Health Promotion International, Vol. 14, No. 3, 281-283,
September 1999
© Oxford University Press 1999
Resource Review |
Measuring Progress
R. Eckersley, CSIRO Publishing, Collingwood, Victoria, 1998
Commonwealth Department of Health and Aged Care, Canberra, Australia The last decade of the 20th Century has seen a flourishing of research which has placed the relationship between health and the social environment on much firmer ground than in the past. Researchers, e.g. Michael Marmot and Richard Wilkinson in the UK, Ichiro Kawachi and George Kaplan in the USA, and Clyde Hertzman and Fraser Mustard in Canada—among many others—are providing powerful new evidence of the impact of social conditions on health. They have shown, e.g. that societies and communities that are fairer, more socially cohesive and inclusive almost invariably have healthier populations than those that do not share these characteristics.
These findings are clearly not new or surprising; health promotion advocates have argued that this is the case since well before the Ottawa Charter. But the evidence is now stronger and supported not only by large-scale epidemiological studies but also by research in other disciplines, e.g. the neurosciences, clinical studies and child development. The case for action on the social determinants of health can now be presented as ‘evidence based’, and cannot be dismissed as ideology dressed up as science.
Concurrently, work has also progressed significantly in the area of environment and health. Ecologically sustainable development is now seen as fundamental to safeguarding human as well as planetary health. Once again, the evidence here is not new, but is now stronger than it has ever been.
Despite the breadth and depth of research showing that societies which are cohesive and which care for their natural environments are ‘better’ societies in a wide variety of ways, these are not the qualities normally emphasized by politicians or the media, nor recognized by economists, as indicators of progress. Economic growth—as measured by gross domestic product (GDP)— remains the dominant indicator of national performance for most developed countries.
Yet improvements in GDP can occur, while stocks of social, health and natural capital decline, and it is this paradox which is at the heart of Australian Richard Eckersley's book Measuring Progress.
Subtitled Is life getting better?, Measuring Progress covers a wide range of issues which should be of significant interest to those who take a broad perspective on health promotion and public health, and particularly those with an interest in health indicators, e.g. those developed for healthy cities or communities, or who are concerned with the measurement of the ecological, social, mental and spiritual dimensions of health.
The book consists of 17 chapters on various topics, divided into four main sections: (i) Progress and its Measurement; (ii) Well-being and Quality of Life; (iii) Work, Poverty and Income; and (iv) The Natural Environment. In addition, a final section provides responses to the material contained in these chapters, by a panel of senior public servants and leaders of non-government organizations. This format follows that of the conference on which the book is based. Because of the wide scope of the book, only a few of the contributions can be mentioned here.
In the introductory chapter to Section 1, Progress and its Measurement, Eckersley makes a persuasive case for the need to challenge conventional thinking about progress—defined as a rising standard of material well-being—and the relationships between economic activity, quality of life, health and well-being, and ecological sustainability.
It is this first section that sets out one of the book's major themes—the challenge to the GDP as a measure of progress, and the strengths and weaknesses of the GDP's major challenger, the genuine progress indicator (GPI), developed by the San Francisco-based organization Redefining Progress. This section includes a chapter by American Ted Halstead, founder of Redefining Progress, and a detailed and critical illustration of the construction of the GPI using Australian data in a chapter by Clive Hamilton. The GPI is a development of the Index of Sustainable Economic Welfare, first published in 1989 in the influential book For the Common Good written by former World Bank economist Herman Daly and thelogian John Cobb.
The GPI starts with the same data that underlies the GDP, but then is modified by both additions and subtractions. For example, the GPI adds the value of household and community work, and deducts costs of commuting, pollution, land degradation and transport and industrial accidents. Deductions are also made for so-called ‘defensive expenditures’ by consumers, i.e. expenditure that does not represent an addition to welfare but which attempts to offset some change in social, environmental or individual circumstances causing a decline in welfare. A proportion of health care expenditure is included in the ‘defensive’ category. It would be interesting, given current knowledge of the contribution of the social determinants of health, to see whether health economists could establish what proportion of spending on health care could legitimately be defined as a defensive response to social and economic conditions.
A limitation of the GPI, as Hamilton points out, is that as an index derived from traditional economic analysis, it does not take account of either the accumulation or decline of human capital (health, skills, knowledge and experience) or social capital—defined as sound and stable institutions, and supportive and trusting communities. This is partly a result of the difficult conceptual and measurement issues involved. Hamilton suggests this as an important area of future development for those working on GPI-type measures.
This first section of Measuring Progress also includes an interesting chapter on how recent understandings of the concept of citizenship are related to the debates about the nature and measurement of progress. The author discusses, e.g. John Raulston Saul's view that new measures of progress should be part of a larger process of civic renewal.
Closely related to the topic of citizenship, and currently an influential concept in health promotion circles, is Eva Cox's discussion of social capital and its measurement, in Section 2. Cox is well known in Australia for bringing the concept of social capital to mainstream attention in this country, through her radio broadcast series and book A Truly Civil Society. Part two also includes a chapter by Mathers and Douglas, Measuring Progress in Population Health and Well-being, in which they discuss the new measures of population health which take account of disability and quality of life. These include, e.g. the disability adjusted life year (DALY) used in the global burden of disease studies; and health-related quality of life (HRQOL) instruments. Douglas and Mathers conclude with a proposal for a comprehensive index of social well-being.
Also likely to be of particular interest to readers of Health Promotion International are chapters on: the measurement of subjective well-being; indicators of income inequality; and indicators of national progress towards environmental sustainability, the latter by Val Brown who has also published widely in the health promotion literature.
The responses and commentaries with which the book concludes are themselves extremely useful, as they offer a hard-edged assessment by senior decision-makers of the policy relevance and feasibility of the theories, concepts and methodologies proposed. There is an interesting debate as to whether one aggregate measure—the GPI—can do everything its proponents would like it to; or whether the more useful development would be a series of widely accepted social and quality of life indicators, which would sit alongside the GDP. The GPI advocates argue that the GDP commands such overwhelming attention—in part because of its apparent simplicity—that it needs to be replaced by a similar, single measure, which is underpinned by considerations of sustainability.
While some of the content of Measuring Progress is uniquely Australian, many of the chapters provide a very useful introduction to current debates in their particular fields—drawing extensively on the international literature—which would be relevant for readers in most countries.
This is not an easy book to read. Its 370 pages are packed with argument, illustrations and technical analysis ranging across numerous topics written by contributors from a wide range of disciplines. But potential readers should not be daunted. Each chapter is self-contained and well referenced, and any one chapter can serve as a starting point depending on the reader's primary interest. In this sense, Measuring Progress can serve as a useful reference book, to be dipped into and returned to.
Despite the fact that the term health promotion does not appear in the book, Measuring Progress contains an enormous amount of information of immense importance and relevance to contemporary health promotion concerns.
For those readers outside Australia who may find ordering a Commonwealth Scientific and Industrial Research Organization (CSIRO) publication difficult, an on-line version of the book may be browsed using Adobe Acrobat Reader 3.0 at the CSIRO web site <http://www.publish.csiro.au>. The book may also be ordered through the web site.
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