2010/02/01 by J. Morris, Christopher Deeming, Paul Wilkinson +1 · 1 citation
Nursing · Health Professions · Business, Management and Accounting · #Child Nutrition and Water Access #Food Security and Health in Diverse Populations #Global Public Health Policies and Epidemiology
paper · doi:10.1093/ije/dyp403
openalex publication_date 2010/02/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/08/01
Worldwide biomedical and social research has been establishing knowledge on key essentials of health and well-being.1,2 In general, this knowledge is inadequately applied in public policies, resulting in avoidable health deficits, waste of human potential and costs to society. Remedial measures plainly are required to improve living and working conditions and create social protection policy supportive of all. Formulation of the evidence into practicable ways of living and the minimal costing of these to society and to the individual is relatively straightforward, and we have so far assembled data on healthy living for two UK population groups: adults of working age and older people. We have then ascertained the minimal personal costs these currently would entail, allowing for certain social provisions. This yielded our evidence-based minimum personal income adequate for healthy living (MIHL), which may now be accepted as a definable social determinant of health and, when deficient, poses risks to health and well-being.3 National statistics indicate that 3.6 million adults in the UK are below this defined MIHL. We submit that a national minimum to increase equality of opportunity for health via such a defined MIHL would be a practicable and readily comprehensible step to improving public health and hopefully reducing prevalent inequalities. MIHL would also provide a benchmark for health in public policy generally on criteria of poverty and safe minimal standards of living. We suggest practical measures in response to today’s challenge that arises from the knowledge on personal essentials for health that is accruing from the phenomenal modern research effort. How can we better apply this knowledge to our populations and all in them? The response at present is unarguably inadequate. Article 25 of the UN Universal Declaration on Human Rights is relevant to our argument for minimum income standards—informed by public-health evidence. Article 25 states: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care. and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.4 There are a number of key steps in our approach to MIHL that can be specified.5–8 Today, we are in a position to formulate and offer an objective epistemologically grounded concept of needs for health, which captures the available biomedical and social research evidence. The basic premise of MIHL is that modern research is providing us with solid knowledge of basic needs for personal healthy living, in nutrition, physical activity, housing, psychosocial relations and social inclusion. The health science is, of course, incomplete. Household expenditure data taken from national social surveys can also be used to define the cost of other basic essentials in the absence of formal health science. Because we are interested in establishing a minimum income for healthy living, we select, when necessary, relevant study population households towards the bottom of the income distribution. Our proposition is that the health knowledge base is sufficient to form a constructive definition of MIHL today. Table 1 describes the basic methodological principles. Following these sequential steps will yield a minimum disposable income required for healthy living; i.e. an MIHL. This, we submit, should be a benchmark for Public Health and for its stance in the formulation of public policy. We formulate our assessment of current best evidence on personal needs in key areas of health for particular population groups. This evidence is then translated into ways of living, exploiting available surveys of lifestyle and public opinion.9,10 Next, we cost these lifestyles minimally in prevalent real-life conditions and allowing for public provisions (e.g. for older people these include free medical prescriptions, government winter fuel allowances and travel passes). Minimum personal costs of all of these are determined from low-price retailers in the high street and where we are unable to do so from the actual expenditure of low-income households.11 Finally, the minimal costs that currently would be entailed to each individual and household unit are assessed, allowing for these social provisions. Methodological principles of MIHL Methodological principles of MIHL We trawl the scattered modern literature for international and national expert reviews, for the findings of randomized control trials and other research, and, where necessary, depend on our own study of the evidence with wide consultation. The evidence is strong for application in public policy in many critical areas of human needs including diet and nutrition,12–17 on physical activity18–20 and health care.21,22 It is sufficient to allow informed judgement in relation to psycho-social relations,23,24 hygiene and personal care.25–27 There are particular problems in housing.28,29 In setting the context for MIHL we may be over-simplifying concepts and issues in the research literature that are heavily contested. Two key observations on the literature are critical for our argument. First, there is general agreement that there are basic major human needs for health and well-being. These ‘needs’ in health terms capture elements of cognate approaches to conditions of health in the social sciences—the ‘primary goods’,30 ‘necessary capabilities’,31,32 ‘resources for equality’33 and ‘basic goods’.34 Any such theory of human needs rests on evidence that if needs are not met, significant loss will result.35 The loss of life due to starvation and malnutrition during a famine serves to illustrate this point. A total of 3 million people died in the Bengal famine of 1943, which has often been described as being ‘man made’. Workers and the poor were unable to secure sufficient food due to social and economic factors, such as declining wages, rising food prices and poor food-distribution systems due to conflict and war.36,37 The current knowledgebase underpinning human needs can be further illustrated by the vast international literature on inequalities in health in which low income features prominently.3,38–43 Universal basic human needs can be distinguished from ‘wants’ that derive from an individual’s particular preferences and cultural environment. Objective harm, both physical and social, usually marks the distinction between needs and mere ‘wants’.35 We acknowledge this and will not consider ‘wants’ further as we have discussed this at more length elsewhere.6 Our contribution to this debate will be to argue for a new formulation of health needs for public policy today: needs for healthy living that can be objectively determined and priced. Consideration of need satisfaction leads to a second proposition about how they are met. It is clear that basic human needs can be and are being met in different ways. There is a substantial literature that discusses the satisfaction of human needs within various economic and political systems; the level of welfare that is produced between state, market, non-government organizations (NGOs) and family.44,45 What is required now is an evidence-based approach to the field of needs, to set the foundations for improved working conditions and systems of social protection around the world. We have assessed an MIHL for adults5,46 and for older people aged ≥65 years.7,8 Our initial focus on adults of working age was prompted by the UK governments’ institution in 1999 of a statutory National Minimum Wage. We were dismayed by the absence of consideration of such a wage’s capacity to meet obvious and basic needs for health and well-being.47,48 There was little, if any, mention of these in Parliament, the health and public policy community generally or the media. The findings in this test case demonstrated that the wage introduced by Government (since substantially increased) was incapable of meeting the cost of our MIHL, i.e. minimally assessed essentials for healthy living (Table 2). Figures from the national survey of earnings suggest that 800 000 workers in the UK had incomes below our conservative MIHL benchmark (Table 3). A further 1.6 million people who are unemployed and claiming Job Seekers Allowance are living on incomes well below the MIHL (Table 3). MIHL components and aggregate costs5,7,8,46 aCalculations include housing cost such as rent and local government council tax payments. Original MIHL estimates have been updated for the movement in prices using the UK Consumer and Retail Price Index. bCalculations relate to older people (≥65 years of age) living in the community without defined significant disability; they exclude housing costs such as rent, and local government council tax payments which may be met by local government after means testing. cOccasional taxi, train fair. dThe few residuals in the UK, dental care. eIncluding personal hygiene, household cleaning, laundry and dry cleaning. fClothing and household goods. MIHL components and aggregate costs5,7,8,46 aCalculations include housing cost such as rent and local government council tax payments. Original MIHL estimates have been updated for the movement in prices using the UK Consumer and Retail Price Index. bCalculations relate to older people (≥65 years of age) living in the community without defined significant disability; they exclude housing costs such as rent, and local government council tax payments which may be met by local government after means testing. cOccasional taxi, train fair. dThe few residuals in the UK, dental care. eIncluding personal hygiene, household cleaning, laundry and dry cleaning. fClothing and household goods. Adults living below the MIHL, UKa aAll numbers have been rounded to the nearest 10 000. bEstimates relating to the number of job seekers (unemployed) with income below MIHL are based on the number of people claiming Job Seeker’s Allowance during November 2009.49 For an adult aged 25 years without dependants the allowance was £64.30 a week; £50.95 for adults aged 16–25. Rent and local government council tax may be paid by local government after means testing. cEstimates relating to the number of workers with income below MIHL are derived from the 2009 national survey of earnings.50 Our MIHL for adults in work includes allowances for rent and local government council tax. dEstimates for the number of pensioners below MIHL relate to national household survey data from 2007.51 For pensioners, MIHL excludes rent and local government council tax payments as these costs may be met by local government after means testing. Adults living below the MIHL, UKa aAll numbers have been rounded to the nearest 10 000. bEstimates relating to the number of job seekers (unemployed) with income below MIHL are based on the number of people claiming Job Seeker’s Allowance during November 2009.49 For an adult aged 25 years without dependants the allowance was £64.30 a week; £50.95 for adults aged 16–25. Rent and local government council tax may be paid by local government after means testing. cEstimates relating to the number of workers with income below MIHL are derived from the 2009 national survey of earnings.50 Our MIHL for adults in work includes allowances for rent and local government council tax. dEstimates for the number of pensioners below MIHL relate to national household survey data from 2007.51 For pensioners, MIHL excludes rent and local government council tax payments as these costs may be met by local government after means testing. Providing a healthy living wage requires supportive economic and public policy that is based on the costs of meeting health needs and this requires review on a regular basis. Governments, NGOs and research centres should estimate the cost of healthy living for workers in order to calculate healthy living wage levels in each country; including low- and middle-income countries where low labour costs often provides a competitive advantage. Educational attainment is linked to improved health outcomes, partly through its effects on adult income and employment. Public policy initiatives may be required to help the unemployed to gain the education, training and skills that will help them to participate in the workforce. Training opportunities are required that suit the needs of older people who wish to continue in employment. The second case study deals with older people, living independently in the community in the UK, and free of defined disability, i.e. covering some 60% of the total population aged ≥65 years.7,8 This found again that our deliberately economical MIHL (Table 2), allowing of course for the important public provisions was greater than the national Old Age Pension and greater also than the means-tested Government’s official safety net for older people, the Pension Credit Guarantee (PCG; which of course may also have to cover the costs of disability). Neither the Old Age Pension nor the PCG are discernibly based on any assessment of health needs—the prevalent international situation. The MIHL for younger adults is greater than that for older adults (Table 2). In part this may be explained by the public provisions that are available to adults aged >60 in the UK. Older people are entitled to a free bus travel pass but such travel costs are included in the MIHL for younger adults. A free TV licence and winter fuel payments are available to older people in the UK and such provisions have been factored into our MIHL calculations. There are also differences in housing costs to consider. The MIHL for older people does not include allowances for rent and local government council tax but the MIHL for working adults does. Older people in receipt of the PCG may have their rents and local government council tax payments met by local government after means testing. Figures from Government’s main UK-wide general household survey show that about 1.2 million pensioners >65 years of age had incomes below our conservative MIHL benchmark (Table 3). On this reckoning, they were below a basic minimum to live healthily and therefore liable to ill-health, disability, waste of human potential, with manifest social costs too. People aged ≥85 years, our most rapidly growing age group, are a particular concern. Universal social protection systems are an important component of public policies that seek to enable healthy living. In low-income countries, developing and expanding social protection systems can be a challenge. We welcome the UN proposal for a universal pension fund. This would guarantee at least a minimum payment to all older people around the world equivalent to the international extreme dollar a day poverty line. The UN report suggests that: In most contexts, basic non-contributory pension schemes seem affordable, even in low-income countries. A simple numerical exercise under reasonable assumptions suggests that abolishing extreme poverty in old age by providing a basic universal pension equivalent to 1 per day to all over age 60 would cost less than 1 per cent of gross domestic product (GDP) per annum in 66 out of 100 developing countries … The costs of a basic pension scheme for such countries, despite rapidly ageing populations, are projected to be relatively modest by 2050.52 Each of the major health needs presented its own complexities in translating the plethora of literature into a practical evidence-based specification that would appeal to policymakers and the general public and satisfy the scientific community. We illustrate the most difficult technical problems from the issues that arise in housing. Because of years of too little research, decisions here presented the greatest challenge. The evidence is limited and not well focused on relevant aspects of physical, psychological and social well-being, yet decisions are crucial. The long-established Public Health tradition on housing focused on ‘infection’, ‘sanitary issues’, ‘damp’ and ‘space/crowding’—overcrowding for long was a common proxy for poverty in industrial societies.54 We take these aspects for granted. We considered the evidence sufficient to specify a standard ‘heating regimen’ as a minimum to protect against winter cold.55 Yet for householders >75 years of age, who are particularly vulnerable to cold and likely to spend much of their time at home, this is probably too conservative. Initiatives to help improve home ‘energy efficiency’ with Local Authority support may be expected to achieve a number of important health benefits and to reduce fuel costs for low-income families29 (as well as helping to achieve ‘greenhouse gas reduction’ targets). But recent fuel price volatility has emphasized how sensitive and unpredictable fuel expenditure is as a key element of household budgets. We also considered it important to ensure good ‘maintenance’ and ‘repair’, to help protect against risk of falls, fire,29 carbon monoxide exposure56 and of heating system failure during the critical periods of cold. This means unavoidable provision for repair work and periodic capital expenditure, and also, in the case of older people, a protective insurance ‘maintenance contract’ that we regarded as essential to cover central heating, other gas and key electrical appliances and plumbing and drains—and thus hopefully to allay anxieties and the familiar crises! Essential adaptations (grab rails, non-slip floors and the like) were not included on the assumption that they would be provided with the support of the Local Authority grants available in the UK. The cost of such provision is difficult to assess: there is little research, the actual experience of pensioners is and expenditure on important is often or by on low so that their expenditure is likely to be In general, experience of low-income pensioners is too limited to be of help in needs for healthy living and little to the costs of and The are that more research is and that our assessment of costs is too low (Table issues relating to housing in the evidence is we the on housing are not so as to at assessment in the areas we have The MIHL is, we submit, an on lack of grounded in evidence to support policy a older people. in the assessment of MIHL costs a older people. in the assessment of MIHL costs of the MIHL has potential an evidence-based standard of health for public policies at an adequate minimal disposable income and an of poverty and a basic minimum living standard for all. a for a critical of inequalities in research on areas where more on essential needs for healthy living are in housing, as in health and of course the biomedical of the numbers with in our ageing focus policy on particular aspects of social need about components of the MIHL as illustrated for housing and by are and welcome ways of living, and also our provide society and the public with a for with the research evidence on of provide a between the Public Health and the community. at present is to their below an MIHL but be a to health, and it is reasonable to that if a concept such as the MIHL is not below its will be MIHL would therefore be an an equality of opportunity for healthy living. of such an would be and of and population would be course, the conditions of healthy living relate to much more than also are education, and from The MIHL policy is a necessary but not sufficient to as well as enable healthy The national debate that would such a in public policy towards health can be expected to have cultural and personal hopefully and providing opportunities for and personal The policy would be in context of rising living In low-income of health such as lack of to and and lack of household are often The formulation and costing of minimum essentials for healthy living therefore be to little to may be evidence of health even in these where many are likely to live on incomes below a level necessary for health, an of health needs and required income provide a The Health a or be in all countries and used to and and further that are strong for setting universal protection even in poor In income populations the evidence is more to derive and But in all the real-life challenge is also to the of an MIHL formulation into social and economic These have also to consideration to issues of and how particular policies the of tax and benefits in the The specification of minimum income needs would therefore be a step in important social and The for Public Health and the health community in general is to in that society to modern knowledge about health needs as the for a safe minimum standard of living, covering all of the there will be many in this The are to their for and and to and for critical on an of the they are to for and for the for pensioners in Table 3 and for and support in the of the of research provides evidence for the major personal for health and well-being in nutrition, physical activity, housing, psychosocial relations and social inclusion. costs of these can be assessed to an MIHL for population in different countries and living below MIHL can be using national survey data and official government Public as social has to in such application of knowledge to improve living and working conditions and create social protection policy supportive of all.