Closing the Gap:

tackling health inequalities

Michael Marmot

Copenhagen

May 2013

The Commission on

Social Determinants of

Health (CSDH) – Closing

the gap in a generation

Strategic Review of Health

Inequalities in England:

The Marmot Review – Fair

Society Healthy Lives

Review of

Social

Determinants

of Health and

the Health

Divide in the

WHO Euro

Region

Social determinants of health

CSDH (2008)

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Why we need to tackle health inequalities

• Moral responsibility

• Much can done in countries at all levels

• Financial difficulties are not a barrier

Concepts, Values and Principles

• Social justice

– Health equity

– Intergenerational equity

– Gender equity

• Human rights

• Life course approach

– Social arrangements,

institutions and policies

– Conditions of daily life

• Vulnerability and

exclusionary processes

• Empowerment

• Social inequities

• Social gradient in health

• Mutual responsibility

• Evidence

Absolute inequality in males death rates by

level of education

Mackenbach et al 2008

Remaining life expecancy at 30 years of age for women and men based on educational level, 1991 -2010: Sweden

Women Men Age Age

Post secondary

education

Secondary

education

Lower secondary

6

4.1

3,2

5

Trends in probability of survival in men by

education: Russian Federation

0.4

0.45

0.5

0.55

0.6

0.65

0.7

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Calendar year

45

p 2

0

45 p20 = probability of living to 65 yrs when aged 20 yrs

University

Less than secondary

Source: Murphy et al 2006

Life expectancy and disability-free life expectancy at birth

by neighbourhood income deprivation, 1999-2003

Life expectancy for men at age 25 by

education, 2008-10

30

35

40

45

50

55

60

65

EE HU RO BG PL HR CZ SI PT FI DK MT NO IT SE

ISCED 0-2 ISCED 5-6 Total

Life expectancy at 25 (years)

Malta

Denmark Finland

Portugal

Slovenia

Czech Republic

Croatia

Poland

Bulgaria Romania

Hungary Estonia

ISCED 0-2 Pre-primary, primary and lower secondary education

ISCED 4-6 Tertiary education

Sweden Italy

Norway

Source: Eurostat Database

Life expectancy for women at age 25

by education, 2008-10

30

35

40

45

50

55

60

65

BG RO HU HR EE PL CZ DK MT SI PT NO FI SE IT

ISCED 0-2 ISCED 5-6 Total

Life expectancy at 25 (years)

Sweden Finland Norway

Portugal Slovenia Denmark

Czech Republic

Poland Croatia

Hungary Romania

Bulgaria

Source: Eurostat Database

Italy Malta

Estonia

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Links between socioeconomic status and factors

affecting child development, 2003-4

Source: Department for Children, Schools and Families

Early child care and education

• Parenting and family support

– Perinatal services

– Care before and during pregnancy

– Help for new mothers

• Pre-school education and care

• Primary, secondary and tertiary education and

training

Country ranking: equality in child wellbeing -

material, education, and health

Source: UNICEF Report Card 9, ranking 24 OECD countries by their

performance in each of three dimensions of inequality in child well-being

Score Country

8 Denmark, Finland, Netherlands, Switzerland

7 Iceland, Ireland, Norway, Sweden

6 Austria, France, Germany, Poland, Portugal,

Canada

5 Belgium, Czech Republic, Hungary,

Luxembourg, Slovakia, Spain, United Kingdom

3 Greece, Italy, United States

Country comparison on average rank in four dimensions of

child wellbeing – material, health, education, behaviours &

risks, in early 2000s and late 2000s

UNICEF 2013

Report Card 11

Differences in PISA scores by attending preschool for more

than one year before and after accounting for socioeconomic

background

OECD PISA 2009 database

0 20 40 60 80 100 120 140

Israel

Belgium

France

Italy

Switzerland

Denmark

United Kingdom

Turkey

Lithuania

Serbia

TFYR Montenegro

Netherlands

Ireland

Slovenia

Before accounting for socioeconomic background

After accounting for socioeconomic background

0 10 20 30 40 50 60

Romania

Latvia

Bulgaria

Lithuania

Italy

Greece

Spain

Poland

Portugal

Luxembourg

Hungary

United Kingdom

Malta

Estonia

Switzerland

Ireland

Slovakia

France

Belgium

Netherlands

Germany

Austria

Czech Republic

Sweden

Finland

Cyprus

Slovenia

Denmark

Norway

Iceland

Poverty rate

Before social transfers After social transfers

Child poverty rates <60%

median before and after

social transfers 2009

Source: EU SILC

Gross enrolment ratio in pre-primary education

(%) (selected countries) year ending 1999 & 2009

0,0

10

20

30

40

50

60

70

80

90

100

1999

2009

Source: Unicef statistical tables

Access to preschool by wealth: CEE/CIS

Areas for improving outcomes:

• Child Development – Cognitive

– Communication & language

– Social & emotional

– Physical

• Parenting – Safe and healthy environment

– Active learning

– Positive parenting

• Parent’s lives – Mental wellbeing

– Knowledge & skills

– Financially self-supporting

Children achieving a good level of development at age five, local

authorities 2011: England

40

45

50

55

60

65

70

75

80

0 30 60 90 120 150

Good level of development

at age 5 %

Local authority rank - based on Index of Multiple Deprivation

Source: LHO (2012)

Birmingham Brighter Futures

• Aims to improve the lives of all the city's children

and young people;

• Focus on improving children’s physical health,

literacy and numeracy, behaviour, emotional

health, social literacy, and job skills.

• Specific programmes relevant to early years

include: Family Nurse Partnership (FNP),

Incredible Years Parenting Programme,

Promoting Alternative Thinking Strategies

(PATHS), Triple P Parenting Programme.

Per cent 5 year olds achieving ‘good development

score’,* Birmingham LA, West Midlands & England

*in personal, social and emotional development

and communication, language and literacy

Source: Department for Education: preliminary data

%

Integrated approach across the social

determinants

• Family income

• Parental leave arrangements,

• Availability & affordability of childcare at

particular ages and stages

• Aligning policy - child care and education,

employment, housing and transport

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Employment and working conditions have

powerful effects on health and health equity

When these are good they can provide:-

• financial security

• paid holiday

• social protection benefits such as sick pay, maternity leave, pensions

• social status

• personal development

• social relations

• self-esteem

• protection from physical and psychosocial hazards

… all of which have protective and positive effects on health

(CSDH Final Report, WHO 2008)

Occupational stress in European countries

0

10

20

30

40

50

Very low Low High Very high

Effort rewardimbalance

Low control

Per cent

Occupational class

Unemployment rates by education and country of

origin in selected countries

Source:

Eurostat

database

Unemployment and Mortality 1% rise in

unemployment

associated with:

- 0.8% ↑Suicide

- 0.8% ↑Homicide

- 1.4% ↓Traffic

death

No effect on all-

cause mortality

Source: Stuckler et al 2009 Lancet

Changes in adult

unemployment and in age-

standardised suicide rates

(age 0–64 years) in old (pre-

2004) and new European

Union Member States

(Stuckler et al Lancet 2011) 2007 is the index year, and y-axis values represent

proportional change relative to that year

Unemployment

Suicides

Social Protection

Each 100 USD per

capita greater social

spending reduced the

effect on suicides by: 0.38%, active labour

market programmes

0.23%, family support

0.07%, healthcare

0.09%,unemployment

benefits

Spending> 190 USD no effect of

unemployment on suicide

Source: Stuckler et al 2009 Lancet

Older ages

• People in professional and managerial

classes reach the same level of disability as

those in routine and manual classes about

15 years later.

• Professional and managerial classes have

less illness in their 70s than ‘routine and

manual’ classes 15 years earlier

Source: English Longitudinal Study of Ageing (ELSA)

Spending on basics as % of income rises

steeply among poorer groups

Spending on basics as % of income

2008/9 Percentage point change in

spending as % of income

2004/5-2008/9

Poorest 48.3 12.5

2nd 34.4 2.2

3rd 27.6 -1.5

4th 22.6 -4.1

Richest 16.4 -7.1

All 29 .7 0.7

Source: English Longitudinal Study of Ageing (ELSA)

ELSA: well-being by access to amenities and

services (number of access problems) and age

,0

10,0

20,0

30,0

40,0

50,0

60,0

Age: 50-64 Age: 65-74 Age: 75+

% a

bo

ve

thre

sho

ld

Elevated depressive symptoms

by access to services/amenities

and age in wave 4

No

problem

1 access

problem

>=2 access

problems

15,0

20,0

25,0

30,0

Age: 50-64 Age: 65-74 Age: 75+

Mea

n s

core

(p

oss

ible

ran

ge:

5-3

5)

Life satisfaction by access to

services/amenities and age in

wave 4

No

problem

1 access

problem

>=2 access

problems

Source: English Longitudinal Study of Ageing (ELSA)

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Macrolevel context:

Economic Issues

Sustainability and environment

Evidence from previous economic downturns

suggests that population health will be affected:

• More suicides and attempted suicides; possibly more

homicides and domestic violence

• Fewer road traffic fatalities

• An increase in mental health problems, including

depression, anxiety and lower levels of wellbeing

• Worse infectious disease outcomes such as TB +

HIV

• Negative longer-term mortality effects

• Health inequalities are likely to widen

Trends in the numbers of suicides and unemployment

claimants in England, 2000-10, by sex.

Barr B et al. BMJ 2012;345:bmj.e5142 ©2012 by British Medical Journal Publishing Group

Excess suicides and suicide attempts due to

economic reasons in Italy

De Vogli et al, JECH 2012

Annual average concentrations of particulate matter, in

the capital city in 2009* and change since 2005

Source: WHO Health for All database 2012

0 10 20 30 40 50 60 70

Iceland

Estonia

Ireland

Finland

Denmark

Sweden *

Switzerland

United Kingdom

Greece **

Poland

Albania

Serbia

Romania *

Bulgaria

Bosnia and Herzegovina

Turkey

2005 Particulate matter 2009*

Higher

concentrations

of particulate

matter

Lower

concentrations

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Wider Society

• Social exclusion

• Social protection across the life course

• Communities

Self reported health by education and social

expenditures: 18 EU countries

0

0,05

0,1

0,15

0,2

0,25

Predicted probability of poor health

Net Total Social Expenditures in PPP's

Primary

Minimum Maximum 0

0,05

0,1

0,15

0,2

0,25

Predicted probability of poor health

Primary

Secondary

Tertiary

Net Total Social Expenditures in PPP's

Source: Dahl & van der Wel, data from EU SILC 2005

Welfare generosity and non employment by

education in 26 European countries

van der Wel, Dahl & Thielen 2011, data from EU SILC (2005)

Increasing generosity Increasing generosity

Primary

Tertiary

Secondary

Prenatal Early Years Working Age Older Ages

Family building

Accumulation of positive and negative

effects on health and wellbeing

LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

Health inequalities and policy strategies

• Health inequalities are not inevitable;

• Not just a responsibility of the health care sector;

• There is no ‘magic bullet’

• Whole of society, whole of government

• Identify the challenges that Malmö is facing regarding social

differences and health inequalities

• Present evidence based strategies on how to reduce health

inequalities in Malmö – Child development

– Democracy and influence in society

– Social and economic conditions • Final report 2013

The Malmö commission

Commission for a Socially Sustainable Malmö (slide courtesy of Anna Balkfors)

Malmö, Sweden

• Commission for a Socially Sustainable Malmo,

chaired by Sven-Olof Isaacson, March 2011

• to translate the findings of the CSDH into a form

suitable to address social determinants and health

inequalities in Malmo

• Report March 2013

73 27% 100%

59% 84% 25

Geographic differences: Malmö

Education

General election

50 11% 61% Child poverty

25 7 % 32% Smoking

38 35% 75% Employment rate

22 70

Lowest Highest Differences

6.4 74.6 yrs 81 yrs

Life expectancy

Source: Välfärdsredovisningen för Malmö 2011, City of Malmö, (slide courtesy of Anna Balkfors)

Malmö: Six areas for action

• Children and young people´s livings conditions

• Living environment and urban planning

• Education

• Income and employment

• Health services’

• Changes in processes for socially sustainable development

London Health Inequalities Strategy

London HI Strategy: 5 strategic objectives:

1. Empowering individuals and communities

2. Equitable access to high quality heath and

social care services

3. Income inequality and health

4. Health, work, and well-being

5. Healthy places

Starting at the beginning:

early years care and education

Linden Children’s Centre,

Aug 2009

Bromley by Bow Centre

Review of health inequalities in England post

2010: Consultation in North West of England

• Values: shape our goals

• Nature of society not just programs and services

e.g. income inequality.

• Measurement: reflect what we want to achieve

• Journey and the destination e.g. local ownership,

collaborative working

A world where

social justice

is taken seriously

INTERNATIONAL INSTITUTE FOR

SOCIETY AND HEALTH

For further information email:

catherine.conroy@ucl.ac.uk

UCL Health and Society

Summer School

8-12 July 2013

www.ucl.ac.uk/healthandsociety/