25/11/2014. Health inequality: causes and responses: action on the social determinants of health. Why we need to tackle health inequalities

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1 Health inequality: causes and responses: action on the social determinants of health Professor Sir Michael Marmot November 214 Why we need to tackle health inequalities Moral responsibility Much can done in countries at all levels Financial difficulties are not a barrier Estimated odds of reporting poor or very poor general health by socioeconomic characteristics, 25 EU Member States*, 21 Level of education None or pre-primary () Primary (ISCED 1) Lower secondary (2) Upper secondary (3) Post-secondary, non-tertiary (4) Tertiary (5&6) - BASELINE Income distribution Lowest decile 2nd 3rd 4th 5th 6th 7th 8th 9th Highest decile - BASELINE 1st-4th 5th-9th Source: Health inequalities in the EU Material deprivation 4+ items 3 items 2 items 1 item items - BASELINE Odds ratio 3 variables in the model One variable in the model Three 1 variablesin inthe model Life expectancy at age 25 by education, men Life expectancy at age 25 by education, women Source: Health inequalities in the EU 213 Source: Health inequalities in the EU 213 1

2 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 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, using data from EU SILC 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 Source: CSDH Final Report, WHO 28 2

3 Occupational stress in European countries Per cent Very low Low High Very high Occupational class Effort reward imbalance Low control Unemployment and Mortality 1% rise in unemployment associated with: -.8% Suicide -.8% Homicide - 1.4% Traffic death No effect on allcause mortality Source: Stuckler et al 29 Lancet Quality of work (effort-reward imbalance) and intended retirement in 15 European countries Older ages: 3 components of healthy ageing: Staying alive Avoiding disease Having good positive physical and mental functioning Intended retirement assessed by asking: Thinking about your present job, would you like to retire as early as possible? Figure: Source: Siegrist J, Wahrendorf M (29) Quality of work, health and retirement (Comment). The Lancet Each of these is strongly related to the social environment Mean SF-36 physical component scores and mental component scores by age group: Whitehall II respondents from phases 3-7. 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 7s than routine and manual classes 15 years earlier Chandola T et al. BMJ 27;334:99 Source: English Longitudinal Study of Ageing (ELSA) 3

4 Are older people more likely to be poor than the rest of the population? Not necessarily... At risk of poverty rate of people aged 65 and over after social transfers, 21 % aged 65 or over with an equalized disposable income below 6% of the national median disposable income after social transfers Source: Eurostat Spending on basics as % of income rises steeply among poorer groups Spending on basics as % of income 28/9 Percentage point change in spending as % of income 24/5-28/9 Poorest nd rd th Richest All Source: English Longitudinal Study of Ageing (ELSA) Wider Society Social exclusion Social protection across the life course Communities Per cent of the population aged 16 and over reporting bad or very bad health in EU-SILC by social protection expenditure per person in Euros purchasing power parity, 21 Per cent of population aged 16+in bad or very bad health 2 15 Latvia Lithuania Poland Hungary Slovakia Portugal Estonia Slovenia 1 Bulgaria Czech Republic 5 Romania Malta Cyprus Greece Spain Iceland Belgium Austria Italy Norway France Germany Denmark Finland United Kingdom Sweden Netherlands Ireland Luxembourg 2, 4, 6, 8, 1, 12, 14, 16, Social protection expenditure per person in Euros using purchasing power parity Source: Report on Health Inequalities in the EU, 213 4

5 Self reported health by education and social expenditures: 18 EU countries Predicted probability.25 of poor health Primary Predicted.25 probability of poor health Primary Secondary.1.1 Tertiary.5 Minimum Maximum Net Total Social Expenditures in PPP's.5 Net Total Social Expenditures in PPP's Source: Dahl & van der Wel, data from EU SILC 25, reported in: WHO Review of Social Determinants and the Health Divide in the European Region 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 Country clusters by level of policy response Cluster 1: Relatively positive and active response to health inequalities. At least one national response to HIs or comprehensive regional HI policy responses. Cluster 2: Variable response to health inequalities. No explicit national policy on HIs, but at least one explicit regional response or a number of other policies with some focus on health inequalities. Cluster 3: Relatively undeveloped response to health inequalities. No focused national or regional responses to health inequalities, no explicit health inequality reduction targets (though there may be targeted actions on the social determinants of health). Source: Report on Health Inequalities in the EU Widening of policy response between member states since 26 Level of policy response Countries by Cluster Group Intensification of policy response Cluster 1: Denmark, Finland, Norway, United Kingdom* Cluster 2: Estonia, Latvia, Spain*, Iceland* Same level of policy response Cluster 2: Belgium, France, Germany, Italy, Poland, Sweden Cluster 3: Lithuania* Decrease in intensity of the policy Cluster 1: Ireland, Netherlands response Cluster 2: Czech Republic Cluster 3: Cyprus, Greece, Hungary * Countries where on-going changes to policies (mentioned elsewhere within this report) may affect assessment. England: National Health Service duty in reducing inequalities New inequalities legislation 212 NHS duty to pay due regard to reducing health inequalities Trusts, CCGs, NHS England, PHE, DH Secretary of State accountable for health inequalities Note: Some countries were not included in the analysis performed in 26 and are therefore omitted from this table (Austria, Bulgaria, Croatia, Luxembourg, Malta, Portugal, Romania, Slovakia, and Slovenia). Source: Report on Health Inequalities in the EU 5

6 Priorities agreed by 65 Health and Well-being Boards Local Government England Prevention Inequality Ageing Mental health 28 Unhealthy behaviours 49 Marmot Principles Malmö, Sweden Commission for a Socially Sustainable Malmo, chaired by Sven-Olof Isaacson, March 211 to translate the findings of the CSDH into a form suitable to address social determinants and health inequalities in Malmo Report March 213 Kings Fund 213 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 Health is a human right Do something Do more Do better Michael Marmot 6