A NGO spearheaded the project; an intergovernmental organization that insured the fi nancial background backed it; and it was executed in conjunction with the government. It is a good example of government–civil-society cooperation. Because the NGO had already gained the trust of the Roma community and medical professionals, it was a good bridge between two groups.
Hungary
References
Decade of Roma Inclusion 2005–2015 (2008). Hungary’s two year action plan for 2003 [web site]. Budapest, Decade of Roma Inclusion 2005–2015 (http://www.romadecade.org/index.php?content=298, accessed 5 October 2008).
Gaal P (2004). Health care systems in transition: Hungary. Copenhagen, WHO Regional Offi ce for Europe on behalf of the European Observatory on Health Systems and Policies (http://www.euro.who.int/__data/assets/pdf_fi le/0008/80783/E84926.pdf, accessed 9 June 2010).
Horváth M (2006). A pénz kevés, az akarat gyenge [The money does not match, the will is weak]. Budapest, Amaro Drom (http://www.
amarodrom.hu/archivum/2006/11/12.html, accessed 14 January 2007; in Hungarian).
Kemény A, Ladányi J, Szelényi I (2002). Cigányok és szegények Magyarországon, Romániában és Bulgáriában [Roma and poor people in Hungary, Romania and Bulgaria]. Szociológiai Szemle, 4:72–94 (in Hungarian).
Kopp M (2001) Az egészségi állapot társadalmi, magatartási, életmódbeli meghatározói [Social, behavioural, lifestyle determinants of health].
Ezredforduló, 4:14–18 (in Hungarian).
Melles M, Vitrai J (2003). Népegészségügyi Jelentés 2003 [National Health Report 2003]. Budapest, National Center for Healthcare Audit and Inspection (http://www.oszmk.hu/index.php?m=29, accessed 13 February 2006; in Hungarian).
Ministry of Foreign Affairs (2004). Fact Sheet on Hungary: Gypsies/Roma in Hungary. Budapest, Ministry of Foreign Affairs (http://www.
kulugyminiszterium.hu/kum/en/bal/hungary/about_hungary/fact_sheets.htm, accessed 5 October 2008).
Ministry of Health (2002). National public health programme. Budapest, Ministry of Health (http://www.eum.hu/english, accessed 17 April 2006).
Prime Minister’s Offi ce (2006). About Hungary – Economy. Budapest, Prime Minister’s Offi ce (http://www.magyarorszag.hu/english/
abouthungary/data/economy/economyhungary.html, accessed 16 May 2007; in Hungarian).
UNDP (2007). Human Development Report, 2007/2008. New York, United Nations Development Programme (http://hdrstats.undp.org/
countries/data_sheets/cty_ds_HUN.html, accessed 27 April 2008).
WHO Regional Offi ce for Europe (2006). Highlights on health in Hungary 2005. Copenhagen, WHO Regional Offi ce for Europe (http://www.
euro.who.int/__data/assets/pdf_fi le/0016/103219/E88736.pdf, accessed 9 June 2010).
WHO Regional Offi ce for Europe (2007). European health for all database [online database]. Copenhagen, WHO Regional Offi ce for Europe (http://www.euro.who.int/hfadb, accessed 2 November 2007).
8. Ireland: Building Healthy Communities Programme
Elaine Houlihan Combat Poverty Agency
Despite Ireland’s unprecedented levels of economic growth in recent years and despite a reduction in the number of people living in consistent poverty, the number of people who are at risk of poverty remains high. Health inequalities also remain a concern, with poorer people experiencing poor health and dying younger. To address this situation, the participation of those experiencing poverty and health inequalities is a commitment in health policy. A number of key policy documents, including the National Development Plan and the National Action Plan for Social Inclusion, state a commitment to tackling health inequalities and to introducing comprehensive primary care service to those in greatest need.
The Combat Poverty Agency is a statutory advisory body responsible for developing and promoting evidence-based proposals and measures to combat poverty in Ireland. Under its current strategic plan, Combat Poverty is undertaking a major programme of work that addresses health inequalities and poverty. As part of this programme, it hosted the Building Healthy Communities (BHC) Programme that directly supported community development organizations involved in tackling health inequalities.
The Programme had the following key aims:
• to promote the principles and practice of community development in improving health and well-being outcomes for disadvantaged communities;
• to build the capacity of community health interests to extract practice and policy lessons from their work;
• to guide and support policy initiatives that relate to the links between poverty and health; and
• to explore mechanisms for effective, meaningful and sustainable community participation in making decisions about health.
The Programme supported projects that focused either on targeted geographic areas or on communities of interest that share common characteristics, such as asylum seekers and refugees, deaf people, Travellers1, lone parents and women with mental health issues.
The projects are involved in three broad activities:
1. tackling the main social determinants of ill health
2. tackling the lack of infrastructure and evidence base for ill health and inequalities
Summary
1 Travellers are members of various groups of traditionally nomadic people, living especially in Ireland and the United Kingdom.
Ireland
Socioeconomic and policy context Socioeconomic context
Over the past decade, Ireland has experienced an unprecedented level of economic growth. Although this growth has slowed down in the past few years, the economy is expected to continue to grow at a slower rate than previously (Barrett, Kearney &
O’Brien, 2008). In 2006, Ireland had the second highest GDP per person, expressed in terms of purchasing power standards within the EU, at 45.4% above the EU average (Central Statistics Offi ce Ireland, 2008b). Based on gross national income, however, Ireland was in fi fth place, at 25.2% above the average of the 27 Member States of the EU on 1 January 2007 (Central Statistics Offi ce Ireland, 2008b). With its economic development, Ireland has reduced signifi cantly the numbers of people unemployed and living in poverty. The unemployment rate is currently 6.1%, (Central Statistics Offi ce Ireland, 2008a), and while the number of people living in consistent poverty2 has fallen to 6.9% of the population the number of people at risk of poverty or who are income poor (on an income of under €202.49 per week in 2006) remains high, at 17% of the population (Central Statistics Offi ce Ireland, 2007, 2008b). During the period 1998–2007, the population of Ireland increased by 17.2%, to almost 4.34 million people, with about 10% of the current population being foreign born (Central Statistics Offi ce Ireland, 2006).
Several particular groups are at risk of poverty. These include lone parents, the long-term unemployed, children, people with disabilities, ethnic minorities, including Travellers, and ethnic minority communities new to Ireland.
Data for Ireland from 2001 illustrate the link between social gradient and health (Balanda & Wilde, 2001). Some examples are as follows.
• The all-cause mortality rate in the lowest occupational class is 100–200% higher than the rate in the highest occupational class.
3. tackling the ill health of a geographical area or vulnerable group.
The projects varied in size, some involving national organizations and others, at the other end of the scale, involving small local interventions. The work funded by the Programme is very often a small part of the overall workload of the group that hosts a project.
The Programme evaluators outlined the following direct effects to date on:
• how health services are delivered, so they include more vulnerable groups;
• the way health services interact with the community of a particular area and/or the way health services interact with a vulnerable group;
• the perception of community development as an approach to tackling health inequalities; and
• building capacity within communities and vulnerable groups.
The Programme concluded in December 2007, and a full evaluation will be available in 2008. The lessons emerging from these projects are used to infl uence the Combat Poverty Agency’s policy positions on health. Combat Poverty will continue to work with the projects in 2008, to consolidate policy lessons emerging from the Programme. While the fi nal evaluation of the Programme is currently being fi nalized, initial fi ndings have indicated that the Programme has met it aims and objectives.
The Programme was successful and had several positive outcomes, considering its size and budget, and also had signifi cant strengths and a number of weaknesses.
2 Income poverty is a term that refers to an income that is less than that regarded as acceptable by general society and that gives a lower than normal standard of living. It is measured as the share of people with an equivalized income below 60% of the national median income. This is also known as relative income poverty or at risk of poverty. Consistent poverty is income poverty combined with the lack of two or more of 11 basic deprivation items: having to go without heating at any time in the past year; being unable to keep the home adequately warm; being unable to buy presents for friends or family at least once a year;
being unable to replace worn out furniture; not having two pairs of strong shoes; not having a warm, waterproof coat; being unable to afford new (not second-hand) clothes; being unable to afford meat, chicken or fi sh (or vegetarian equivalent) every second day; being unable to afford a roast dinner once a week;
not having friends or family for a drink or meal once a month; and not having a morning, evening or afternoon out in the last fortnight for entertainment.
Equivalized income is defi ned as the household’s total income divided by its equivalent size, to take account of the size and composition of the household, and it is attributed to each household member.
• For circulatory diseases, mortality is 120% higher in the lowest occupational classes; for cancer, 100% higher; for respiratory disease, 200% higher; and for injuries and poisoning, more than 150% higher.
• Mortality rates for Ireland were generally higher than the rates in the (combined) 15 countries that were Member States of the EU before expansion on 1 May 2004. In comparison with the same EU group of countries, the all-cause mortality rate for Ireland was 21% higher for females and 9% higher for males.
Research commissioned recently by the Combat Poverty Agency highlighted the links between lower social class, lower educational qualifi cations, lower incomes and poor health (Layte, Nolan & Nolan, 2007). Using data from a national household study, the research found that 38% of those at risk of poverty and 47% of those living in consistent poverty report having a chronic illness, compared with 23% of the general population. Of men in the highest income decile, 11% have a chronic illness;
for men in the middle of the income range, the fi gure is 20%; and for men with the lowest incomes, it is 42%. Also, only 57%
of those living in consistent poverty have good or very good health; the fi gure for the rest of the population is 84%.
Poverty and poor health are closely interrelated (Balanda & Wilde, 2001; Barrington, 2004). Reducing poverty is, therefore, a key to improving the health of people living in poverty. Poor social conditions, such as lack of income and inadequate housing, hugely increase the likelihood of premature death. Also, children with low birth weight are more likely to be born to mothers experiencing poverty (McAvoy et al., 2006). The stress of striving to make ends meet affects both the physical and mental health of people in poverty – women in particular (Daly & Leonard, 2002). Moreover, a recent study by the Women’s Health Council highlighted the issue of debt as a major cause of ill health (The Women’s Health Council & MABS ndl, 2007).
People living in disadvantaged urban areas or remote rural areas fi nd it more diffi cult to access primary care services, such as doctors, even though they are often the most in need, as it can be very diffi cult to attract services to deprived areas (Crowley, 2005b). Also, general practitioner services are unevenly distributed by location, with poor areas having fewer general practitioners. Therefore, people in those areas are more likely to use out-of-hours services and accident and emergency services (Layte, Nolan & Nolan, 2007). Furthermore, the cost of going to a general practitioner for those with low incomes who do not have access to a medical card (which entitles free access to about 28% of the population) is a deterrent to accessing primary care services.