Going upstream – an umbrella review of the macroeconomic determinants of health and health inequalities

Abstract

BackgroundThe social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions.MethodsNine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented.ResultsThe review found a large (n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations.ConclusionsThe results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review.Trial registrationProtocol for umbrella review prospectively registered with PROSPERO CRD42017068357.

An overview of the commercial determinants of health

“…Specifically, the business practices of corporations include, amongst other things, the control of the supply chain and market concentration (through mergers and acquisitions for example); labour practices; taxation payments and profits shifting; and the privatisation of utilities [1,13,15,41]. In 2018, Wiist explained that corporate tax avoidance, for example, leads to a shortage of public tax revenue that could be directed to public health purposes and other needs, such as education and housing [42].…”

“…These global drivers indeed influence the business, market, and political practices of corporations, therefore facilitating the manufacture, sale and marketing of unhealthy commodities [ 1 ]. Market-driven and neoliberal economies, globalisation, and the development of trade and investment agreements, amongst other factors, have for example contributed to the growing power of corporations in recent decades, but also to the ill-health for the population and planet [ 22 , 41 , 72 – 76 ]. Transnationals, in particular, control their markets in many countries, some markets being saturated, and others, in low- and middle-income countries, emerging [ 22 , 34 , 77 – 80 ].…”

The role of welfare regimes in the relationship between childhood economic stress and adult health: a multilevel study of 20 European countries

“…Research suggests that public social spending ( Hillier-Brown et al, 2019 ) and income inequality ( Naik et al, 2019 ) are social determinants of population health. These macro determinants vary by welfare states and are included to complement our regime approach ( Bergqvist, Yngwe, & Lundberg, 2013 ).…”

Using economic development to improve health and reduce health inequalities

“…39 Naik et al, 2019, reviewed the evidence on the influence of high-level economic factors such as markets, finance, the provision of welfare, labour markets and economic inequalities on people's health and health inequalities. 38 The authors found evidence that the risk of dying from any cause is significantly higher for people living in socioeconomically deprived areas than for those living in areas with high socioeconomic status. They also found good evidence that wide income inequality is associated with poor health outcomes.…”