1. CJ
Regazzoni,
Health
Policy
Proposal
1
EDUCATION AS A TOOL FOR HEALTH POLICY
MAKING
Dr.
Regazzoni
Carlos
Javier,
MD,
PhD
Buenos
Aires,
November
2005
A B S T R A C T . There is growing evidence that public health is strongly related to educational
background. Moreover, educational interventions have proved to be strong boosters of a
community’s health. It is mandatory to explore the best-evidence-based government policy
tools available to integrate education and health in a concerted effort towards public health
improvement. In order to accomplish this goal, first, a critical appraisal of existing medical
literature on this subject must be undertaken by local governments, in an effort to determine
the most relevant evidence-based associations between education and a population’s health
outcomes. Subsequently, an analysis of existing policies should be undertaken, and finally, the
strategies able to improve health throughout education policies would be proposed, based on
solid scientific foundations.
I. IN T R O D U C T I O N .
Latin America in general and Argentina in particular need more innovative and
broaden view policies to improve health. In the most inequitable region in the world (Morley
SA, 2001), health is poor and unequally distributed (Suárez-Berenguela RM, 2000). Furthermore,
evidence suggests (Baird M, 2004) that most regions of the developing world will not, at the
current pace, reach the Millennium Development Goals (MDGs) for health by 2015—
including reducing child and maternal mortality, primarily because improving health
outcomes is linked not only to the provision of health services, but also to interventions
outside the health sector like behavioral changes and other societal factors.
While education differentials are a key factor in income inequalities, poor health is a
considerable contributor to the problem. Income explains a good portion of health status; in
addition, good health by itself, is an essential pre-requisite for economic development (Bloom
DE, 2004). On the other hand, both education capital and health capital are strongly
interrelated (Baldacci E, 2004): health capital contributes to the accumulation of education
capital, and education is also associated with health capital. More importantly, education is a
strong determinant of mortality and disease at all ages (Matthews RJ, 2005).
At present, investment in health promotion has been inefficient, and higher public
spending on health as a share of GDP is shown to be tenuously related to improved health
status (Filmer D, 1997) or to greater health equality (Isaacs SL, 2004). Afore-mentioned
evidence urges towards combined and specific goal oriented actions (Morrisson C, 2002)
instead of uncoordinated measures, a typical problem of government programs in Latin
America. In this regard, it seems reasonable to think about education policy as part of a grand
strategy to improve health (Goldman D, 2001). Unfortunately, proposals of this sort are scarce
and mostly based on traditional medical policies like vaccination, hygiene teaching, etc., while
education and health policies remain largely disengaged from each other.
II. LI T E R A T U R E RE V I E W .
Social factors are critical for health (Kaplan GA, 1993); as a matter of fact, people in
upper classes live longer and healthier lives than do people in lower classes (Mathews RJ, 2005),
and education seems critical among these class inequality determinants (Marmot M, 1999).
II.A . E ducational attainm ent influences m ortality. There is an
inverse association of education with all cause and specific disease mortality. Kitagawa and

2. CJ
Regazzoni,
Health
Policy
Proposal
2
Hauser (Kitagawa EM, 1969) found that 1960 educational attainment, as assessed by years of
school completed, and income, were both inversely related to mortality in the white population
especially prior to age 65; but education was stronger predictor of death than income. Later,
Pappas et al. (Pappas G, 1993) showed that for persons 25 to 64 years old, those who had not
graduated from high school had a death rate two to three times higher than those who had
graduated from college, a gap larger than that due to many other well-known risk factors
including cigarette smoking. At the age of 65 (Guralnik JM, 1993), those with 12 or more years
of education have an active life expectancy 2.4 to 3.9 years longer than those with less
education; that is an influence even stronger than race. Preston and Elo (Preston SH, 1994)
confirmed and improved definition of afore-mentioned trends in educational mortality
differentials. More recently (Elo IT, 1996), it has been reported that college graduates tend to
have lower mortality rates than high school graduates, and people who do not attend high
school tend to have even higher mortality rates, especially at working age. Despite the fact
that lower levels of education are also associated with higher incidence of cigarette smoking,
systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol levels
(Wickleby MA, 1992), educational differentials in mortality persist, albeit attenuated, when
controlled for risk factors and other individual’s characteristics like income or behavior. In a
study of more than two million people, who were followed for twenty years (Steeland K, 2002),
lower education was associated with higher death rates even after adjustment for six risk
factors (smoking, body-mass-index, menopausal status, diet, alcohol, and hypertension) in
addition to age. Life expectancy was decreased by 4.8 and 2.7 years for men and women
respectively, for the lowest versus the highest educational group. The same trends have been
found in South Korea (Khang YH, 2005), Lithuania (Kalediene R, 2005), and other countries.
Striking differences in stroke mortality according to maximal school or university
degree achieved have been demonstrated in Europe (Avendaño M, 2004). Education also affects
cancer mortality (Fernandez E, 1999); for all malignancies, both sexes in the lowest educational
level showed a greater risk of death compared with men with a university degree. In general,
researchers (Wong MD, 2002) have estimated that ischemic heart disease contributed 11.7
percent to the educational disparity in life-years lost, followed by lung cancer (7.7 percent),
stroke (5.8 percent), congestive heart failure (5.1 percent), pneumonia (5.1 percent), and lung
disease (5.0 percent). In the elderly (Bassuk SS, 2002), education was inversely associated with
mortality despite adjustment for behaviour, actual health status, and income. Women are
another particularly vulnerable group (Lee JR, 2005): the risk of death owing to cardiovascular
disease (CVD) among women with established CVD was more than twice greater among non–
high school graduates than that of high school graduates at age 60, independent of other risk
factors. This study emphasizes the urgency of educational efforts among women (only 5% of
Argentine women 30 years or older hold a university degree1).
In addition to educational level, the closely related IQ, appears to affect health too. In a
1970 Scottish cohort followed for 25 years for hospital admissions and mortality (Harta CL,
2004), childhood IQ was associated with cardiovascular risk factors, myocardial infarction, and
stroke occurrence. People with higher Intelligence Coefficient in childhood live longer (Kuh D,
2004; Batty D, 2004).
Finally, there is an impressive array of associations between mothers’ educational level
and children’s health status (Filmer D, 1997), and educational attainments of both spouses have
resulted to be significant predictors of one’s own overall mortality (Jaffe DH, 2005) in couples.
II.B . E ducation as a tool for health policies. Better access to
preventive and early care doesn’t explain the better health status of the more privileged; in the
United Kingdom, for instance, similar disparities in health among socioeconomic classes
persist despite presumably universal health access (Marmot MG, 1987); it urges in favor of an
independent “health effect”. Policymakers frequently search for ways to improve both
education and health, but they rarely appreciate the relationship between the two. In 1995, the
World Health Organization launched “WHO's Global School Health Initiative”, which was
designed to improve the health of students and community lives through "Health-Promoting
Schools" -a healthy setting for living, learning and working- (WHO, 2005). This initiative,
1
Calculation based on 2001 National Census. Data available at: http://www.indec.mecon.ar/webcenso/index.asp

3. CJ
Regazzoni,
Health
Policy
Proposal
3
however, focuses largely on the convenience of schools as means of implementation of specific
health education and promotion activities. Health literacy—the degree to which people have
the capacity to obtain, process, and understand basic health information and services needed to
make appropriate health decisions—is just another example of intersection between both fields
(Parker RM, 2003). Research on new policy tools to incorporate health and formal education
into an integrated strategy for development would be a challenging innovative way to improve
health. Moreover, this approach should set the health problem in the broad perspective of
“social class inequalities” (Isaacs SL, 2004).
III. PR O P O S E D W A Y O F A C T I O N .
An innovative approach, intended to promote educational strategies in order to improve health
status of the population should bare two main objectives in mind. First, it is mandatory to
determine, what are, at present, the best scientifically established links between education and
a population’s health outcomes, and the previous experience with integrated policies. Secondly,
it is recommended to derive a list of well-grounded recommendations, anticipated to integrate
education and health in a concerted effort oriented towards public health improvement.
Education attainment, in this case, is understood as the maximal degree achieved
within the formal education system. Education policy in this case is defined as any policy
based on formal educational system intended to promote new quantitative or qualitative
educational goals. Health outcome, in this case, is defined as disease occurrence or mortality.
The working questions for the researcher could be stated as follow: 1-What are the established
links between education attainment and health outcomes? 2-What is the quality of the
available evidence in this regard? 3-What recommendations derive from this evidence? 4-
What health outcomes might be expected from the application of these recommendations? Is
there any model in this regard? 5-When and where have education policies been applied in
order to advance health outcomes? 6-Is there any additional evidence of health outcome
changes presumably derived from innovative education policies (Plan “Borsa schola” in Brazil,
for instance)? 7-What conclusions can be derived from these experiences? 8-What is the
perspective of the experts about scientific evidence and previous experiences of education
policies to improve health? Finally-What policies could be recommended for Argentina in
particular and Latin America in general, as an interrelated education and health strategy to
improve public health? Is it necessary to create a specific office of coordination, any specific
body of norms, or new research? The aim of the work must be a detailed description of the
state-of-the-art of links between education attainment and health outcomes, a reassessment of
previous experience with joined policies of this sort, and a list of reasonable recommendations
for education policies to be implemented in order to improve health.
IV. EX P E C T E D C O N C L U S I O N S A N D F U T U R E I M P L I C A T I O N S .
With the research, the scholar expect to perform an extensive review of up-to-date published
data on the relationships between health and education, as well as a collection of the trials
carried out elsewhere in order to test the hypothesis that interventions on general education
are useful and cost-effective measures for population’s health improvement. This work should
allow us to make recommendations about the implementation of educational policies intended
to improve health.
Although there is still much to learn about the relative contributions of education, income, and
occupation to health, the fact that they do have an influence means that policies affecting these
areas must be examined for their effects on health (Isaacs SL, 2004). This requires broadening
the concept of health policy to include areas not normally considered when thinking about
health (Tarlov AR, 1999). Investments in social and economic policy made upstream can pay
health dividends downstream. Policies regarding education cannot be divorced from their
effects on health. Experts (Hurowitz JC, 1993) caution against expecting too much from reform
of the health care system without more fundamental social and economic reform; issues like
child mortality or heart attack aren’t purely medical matters; otherwise, it would be an
approach expensive and ineffective. It may be time to regard medical illness as the result --

4. CJ
Regazzoni,
Health
Policy
Proposal
4
direct or indirect -- of social factors, and to treat it as such. Health reform, to date, has focused
primarily on health financing and medical assistance; but it is worth considering that ensuring
adequate medical care for all will have only a limited effect on Latin America’s health. More
important is enabling people, in the lower economic classes, to adopt healthier behaviors and
skills.
Two main reasons make this approach to health policy critical: firstly, it could serve to
implement new combined policies. The combined policies should imply new assignments and
budget distributions, which implies that money traditionally earmarked for health care should
be diverged to education, but at least part of the results could be measured as health gains (for
instance: to lower child mortality or mother mortality through a plan mainly based on
educational strategies). The same should be taken into account when assuming decisions about
human resources, infrastructure, and others. Secondly, it could serve as a primer for research
and innovation in an area relatively unexplored in the region, as it is the case for the
implementation of coordinated health and education policies in order to achieve a mutual
benefit of both fields. It ultimately should result in a more integral achievement of human
development in a region that worth deserves it.
V. BI B L I O G R A P H Y .
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Proposal
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