commission on social determinants of health · – –social determinants of health and health...

Taking Forward Action on the Social Taking Forward Action on the Social Determinants of Health:Determinants of Health:

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

Michael MarmotMichael MarmotUCLUCL

Chair of WHO Commission on Social Chair of WHO Commission on Social Determinants of Health 2005 Determinants of Health 2005 -- 20082008

MadridMadrid2828thth May 2009May 2009

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

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 –– everyone's business everyone's business Action on SDH Action on SDH –– areas for actionareas for action

Life expectancy at birth (men)Life expectancy at birth (men)UK, Glasgow (UK, Glasgow (CaltonCalton)) 5454IndiaIndia 6262US, Washington D.C. (black)US, Washington D.C. (black) 6363PhilippinesPhilippines 6464LithuaniaLithuania 6565PolandPoland 7171MexicoMexico 7272CubaCuba 7575USUS 7575UKUK 7777JapanJapan 7979US, Montgomery County US, Montgomery County (white)(white)

8080

UK, Glasgow (UK, Glasgow (LenzieLenzie N.)N.) 8282Sources: WHO World Health Statistics 2007; Hanlon, Walsh & Whyte 2006; Murray et al. 2006

Mortality over 25 years according to level in Mortality over 25 years according to level in the occupational hierarchy: Whitehallthe occupational hierarchy: Whitehall

01020304050607080

40-64yrs 65-69yrs 70-89yrsAll

caus

e m

orta

lity

(per

100

0 pe

rson

yrs

) Admin Prof/Exec Clerical Other

(Marmot & Shipley, BMJ, 1996)

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

Mortality in men aged 45 Mortality in men aged 45 --74 by 74 by provincial income quartiles: Spainprovincial income quartiles: Spain

Source: Regidor et al AJPH, 2006.

100011001200130014001500160017001800

1985 2000

Q1 - poorest Q2 Q3 Q4 - richestAge-standardized mortalityrate per 100,000 person-years

year

Improvements in mortality in all provinces BUT increase in relative and absolute inequalities between poorest and richest provinces

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

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


Economic costs of health inequalities: Economic costs of health inequalities: EuropeEurope

As As ‘‘capital goodcapital good’’ (leading to less (leading to less labourlabour productivity) productivity) -- about 1.4% of GDP or about 1.4% of GDP or €€141 141 billion per annum.billion per annum.As As ‘‘consumption goodconsumption good’’ -- about about €€1,000 1,000 billion, or 9.5% of GDP per annum. billion, or 9.5% of GDP per annum.

Mackenbach, Meerding & Kunst 2007

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 –– everyone's businesseveryone's businessAction on SDH Action on SDH –– areas for actionareas for action

Every sector is a health sectorEvery sector is a health sector–– Health and well being as outcomesHealth and well being as outcomes

EmpowermentEmpowerment

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

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 –– everyone's business everyone's business Action on SDH Action on SDH –– areas for actionareas for action

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 Linked Areas for Actionthree Linked Areas for Action

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 GlobalGovernance

Market Responsibility

Gender Equity

Political empowerment – inclusion and voice

CSDH CSDH –– Areas for ActionAreas for Action

Debt service and development assistance,Debt service and development assistance, by region, 2000 by region, 2000 -- 20052005

-200 -150 -100 -50 0 50

2005

2004

2003

2002

2001

2000

Debt service outflowsDevelopment assistance receipts

Sub-Saharan Africa

South Asia

Middle East and North Africa

Latin America

East Asia and the Pacific

US $ (billions)

Source: World Bank, World Development Indicators (accessed March, 2008)

Graph generated by Ted Schrecker, 2008

EducationEducation•Kenya abolition of school fees for primary education 2003;•Needs -

•School infrastructure, teachers;•Capacity building;•Budget allocation

Kenya’s last two budgets allocated US$ 350 million more to debt relief than education

Translating the CSDH recommendations Translating the CSDH recommendations into different country/regional contextsinto different country/regional contexts

“…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…”

The causes and the causes of the The causes and the causes of the causescauses

Social inequalities and health Social inequalities and health inequalitiesinequalities

Strategic Review of Health Inequalities in England – ‘Marmot Review’

Evidence relevant to future policy and Evidence relevant to future policy and actionsactionsObjectives and measures Objectives and measures Showing how evidence can be turned into Showing how evidence can be turned into practicepracticeFinal Report Final Report -- contribute to the contribute to the development of a postdevelopment of a post--2010 health 2010 health inequalities strategyinequalities strategy

Strategic Review of Health Inequalities in England – Marmot Review

Task groups:Task groups:–– early child development and education,early child development and education,–– employment arrangements and work conditions, employment arrangements and work conditions, –– social protection, social protection, –– built environment, built environment, –– sustainable development, sustainable development, –– social exclusion and social mobility, social exclusion and social mobility, –– priority public health conditions, priority public health conditions, –– economic analysis, economic analysis, –– delivery systemsdelivery systems







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

Inequality in Early Cognitive Development of British Inequality in Early Cognitive Development of British Children in the 1970 Cohort, 22 months to 10 yearsChildren in the 1970 Cohort, 22 months to 10 years

0

10

20

30

40

50

60

70

80

90

100

22 26 30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94 98 102 106 110 114 118

months

Ave

rage

pos

ition

in d

istr

ibut

ion

High Q at 22m

Low Q at 22m

Source: Feinstein, L. (2003) ‘Inequality in the Early Cognitive Development of British Children in the 1970 Cohort’, Economica (70) 277, 73-97

High SES Low SES







Gender Equity



Healthy PlacesHealthy Places

Sustainable development and built Sustainable development and built environmentenvironmentEnergy efficiencyEnergy efficiencyEmpowering communitiesEmpowering communities

SEWA Case Study: The SEWA Case Study: The ParivartanParivartan Programme Programme -- AimsAims

Improve the basic physical infrastructure within the slums and in the homes;

Community development;

City-level organisation for environmental upgrading of the slums

SEWA Case Study 2008

MELADI NAGARMELADI NAGARBefore After

Slide courtesy of Gujarat Mahila Housing SEWA Trust

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)

During current recession During current recession -- Not all Not all business is declining business is declining ……

McDonald's UK: 4,000 new jobsMcDonald's UK: 4,000 new jobs

extra two million customers a extra two million customers a month compared to last year (Aug month compared to last year (Aug 2008) 2008)

McDonalds Europe: 240 new McDonalds Europe: 240 new restaurants mostly in Spain, restaurants mostly in Spain, France, Italy, Russia and PolandFrance, Italy, Russia and Poland

‘‘consumers, particularly in consumers, particularly in Germany and Spain, favouring the Germany and Spain, favouring the cheapest menu itemscheapest menu items’’ (Jan 09)(Jan 09)


Healthy Places Fair Employment

Social Protection Universal Health Care




Gender Equity



Employment policy is health policyEmployment policy is health policy

Good work Good work

Financial securityFinancial securitySocial protectionSocial protectionPaid holidayPaid holidaySocial statusSocial statusPersonal developmentPersonal developmentSocial relationsSocial relationsSelf esteemSelf esteemProtection from physical and psychosocial Protection from physical and psychosocial hazardshazards

Unemployment rates in Europe, February 2009, seasonally adjusted

Source: Eurostat April 2009

2.7

4.5 4.5 4.6 4.8 4.95.5 5.8 5.9

6.4 6.4 6.8 6.9 7.1 7.4 7.4 7.5 7.8 7.9 8.3 8.6 8.79.8 9.9 10

13.714.4

15.5

0

2

4

6

8

10

12

14

16

18

NL

CY AT SI

DK

CZ

BG

RO

** LU MT

UK

* FIIT

** BE

DE PL

SE

EL*

*E

U27 P

T

FR HU SK

EE IE LT LV ES

%

Mortality* of men aged 16-64 by social class and employment status at the 1981 census

1981 LS Cohort. *England & Wales: mortality 1981-92

* adjusted for age and salary

50

70

90

110

130

150

170

190

Social class

Sta

ndar

dise

d M

orta

lity

Rat

e

I II IIIN IIIM IV V I II IIIN IIIM IV V

Employed in 1981 Unemployed in 1981

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

Artazcoz et al 2005

%

0

1

2

3

All Causes Cancer All Cardiovascular External causes

Adj

uste

d H

azar

d R

atio

s*Mortality 1990-2001 for women on temporary

contracts: Finland

reference group women in permanent employment

Kivimaki et al 2003; American Journal Epid 158:663-668

* adjusted for age and salary

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)

Prevalence of childrenPrevalence of children’’s mental s mental disorders by family characteristics: GB disorders by family characteristics: GB

20042004

0

4

8

12

16

20

Both parents working Neither parentworking

(Source: Survey of the mental health of children and young people in Great Britain, ONS)

%

0

4

8

12

16

20

Lone parent fanilies Two parent families

%


Healthy Places Fair Employment

Social ProtectionUniversal Health Care




Gender Equity



Unemployment benefits replace on average 40% of previous earnings – but there is huge variation

within OECD

Source: OECD 2007 SOCIETY AT A GLANCE

Average of net replacement rates over a period of 60 months of unemployment in 2004,for four family types and two earnings levels in percentage – data are for 2004

Spain

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

Moving forward Moving forward –– Global movementGlobal movement

Global Meeting London Global Meeting London ‘‘Closing the GapClosing the Gap’’ 2008 2008 Country initiatives: England, Brazil, Chile, Country initiatives: England, Brazil, Chile, Argentina, Thailand, Nordic Argentina, Thailand, Nordic ……Regional Meetings: Euro, Sri Lanka, Cairo, Regional Meetings: Euro, Sri Lanka, Cairo, PAHO, Addis Ababa, Asian ParliamentariansPAHO, Addis Ababa, Asian ParliamentariansWHO resolutionWHO resolutionECOSOC Agenda ECOSOC Agenda -- Core Development GoalCore Development GoalProposed Global Report on SDH and equity Proposed Global Report on SDH and equity South American CommissionSouth American Commission

EU? Bring the directorates togetherEU? Bring the directorates together

Health equity as an outcome of good social Health equity as an outcome of good social policypolicy

www.who.int/social_determinants/en

A world where social

justice is taken

seriously

Closing the Gap in a Generation

commission on social determinants of health · – –social determinants of health and health...

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