1. To bold text: Use Futura Std Medium, and click B in formatting toolbar Health, social expenditure and inequality Findings from a cross-national empirical analysis 25 May 2016 Alex Sutherland, Jennifer Rubin, Jirka Taylor, Joachim Krapels, Charlene Rohr, Melissa Felician, Jodi Liu and Lois Davis

2. To bold text: Use Futura Std Medium, and click B in formatting toolbar Increased spending on healthcare in the US has not delivered the health outcomes seen in European countries Is social expenditure a key part of the health outcome story?

3. To bold text: Use Futura Std Medium, and click B in formatting toolbar 1. Population health and spending on health and social care: Bradley et al (2011) Bradley and Taylor (2013) 2. Social determinants of health: UK: Marmot et al (2008) US: Woolf and Laudan (2013) 3. Inequality and health: Wilkinson & Pickett (2006) Pickett & Wilkinson (2015) US: Woolf and Braveman (2011) 4. All of these…??? Relevant previous research

4. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Do wider contextual factors – like inequality or social capital – affect the findings? Do these relationships hold within a country, in this case the US?

5. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Do wider contextual factors – like inequality or social capital – affect the findings? Do these relationships hold within a country, in this case the US?

6. To bold text: Use Futura Std Medium, and click B in formatting toolbar How did we look at this? Collated thirty years of expenditure data as % of GDP from 34 OECD countries. About 800-1,000 observations depending on the measures. Combined this with data measuring: Health outcomes from OECD and WHO, for example: –Life expectancy at birth –Low birth weight –All-cause mortality Inequality: Gini coefficient & Palma ratio Social capital from the European Social Survey and World Values Survey. Additional data for sub-national analysis of the US came from the Bureau of Economic Analysis, National Vital Statistics System, Behavioural Risk Factor Surveillance System, Institute for Health Metrics and Evaluation, RAND State Statistics.

7. To bold text: Use Futura Std Medium, and click B in formatting toolbar We observed a significant association between social expenditure and health outcomes (as with Bradley and co.) Ratio of social to health as well overlaid – OR JUST SAY IT Variable Model 1Model 2Model 3 life expectancylog infant mortality% low birthweight Social spending % of GDPb0.05-0.020.02 se0.010.000.01 p0.00 0.06 Log GDPb7.87-1.121.35 se0.240.060.21 p0.00 Interceptb-3.3313.35-7.77 se2.480.622.14 p0.180.00 N country-years 319308312 rho variation between countries over time0.940.950.86

8. Incorporating a time lag increased the strength of relationships Results held when we included more countries, over longer time periods and tested multiple health outcomes Different ‘types’ of spending had different impacts – but not in the way we expected Public social expenditure by governments seems to have a particularly strong association with health outcomes

9. To bold text: Use Futura Std Medium, and click B in formatting toolbar Public social expenditure by governments seems to have a particularly strong relationship with health outcomes This table shows how many times larger the association between public-only expenditure was to each outcome, compared to public- private expenditure… Life expectancy Infant mortality % low birthweight All-cause mortality 3.62.34.03.2

10. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Answer: relationships appear robust to different approaches. Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Answer: type of social spending matters Do wider contextual factors – like inequality or social capital – affect the findings? Do these relationships hold within a country, in this case the US?

11. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Answer: relationships appear robust to different approaches. Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Answer: type of social spending matters Do wider contextual factors – like inequality or social capital – affect the findings? Do these relationships hold within a country, in this case the US?

12. To bold text: Use Futura Std Medium, and click B in formatting toolbar Wider contextual factors may also matter As social spending increases, inequality decreases (and vice-versa)

13. To bold text: Use Futura Std Medium, and click B in formatting toolbar Higher inequality is associated with an even stronger association between social spending and health outcomes So, social protection may be more important for health outcomes in more unequal societies Lower = better More unequal

14. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Answer: relationships appear robust to different approaches. Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Answer: type of social spending matters Do wider contextual factors – like inequality or social capital – affect the findings? Answer: other wider contextual factors may matter, particularly in how they interact with social expenditure Do these relationships hold within a country, in this case the US?

15. To bold text: Use Futura Std Medium, and click B in formatting toolbar The focus of our research How robust is the relationship between social expenditure and health? Answer: relationships appear robust to different approaches. Does the ‘type’ of social spending, i.e. on particular age groups or social challenges, influence the findings? Answer: type of social spending matters Do wider contextual factors – like inequality or social capital – affect the findings? Answer: other wider contextual factors may matter, but they do not have such a large impact as social expenditure Do these relationships hold within a country, in this case the US?

16. To bold text: Use Futura Std Medium, and click B in formatting toolbar Do these relationships hold within a single country? States that spent more on social programmes had better health outcomes. (Again, measured over time.)

17. A key limitation of the study is that we observe correlations, not causal relationships…and we focus on aggregate, not individual, outcomes Need to continue building our understanding of how individual circumstances and social contexts influence health outcomes So, where to now? Broaden analysis to incorporate other factors, eg education, immigration, ethnicity, race, poverty Deepen analysis to examine the role of the design and implementation of social programmes Need to evaluate real-life experiments of the impacts of social programmes, on individuals, and think more about ‘what works, for whom, and why?’

18. These findings appear to highlight associations strong enough and persistent enough to merit further investigation: What is the transmission mechanism? Should governments explore shifting expenditure from health systems to prevention and social programmes? How politically feasible is this, given the tendency to ring-fence health budgets but not welfare and wider social programmes? If so, what would an optimal ratio be? What about addressing wider contextual factors? What could be done to increase levels of trust alongside any shifts in expenditure? And reducing inequality? Others factors that merit attention?

20. Palma ratio results

21. To bold text: Use Futura Std Medium, and click B in formatting toolbar Model structure We used two modelling approaches: (1)Is a mixture of variation between and within countries. (2)Is a within-country only approach.

22. To bold text: Use Futura Std Medium, and click B in formatting toolbar Different ‘types’ of spending had different impacts – but not in the way we expected

23. To bold text: Use Futura Std Medium, and click B in formatting toolbar What next questions continued…

24. To bold text: Use Futura Std Medium, and click B in formatting toolbar OECD SOCX dataset

25. To bold text: Use Futura Std Medium, and click B in formatting toolbar Wider contextual factors may also matter As social spending increases, trust increases – or is it the other way around?