Closing the gap in a generation

Closing the gap in a Closing the gap in a generationgeneration

Michael MarmotMichael MarmotUCLUCL

Chair of WHO Commission on Social Chair of WHO Commission on Social Determinants of HealthDeterminants of Health

Santiago, Chile September 2008

Social Justice

Empowerment•Material•Psychosocial•political

Creating conditions forpeople to lead flourishinglives

OutlineOutline

Inequities and the social gradientInequities and the social gradient

Convergence of challenges;Convergence of challenges;

Addressing the challenges – taking action Addressing the challenges – taking action on the social determinants of health on the social determinants of health

Between country inequities…Between country inequities…

Life expectancy 43 years shorter for women in Life expectancy 43 years shorter for women in Zambia (43) than for women in Japan (86) Zambia (43) than for women in Japan (86) (WHO (WHO 2008)2008)

The lifetime risk of maternal death is one in The lifetime risk of maternal death is one in eight in Afghanistan; it is only 1 in 17 400 in eight in Afghanistan; it is only 1 in 17 400 in Sweden Sweden (WHO et al 2007)(WHO et al 2007)

Within country inequities…Within country inequities…

Life expectancy 17 years shorter for black Life expectancy 17 years shorter for black men Washington DC than for white men in men Washington DC than for white men in nearly Montgomery County.nearly Montgomery County.

Maternal mortality 3-4 times higher among Maternal mortality 3-4 times higher among the poor compared to the rich in the poor compared to the rich in Indonesia.Indonesia.

Deaths rates (age standardized) for all causes of death by Deaths rates (age standardized) for all causes of death by

deprivation twentieth, ages 15-64, 1999-2003, England and Walesdeprivation twentieth, ages 15-64, 1999-2003, 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

Difference in adult mortality between least and most deprived neighbourhoods Difference in adult mortality between least and most deprived neighbourhoods

in UK more than 2.5 times.in UK more than 2.5 times.

Cardiovascular deaths of people aged 45 - 64 Cardiovascular deaths of people aged 45 - 64 and social inequalities: Porto Allegre, Braziland social inequalities: Porto Allegre, Brazil

050

100150200250300350400

High Mediumhigh

Mediumlow

Low ALL

CVD deaths Attributable CVD deaths

CVD deathsper 100,000inhabitants

Socioeconomic level of districts

45% all premature CVD deaths in Porto Allegre caused by socioeconomic inequality

Premature mortality by CVD 2.6 times higher in lowest compared to highest districts by socioeconomic level

(Source: Bassanesi, Azambuja & Achutti, Arq Bras Cardiol, 2008)

Dramatic inequalities dominate global Dramatic inequalities dominate global health health

A social gradient in health exists in all A social gradient in health exists in all countries and within citiescountries and within cities

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 wealth Under 5 mortality per 1000 live births by wealth quintilequintile

Gwatkin et al 2007, DHS data

Average U5M for high income countries is 7/1000

OutlineOutline



Addressing the challenges – taking action Addressing the challenges – taking action on the social determinants of health on the social determinants of health

Double burden of diseaseDouble burden of disease- communicable and non-- communicable and non-

communicablecommunicable

Source: World Health Statistics, WHO, 2008

Projected deaths by cause for high-, middle, and low-income countries

CVD

CVD

CVD

Proportion of population aged 60 or overProportion of population aged 60 or over

0

5

10

15

20

25

30

35

1950 1975 2007 2025 2050

World More developed regions Less developed regions

%

Source: World Population Ageing 2007, UNDESA

Climate change – adds urgency to take Climate change – adds urgency to take action on SDHaction on SDH

OutlineOutline



Addressing the challenges – taking action Addressing the challenges – taking action on the social determinants of healthon the social determinants of health

Conceptual FrameworkConceptual Framework

SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES

SOCIOECONOMIC& POLITICAL

CONTEXT

Governance

Policy

Macroeconomic

Social

Health

Cultural and Societal norms

and values

Education

Occupation

Income

Gender

Ethnicity / Race

Social Position Material Circumstances

Social Cohesion Psychosocial Factors Behaviours Biological Factors

Health Care System

DISTRIBUTION

OF HEALTH

ANDWELL-BEING

WHO Commission on Social Determinants WHO Commission on Social Determinants of Healthof Health

2005 -2008 2005 -2008

CommissionersCommissioners 9 Knowledge 9 Knowledge

NetworksNetworks Country PartnersCountry Partners Civil society workCivil society work Global initiativeGlobal initiative WHO integration WHO integration

Set up by the World Health Organisationwww.who.int/social_determinants

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

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

CSDH – Areas for ActionCSDH – Areas for Action

Monitoring, Training, Research

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

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

Monitoring, Training, Research

Early child development and education

Healthy Places Fair Employment Social Protection

Universal Health Care

Health Equity in all Policies

Fair Financing Good Global Governance

Market Responsibility

Gender Equity

Political empowerment – inclusion and voice








Gender Equity









Gender Equity



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

05

1015202530354045

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%

Pov

erty

%

Taxation in East Asia (left) and sub-Saharan Taxation in East Asia (left) and sub-Saharan Africa (right), 1970–79, 1980–89, and 1990–99Africa (right), 1970–79, 1980–89, and 1990–99

Cobham 2005

direct

sales

trade

East Asia sub Saharan Africa

Debt service and development assistance, by Debt service and development assistance, by region, 2000 - 2003region, 2000 - 2003

(Labonte & Shrecker, 2007, data from World Bank)

Global aid and global needGlobal aid and global need

Over 60% of the total increase in ODA Over 60% of the total increase in ODA between 2001 and 2004 went to between 2001 and 2004 went to Afghanistan, the Democratic Republic of Afghanistan, the Democratic Republic of Congo, and IraqCongo, and IraqThese three countries account for less These three countries account for less than 3% of the developing world’s poor. than 3% of the developing world’s poor. Much of the ODA increase in 2005 can be Much of the ODA increase in 2005 can be accounted for by debt relief to Iraq and accounted for by debt relief to Iraq and Nigeria.Nigeria.

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

CSDH FR 2008

The Growing Gap: per capita aid from donor The Growing Gap: per capita aid from donor countries relative to per capita wealth, 1960-2000countries relative to per capita wealth, 1960-2000

Randel et al 2004







Gender Equity



Health equity impact assessment in Health equity impact assessment in economic agreements economic agreements

Flexibility in agreements Flexibility in agreements

A responsible private sectorA responsible private sector

Johannesburg water pricingJohannesburg water pricing

R -R 1R 2R 3R 4R 5R 6R 7R 8R 9

R 10

1 11 21

31

41

51

61

71

81

91

10

1

Consumption (kl/month)

Actual Tariffs (Rand/kl) Johannesburg

Ideal for hh of 10

Current – favoursricher consumers

Ideal – subsidises poorer consumers

Source: GKN 2007







Gender Equity



Levels of wages of women Levels of wages of women compared to men in selected areascompared to men in selected areas

70

73

76

80

80

81

60 65 70 75 80 85

4 areas in sub Saharan Africa

8 areas in Latin America &Caribbean

10 areas in transition

22 Industrialized areas

6 areas in East Asia & Pacific

4 areas in Middle East & N Africa

UNICEF 2006

Percentage of women who have a say in decision – Percentage of women who have a say in decision – making about their own health care, selected low and making about their own health care, selected low and

middle income countriesmiddle income countries

0

10

20

30

40

50

60

70

80

90

100

Bur

kina

Fas

o

Sen

egal

Nig

eria

Mal

awi

Cam

eroo

n

Gui

nea

Mor

occo

Eth

iopi

a

Zam

bia

Ban

glad

esh

Leso

tho

Ken

ya

Rw

anda

Gha

na

Arm

enia

Tan

zani

a

Moz

ambi

que

Rep

. of M

oldo

va

Mad

agas

car

Egy

pt

Bol

ivia

Col

ombi

a

Erit

rea

Indo

nesi

a

Phi

lippi

nes

Jord

an

%

DHS data CSDH FR







Gender Equity



Child survival and early child developmentChild survival and early child development

Physical, cognitive/language, Physical, cognitive/language, social/emotionalsocial/emotional

Poor self-rated health at age 50+ and accumulation of Poor self-rated health at age 50+ and accumulation of socio-economic risk factors over life course – Russian socio-economic risk factors over life course – Russian

menmen

00.5

11.5

22.5

33.5

44.5

5

MEN WOMEN

O 1 2 3No. of risk factors

Risk factors: •Ever hungry to bed aged 15 yr•Elementary /vocational education•Adult household income below median

Odd

s R

atio

for

Poo

r H

ealth

(Nicholson et al 2005)







Gender Equity



Global slum upgradingGlobal slum upgrading

Cost estimate: less than US$ 100 billion.Cost estimate: less than US$ 100 billion.

Finance on shared basis, for instance byFinance on shared basis, for instance by– international agencies and donors (45%),international agencies and donors (45%),– national and local governments (45%), andnational and local governments (45%), and– households themselves (10%), helped by households themselves (10%), helped by

micro-credit schemes. micro-credit schemes.

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.


Healthy Places

Fair Employment Social Protection





Gender Equity



Employment conditions: Employment conditions: Five “dimensions” of global scopeFive “dimensions” of global scope

Unemployment Unemployment

Precarious employment Precarious employment

Informal employment and informal jobsInformal employment and informal jobs

Child labourChild labour

Slavery / bonded labourSlavery / bonded labour

EMCONET

FAIR EMPLOYMENTFAIR EMPLOYMENT Freedom 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

EMCONET

Deaths from workplace exposure to dangerous Deaths from workplace exposure to dangerous substances, various countries and regionssubstances, various countries and regions

0

20,000

40,000

60,000

80,000

100,000

120,000

MEC LAC FSE OAI SSA EME IND CHN

Num

ber

of d

eath

s in

200

1

ILO, 2005

Forced Labour by trafficking Forced Labour by trafficking (minimum estimation)(minimum estimation)

(ILO)(ILO)

Trafficking Trafficked as % of total (absolute number) forced labour

Industrialized economies 270,000 74.8Transition economy 200,000 94.3Asia and Pacific 1,360,000 14.3Latin America and Caribbean 250,000 19.0Sub-Saharan Africa 130,000 19.6Middle East and North Africa 230,000 88.1TOTAL 2,440,000 19.8

EMCONET

Informal economyInformal economy

Women are much more Women are much more likely than men to be in likely than men to be in the informal economy. In the informal economy. In developing countries, the developing countries, the majority of economically majority of economically active women work in the active women work in the informal economy. informal economy.

Social protection in old Social protection in old age for workers in the age for workers in the informal economyinformal economy

0102030405060708090

100

Brazil Kenya India

women men

% non-agricultural labor forceIn the informal economy, 1991-1997

Source: Chen 2001

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 termtemporary

Non-fixed termtemporary

No contract

Source: Artazcoz et al 2005

%

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

No report of iso strain 1 report 2 reports

under 45

46-55

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

What must be doneWhat must be done

Make full and fair employment a central Make full and fair employment a central goal of national and international goal of national and international economic policy making;economic policy making;

Safe, secure and fairly paid work, year Safe, secure and fairly paid work, year round; healthy work-life balance;round; healthy work-life balance;

Improve working conditions – material Improve working conditions – material hazards, work-related stress, health hazards, work-related stress, health damaging behavioursdamaging behaviours

CSDH Final Report 2008


Healthy Places Fair Employment

Social Protection Universal Health Care




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

Povety Povety (%)(%)

Family Policy Family Policy Generosity (%)Generosity (%)

Source: Lundbrg et al 2007 CSDH Nordic Network

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

Minimum income for healthy living – Morris et al.Minimum income for healthy living – 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

TelephoneTelephone

Stationery, stampsStationery, stamps

Gifts to Gifts to grandchildren/othersgrandchildren/others

Cinema, sports, etcCinema, sports, etc

Meeting friends, Meeting friends, entertainingentertaining

TV set and licenceTV set and licence

NewspapersNewspapers

Holidays (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, mortgage and council taxMorris et al 2007 IJE

Social pensions in selected low and Social pensions in selected low and middle income countriesmiddle income countries

CountryCountry Age Age eligibleeligible

Universal Universal or means or means testedtested

Monthly Monthly amountamount

(US$)(US$)

% of % of pop 60+pop 60+

% of % of people people 60+ 60+ receivingreceiving

BangladeshBangladesh 57+57+ MM US$ 2US$ 2 6%6% 16% 16% (age 57+)(age 57+)

IndiaIndia 65+65+ MM US$ 4US$ 4 8%8% 13%13%

ThailandThailand 60+60+ MM US$ 8US$ 8 11%11% 16%16%

BotswanaBotswana 65+65+ UU US$ 27US$ 27 5%5% 85%85%







Gender Equity



Universal Primary Health Care Universal Primary Health Care

Community basedCommunity based

Disease preventionDisease prevention

Health promotion – using social Health promotion – using social determinants frameworkdeterminants framework

Catastrophic health expenditure and impoverishment due Catastrophic health expenditure and impoverishment due to out-of-pocket health expenditure, by WHO regionto out-of-pocket 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

Health outcomes (HALE) positively associated with public Health outcomes (HALE) positively associated with public spending as a proportion of total health expenditurespending as a proportion of total health expenditure

Source: Koivusalo & Mackintosh (eds) 2005

What’s next?What’s next?

Global Conference in London 2008 to promote Global Conference in London 2008 to promote uptakeuptakeSri Lanka 2009, practical uptakeSri Lanka 2009, practical uptakeCountries 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 - ? Core Development GoalECOSOC Agenda - ? Core Development GoalGlobal Report on Social Determinants and Global Report on Social Determinants and Health equity Health equity Capacity building – Research and TrainingCapacity building – Research and Training

Global MovementGlobal Movement

““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

OptimismOptimism

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%

Least reduction

14%

UNICEF

Reduction 42%

Reduction 33%

Reduction 47%

Reduction 51%

Reduction 49%

EMPOWERMENTEMPOWERMENT– MATERIALMATERIAL– PSYCHOSOCIALPSYCHOSOCIAL– POLITICALPOLITICAL

Dreams ?Dreams ?

www.who.int/social_determinants/en

A world where social

justice is taken

seriously

Documents

Closing the gap in a generation