”. Addressing these issues is a central challenge.  

 

In transport funding and transport policy development, the factors to be considered have been broadened by the NZTS, and are listed as the five key objectives of the strategy (emphasis added below):

 

 

This set of objectives has now been translated into legislation in the Land Transport Management Act 2003.  The aim is to progress all five outcomes in parallel,[74] but significantly more emphasis is given to social and environmental issues than has been the case in previous transport policy statements.

 

The Ministry of Transport’s 2003-2004 Statement of Intent identifies health issues associated with road congestion, road safety and vehicle emissions, as an important part of the medium-term transport ‘picture’:

There is now evidence that health considerations are starting to influence policy advice in respect of transport, ‘on the ground’ – for example, the Joint Officials Group report on development of a sustainable transport strategy for Auckland found a ‘package’ developed by Auckland authorities “wanting” on health grounds among others, and explicitly included health as an important criterion in formulating its preferred approach.[75]

 

However, by contrast, the Government’s Health Strategy remains weak on transport-health linkages. For example, walking and cycling are not mentioned once in the Strategy.  Goal 4 (A healthy physical environment), mentions public transport (“Support policies that improve access to public transport”), and there is general mention of environmental hazards (“Reduce the adverse health effects of environmental hazards”), but – surprisingly – there is no mention of encouraging physical activity through active travel, e.g. through walking and cycling.[76]  The most that can be said is that at least physical activity is mentioned in the context of Healthy Lifestyles (goal 6).

 

There is a large volume of international evidence (e.g. Litman, 1999; WHO, 2000; Woodward et al, 2002; Sunyer et al, 2003) that private vehicle transport generates very substantial external costs, most of which are health costs in either a narrow or wider sense (see, for example, Table 1 below).

 

 

Table 1: The external costs of transport in the EU, Norway and Switzerland, 1995

Source: World Health Organisation (2000), p39.

 

 

 

In New Zealand, there are widespread concerns about whether the adverse external effects of road use and congestion are being comprehensively and adequately assessed, especially in Auckland.  For example, how much does transport system quality affect perceived urban quality of life?  This turns on factors such as the social and environmental externality impacts of traffic noise, vibration and air pollution, but there are also equity and other social impacts of urban road congestion in Auckland.   However, not only are there concerns about the extent of health impacts, there are concerns about the quality and nature of the possible solutions (e.g. more road construction) which may be deployed to address perceived transportation issues.  In short, there are clearly a wide range of health and quality of life implications arising in respect of both health impacts of transport and the choice of policy instruments used to address these issues.

 

A related transport policy debate concerns the external costs and benefits of more active modes (walking, cycling, public passenger transport) and the case for travel demand management and promotion.  Substantial central and local government work is taking place at present on the transport dimension of ‘sustainable cities’ (see section 2.4.1 above).  This essentially follows from the Health section of the Transport Strategy (chapter 5), which states, for example, that “Walking and cycling for short trips will be promoted and reduced dependence on private vehicles for mobility is encouraged.”

 

This is highly desirable given the inadequate attention in the past to sustainability and health issues around transport systems (and associated urban design issues).  Tangible and effective policies are needed, both at central and local government level, to address the links between:

 

4     Conclusion

 

This exploratory assessment has examined a number of current ‘microeconomic’ policy strands with implications for the interface between economic development and health outcomes.   It has drawn on international and New Zealand literature, and available information on the state of play in respect of the policy issues in New Zealand. 

 

Health outcomes are mentioned very rarely in the policy frameworks covered.  However, our assessment leads us to conclude that there are some significant linkages between economic development, well-being and health which warrant further analysis and reporting by the National Health Committee.  These areas of economic development are ones in which there are both significant real interconnections – in the form of risks to health or benefits to health from appropriate investment – and also some current policy momentum which provides an opportunity for the health implications to be teased out, and initiatives developed. 

 

We see four priority areas:

 

Across all these areas, there is a continuing need for effective policies which address inequalities, in terms of income, occupation, ethnicity and region, and which work for the consistently least well off, particularly at-risk children. 

 

 

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