Closing the Gap: Global health equity and the Commission ... · PDF fileequity and the...

Closing the Gap: Global health Closing the Gap: Global health equity and the Commission on equity and the Commission on Social Determinants of HealthSocial Determinants of Health

Michael MarmotMichael MarmotUCLUCL

Chair: Commission on Social Determinants of HealthChair: Commission on Social Determinants of Health

McLaughlinMcLaughlin--GallieGallie Visiting Professor LectureVisiting Professor LectureMontreal, CanadaMontreal, CanadaFebruary 5February 5thth 20092009

Hoary MarmotHoary Marmothighhigh--pitched welcoming whistle;pitched welcoming whistle;gains bodygains body--fat in summer;fat in summer;Sleepy in winter.Sleepy in winter.

Social justiceSocial justiceEmpowerment Empowerment ––material, material, psychosocial, politicalpsychosocial, politicalCreating the Creating the conditions for people conditions for people to take control of their to take control of their liveslives

““This ends the debate decisively. Health This ends the debate decisively. Health care is an important determinant of health. care is an important determinant of health. Lifestyles are important determinants of Lifestyles are important determinants of health. But it is factors in the social health. But it is factors in the social environment that determine access to environment that determine access to health services and influence lifestyle health services and influence lifestyle choices in the first place.choices in the first place.””

Dr Margaret Chan, the DG of the WHO,at the launch of the CSDH Final Report in Geneva 28th August 2008

Photo: WHO/Chris Black

OutlineOutline

Health inequities within and between Health inequities within and between countriescountries–– The social gradient in healthThe social gradient in health–– Social determinants of health and health Social determinants of health and health

inequityinequityAction on SDH Action on SDH –– societal well beingsocietal well beingPrinciples of action on the SDHPrinciples of action on the SDHAction on SDH Action on SDH –– areas for actionareas for action

Life expectancy at birth (men)Life expectancy at birth (men)

7979JapanJapan8080US, Montgomery County US, Montgomery County

(white)(white)

6363US, Washington D.C. (black)US, Washington D.C. (black)

8282UK, Glasgow (UK, Glasgow (LenzieLenzie N.)N.)

7777UKUK7575USUS7575CubaCuba7272MexicoMexico7171PolandPoland6565LithuaniaLithuania6464PhilippinesPhilippines

6262IndiaIndia5454UK, Glasgow (UK, Glasgow (CaltonCalton))

Sources: WHO World Health Statistics 2007; Hanlon, Walsh & Whyte 2006; Murray et al. 2006

Poverty and the social gradientPoverty and the social gradient

If we only target the poorest 10% we miss If we only target the poorest 10% we miss most of the health problemmost of the health problem

Deaths rates (age standardized) for all causes of death by Deaths rates (age standardized) for all causes of death by deprivation twentieth, ages 15deprivation twentieth, ages 15--64, 199964, 1999--2003, England and Wales2003, England and Wales

males

females

The dashed lines are average mortality rates for men and women inEngland and Wales

women

men

Romeri et al 2006

0

50

100

150

200

Uganda2000/01

India 1998/99

Turkmenistan2000

Peru 2000 Morocco2003/04

Poorest Less poor Middle Less rich Richest

Under 5 mortality per 1000 live births by Under 5 mortality per 1000 live births by wealth quintilewealth quintile

Gwatkin et al, DHS data

PanPan--Canadian selfCanadian self--reported health: percentages reported health: percentages by socioby socio--economic status groupeconomic status group

01020304050607080

Alcoholbinging

Smoking Overwt orobese

Physicalinactivity

Self ratedHealth

High SES Average SES Low SES% of respondents

Source: Canadian Institute for Health Information, Reducing Gaps in Health: A Focus on Socio-EconomicStatus in Urban Canada, 2008

Is change possible?Is change possible?

Sweden: Life Expectancy at age 30 by level Sweden: Life Expectancy at age 30 by level of education,1986 of education,1986 –– 2003, women2003, women

44

46

48

50

52

54

56

1986 1988 1990 1992 1994 1996 1998 2000 2002

Compulsory Upper secondary Post-secondary

Source: SCB

+3.0

+1.8

+0.7

Slide: Vagero

The widening trend in mortality by education in The widening trend in mortality by education in Russia, 1989Russia, 1989--20012001

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

20

elementary university

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

Source: Murphy et al, AJPH, 96, 1293-9, 2006

Trends in U5M by wealth quintile: Trends in U5M by wealth quintile: BangladeshBangladesh

128

11097

76 72 72

122

85 81

135

10697

147

127

98

141 140

121

50

70

90

110

130

150

1996/97 1999/2000 2004

Average Richest 4th 3rd 2nd Poorest

Relative inequ: 1.86 1.93 1.69Absolute inequ: 65 67 50

(DHS data)

OutlineOutline

Health inequities within and between Health inequities within and between countries countries –– The social gradient in healthThe social gradient in health–– Social determinants of health and health Social determinants of health and health


Inequalities in health that are avoidable Inequalities in health that are avoidable are inequitableare inequitableTackling health inequities is a matter of Tackling health inequities is a matter of social justicesocial justice

Population health and health equity is a Population health and health equity is a performance measure of economic and performance measure of economic and social development social development Fairer distribution of health increased Fairer distribution of health increased societal wellsocietal well--beingbeing

OutlineOutline

Health inequities within and between Health inequities within and between countries countries –– The social gradient in healthThe social gradient in health–– Social determinants of health and health Social determinants of health and health


Conditions in which people are born, grow, live, work and age

Structural drivers of those conditions at global, national and local level

CSDH CSDH –– three principles of actionthree principles of action

Monitoring, Training, Research

OutlineOutline

Health inequities within and between Health inequities within and between countries countries Action on SDH Action on SDH –– societal well beingsocietal well beingPrinciples of action on the SDHPrinciples of action on the SDHAction on SDH Action on SDH –– areas for actionareas for action



CSDH CSDH –– three principles of actionthree principles of action


National monitoring systems National monitoring systems –– health health equity and the social determinants of equity and the social determinants of healthhealthGlobal health equity surveillance systemGlobal health equity surveillance system



CSDH CSDH –– three Linked Areas for Actionthree Linked Areas for Action


Early child development and education

Healthy Places Fair Employment Social Protection

Universal Health Care




Health Equity in all Policies

Fair Financing Good GlobalGovernance

Market Responsibility

Gender Equity

Political empowerment – inclusion and voice

CSDH CSDH –– Areas for ActionAreas for Action

IntersectoralIntersectorallinkage for health linkage for health and health equityand health equity







Gender Equity



‘‘BrettonBretton Woods 2’ Woods 2’ –– international international response to current economic crisis response to current economic crisis

Imperative that the international community re-commits to a multilateral system in which all countries, rich and poor, engage with an equitable voice. Place fairness in health at the heart of the development agendaPlace equality of influence at the heart of decision-making

CSDH FR







Gender Equity



FAMILY POLICY GENEROSITY AND FAMILY POLICY GENEROSITY AND CHILD POVERTYCHILD POVERTY

SWENOR

SWINET

ITAIRE

GERFRA

FIN

CAN

BELAUT

AUS UK

USA

0

5

10

15

20

25

0 10 20 30 40 50 60 70 80 90 100

–– Countries with generous Countries with generous family policies have lower family policies have lower child poverty rateschild poverty rates

–– This association is mainly This association is mainly due to policies that support due to policies that support dual earner familiesdual earner families

–– The contribution may be The contribution may be direct through the amount direct through the amount of benefits paid, or indirect of benefits paid, or indirect by supporting two earners by supporting two earners and thereby raising the and thereby raising the market income of the market income of the household household

Pove

tyPo

vety

(%)

(%)

FamilyFamily Policy Policy GenerosityGenerosity (%)(%)

Lundberg et al 2007 CSDH NEWS group

Proportion relatively poor pre and Proportion relatively poor pre and post welfare state redistributionpost welfare state redistribution

05

1015202530354045

Finland

Norway

Sweden

BelgiumGerm

any

Netherlands

Italy

SpainCanada UK US

poverty rates post tax & transfers poverty reduction by income redistribution

71% 71% 72%

Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data,CSDH Nordic Network

62% 63% 59%

54%49%

44%50%

24%

Pove

rty

%

Recognising global roleRecognising global role

High income countries and global roleHigh income countries and global roleDebt and overseas development Debt and overseas development assistanceassistanceImplications of trade and trade Implications of trade and trade agreements for global health and health agreements for global health and health equityequity

Donors, multilateral agencies and Member States build and strengthen national capacity for progressive taxation

Taxation in East Asia (left) and subTaxation in East Asia (left) and sub--Saharan Saharan Africa (right), 1970Africa (right), 1970––79, 198079, 1980––89, and 199089, and 1990––9999

Cobham 2005

direct

sales

trade

East Asia sub Saharan Africa

Donor countries honour existing commitments by increasing aid to 0.7% of GDP; expand the Multilateral Debt Relief Initiative; and coordinate aid use through a social determinants of health framework

CSDH FR 2008







Gender Equity



0

20

40

60

80

100

120

140

Sui

cide

Rat

e pe

r 100

,000

0 1 2 3 4 5 6Total Number of Cultural Factors Present

Cultural Factors:Cultural Factors:SelfSelf--government government Land claim Land claim

participation participation

Community Control:Community Control:Health services Health services Education Education Cultural facilities Cultural facilities Police/fire services Police/fire services

Aboriginal Youth Suicide by Factors Aboriginal Youth Suicide by Factors PresentPresent

Chandler & Lalonde, 1998







Gender Equity



Early child development and educationEarly child development and education

Early life Early life –– survival and developmentsurvival and developmentPhysical, language/cognitive and Physical, language/cognitive and social/emotional developmentsocial/emotional development

Sure Start Local Programmes: EnglandSure Start Local Programmes: England

--0.90 0.90 (p value less than 0.001)(p value less than 0.001)Negative parentingNegative parenting

1.3 1.3 ((p value less than 0.001)((p value less than 0.001)Home learning environmentHome learning environment

ParentingParenting

0.32 0.32 (p value less than 0.001)(p value less than 0.001)IndependenceIndependence

0.45 0.45 (p value 0.01)(p value 0.01)Child positive social behaviourChild positive social behaviour

Child developmentChild development

Mean differenceMean difference

Effect of SSLP versus non SSLPEffect of SSLP versus non SSLP

(Melhuish et al 2008)

Gaps in average maths scores among 15 year Gaps in average maths scores among 15 year olds by father’s education: selected OECD olds by father’s education: selected OECD

countriescountries

-80-70-60-50-40-30-20-10

0Sweden US Canada unweighted

OECDaverage

Difference in maths score low to high educationDifference in maths score medium to high education

OECD 2008

Intergenerational mobility across Intergenerational mobility across the earnings distributionthe earnings distribution

0

0.1

0.2

0.3

0.4

0.5

Sweden UK US

Lowest income quintile 2nd quintile3rd quintile 4th quintileHighest income quintile

“Welfare dependency is transmitted across generations” OECD 2008

Probability for son of being in the same income quintile as the father







Gender Equity



Rates of mortality from transportation injury in nine Rates of mortality from transportation injury in nine European countries, by level of education, 1990sEuropean countries, by level of education, 1990s

Figure from Mackenbach 2006

Impact of heat wave in Europe Impact of heat wave in Europe (2003)(2003)

150150BelgiumBelgium13001300PortugalPortugal14001400NetherlandsNetherlands20452045UKUK40004000ItalyItaly42004200SpainSpain70007000GermanyGermany1408214082FranceFranceExcess Deaths*Excess Deaths*CountryCountry

*number of deaths over and above what would normally be expected for the monthof August., source: INSERM 2005 in Environment Alert Bulletin, UNEP

ElderlyElderlyLoss of autonomyLoss of autonomySocial isolationSocial isolationLiving directly below roof of a buildingLiving directly below roof of a buildingLiving in cities Living in cities --‘heat island’ effect ‘heat island’ effect

(Brucker, 2005)

Slum upgrading in IndiaSlum upgrading in India

Slum upgrading in Ahmadabad, India, cost only Slum upgrading in Ahmadabad, India, cost only US$ 500/household. US$ 500/household. community contributions of US$ 50/household.community contributions of US$ 50/household.Following the investment in these slums, there Following the investment in these slums, there was improvement in healthwas improvement in health–– decline in waterborne diseases, decline in waterborne diseases, –– children started going to school, children started going to school, –– women were able to take paid work, no longer having women were able to take paid work, no longer having

to stand in long lines to collect water.to stand in long lines to collect water.

Fast food consumption (1995 and Fast food consumption (1995 and 1999) in selected countries1999) in selected countries

0

50

100

150

200

250

300

350

400

450

Russ

iaPo

land

Hung

aryCz

ech R

epub

licSo

uth Af

rica

Mexico

Chile

Braz

ilAr

genti

naVe

nezu

elaTh

ailan

dMala

ysia

Philip

pines

China India

Mill

ion

tran

sa

1995

1999

Source: Eurobarometer data in Hawkes 2002

Fast food chains more common in Fast food chains more common in deprived areas: England and Scotlanddeprived areas: England and Scotland

012345678

5 (mostdeprived

4 3 2 1 (leastdeprived)

Mean number of fast food outlets* per 100000people

Index of multiple deprivation quintile

Macdonald et al 2007(*McDonald’s, Burger King, KFC and Pizza Hut)


Healthy Places Fair Employment

Social Protection Universal Health Care




Gender Equity



FAIR EMPLOYMENTFAIR EMPLOYMENTFreedom from coercionFreedom from coercion

Job securityJob security

Fair incomeFair income

Job protection and social benefitsJob protection and social benefits

Respect and dignity at workRespect and dignity at work

Workplace participationWorkplace participation

Enrichment and lack of alienationEnrichment and lack of alienation

CSDH EMCONET 2007

Prevalence of poor mental health in manual Prevalence of poor mental health in manual workers by type of contract: Spainworkers by type of contract: Spain

0

5

10

15

20

25

30

35

Permanent

Fixed termtemporaryNon-fixed termtemporaryNo contract

Source: Artazcoz et al 2005

%

The The IsoIso--strain concept of stress at workstrain concept of stress at work

Socially isolated Socially isolated –– (no supportive co(no supportive co--workers or supervisors)workers or supervisors)High strain High strain –– (High demands and low control)(High demands and low control)

0

0.51

1.5

22.5

33.5

4

4.5

No report of iso strain 1 report 2 reports

under 4546-55

Hazard Ratios of incident CHD by Iso-Strain (phase 1 and 2 of Whitehall II); split by age group

Chandola et al. European Heart Journal (2008)

Coronary heart disease and work stress,Whitehall II study

PAR* for coronary heart disease (fatal CHD/non fatal MI/definite angina)

0

10

20

30

40

50

DCS

ERIJu

stice

CombinedFull a

djustmen

t

PAR%

Each domainCombinedFull adjustment

PAR for all combined *

30% 95% CI 10%-46%

adjusted for other predictors

29% 95% CI 9%-45%

odds ratios adjusted for age, sex, employment grade J Head et al,2007*Population attributable risk

Governments reduce insecurity among people in precarious work arrangements including informal work, temporary work, and part-time work through policy and legislation to ensure that wages are based on the real cost of living, social security, and support for parents

CSDH FR 2008


Healthy Places Fair Employment

Social ProtectionUniversal Health Care




Gender Equity



Building social protection for the elderlyBuilding social protection for the elderly–– materialmaterial–– psychosocialpsychosocial

Minimum income for healthy living Minimum income for healthy living –– Morris et al.Morris et al.–– DietDiet–– Physical activity/body and mindPhysical activity/body and mind–– Psychosocial relations/social connections/activePsychosocial relations/social connections/active

mindsminds–– Getting aboutGetting about–– Medical careMedical care–– HygieneHygiene–– HousingHousing

Psychosocial relations/social connections/active mindsPsychosocial relations/social connections/active minds

TelephoneTelephoneStationery, stampsStationery, stampsGifts to Gifts to grandchildren/othersgrandchildren/othersCinema, sports, etcCinema, sports, etcMeeting friends, Meeting friends, entertainingentertaining

TV set and licenceTV set and licenceNewspapersNewspapersHolidays (UK)Holidays (UK)Miscellaneous, Miscellaneous, hobbies, gardening hobbies, gardening etcetc

Morris et al 2007

Weekly disposable incomes for Weekly disposable incomes for people over 65, England 2007people over 65, England 2007

State State pensionpension

Pension Pension credit credit guarantee*guarantee*

Minimum Minimum income for income for healthy healthy living **living **

Single Single personperson

£87.30£87.30 £119.05£119.05 £131.00£131.00

CoupleCouple £139.60£139.60 £181.70£181.70 £208.00£208.00

*Rent, mortgage and council tax may be paid after further means testing** people 65+ living independently in the community; excludes rent, mortgageand council taxMorris et al 2007 IJE







Gender Equity



Health sectorHealth sector

Access, availability, acceptability, qualityAccess, availability, acceptability, qualityExemplar of good practice Exemplar of good practice –– major major employeremployerStewardshipStewardshipHealth equity in all policiesHealth equity in all policies

Universal Primary Health Care Universal Primary Health Care Community basedCommunity basedDisease preventionDisease preventionHealth promotion Health promotion –– using social using social determinants frameworkdeterminants framework

3035404550556065707580

0 20 40 60 80 100Private as % of total health expenditure

Hea

lthy

life

expe

ctan

cy: y

ears

Health-adjusted life expectancy (HALE) and privatespending as a percentage of total health spending

(2000)

Koivusalo & Mackintosh (2005)

Catastrophic health expenditure and impoverishment due Catastrophic health expenditure and impoverishment due to outto out--ofof--pocket health expenditure, by WHO regionpocket health expenditure, by WHO region

Source: World Health Statistics, WHO, 2008

0 30 60 90

Number of people (millions)

Eastern Mediterranean

African

Europe

South-East Asia

Americas

Western pacific

People Impoverished

People suffering catastrophic health expenditure

Moving forwardMoving forwardGlobal Conference in London Nov 6/7 2008 to Global Conference in London Nov 6/7 2008 to promote uptake promote uptake –– announcement of review of announcement of review of health inequalities in Englandhealth inequalities in EnglandSri Lanka 2009, practical uptake in SE AsiaSri Lanka 2009, practical uptake in SE AsiaCountries translate findings into programmes, Countries translate findings into programmes, Brazil, Chile, UK, Canada, Argentina?, India?Brazil, Chile, UK, Canada, Argentina?, India?WHO resolutionWHO resolutionECOSOC Agenda ECOSOC Agenda -- ? Core Development Goal? Core Development GoalGlobal Report on Social Determinants and Global Report on Social Determinants and Health equity Health equity Capacity building Capacity building –– Research and TrainingResearch and Training

Global movementGlobal movement

“…And we will learn from other countries along the way…”

Gordon Brown, Prime Minister, UKGordon Brown, Prime Minister, UKat Closing the Gap Conference, 6th Nov 2008at Closing the Gap Conference, 6th Nov 2008

“I am pleased to announce that Sir Michael Marmothas agreed to undertake a new review of health

inequalities in England…”

Optimism?Optimism?

Under 5 mortality rate: change 1990 Under 5 mortality rate: change 1990 --20062006

6

27

27

29

83

46

160

10

53

55

55

123

79

187

0 50 100 150 200

Industrialized countries

CEE/CIS

Latin America & Caribbean

East Asia & Pacific

South Asia

Middle East & North Africa

Sub-Saharan Africa

Reduction 40%

Leastreduction

14%

UNICEF

Reduction 42%

Reduction 33%

Reduction 47%

Reduction 51%

Reduction 49%

www.who.int/social_determinants/en

A world where social

justice is taken

seriously

Closing the Gap in a Generation

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