Closing the Gap: Global health equity and the Commission on Social Determinants of Health Michael Marmot UCL

Transcription

1 Closing the Gap: Global health equity and the Commission on Social Determinants of Health Michael Marmot UCL Chair: Commission on Social Determinants of Health McLaughlin-Gallie Visiting Professor Lecture Montreal, Canada February 5 th 2009

2 Hoary Marmot high-pitched welcoming whistle; gains body-fat in summer; Sleepy in winter.

3 Social justice Empowerment material, psychosocial, political Creating the conditions for people to take control of their lives

4 Photo: WHO/Chris Black This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place. Dr Margaret Chan, the DG of the WHO, at the launch of the CSDH Final Report in Geneva 28 th August 2008

5 Outline Health inequities within and between countries The social gradient in health Social determinants of health and health inequity Action on SDH societal well being Principles of action on the SDH Action on SDH areas for action

6 UK, Glasgow (Calton( Calton) India Japan US, Montgomery County (white) Life expectancy at birth (men) US, Washington D.C. (black) Philippines Lithuania Poland Mexico Cuba US UK UK, Glasgow (Lenzie( N.) Sources: WHO World Health Statistics 2007; Hanlon, Walsh & Whyte 2006; Murray et al. 2006

7 Poverty and the social gradient If we only target the poorest 10% we miss most of the health problem

8 Deaths rates (age standardized) for all causes of death by deprivation twentieth, ages 15-64, , England and Wales males men females women The dashed lines are average mortality rates for men and women in England and Wales Romeri et al 2006

9 Under 5 mortality per 1000 live births by wealth quintile Poorest Less poor Middle Less rich Richest Uganda 2000/01 India 1998/99 Turkmenistan 2000 Peru 2000 Morocco 2003/04 Gwatkin et al, DHS data

10 Pan-Canadian self-reported health: percentages by socio-economic status group % of respondents Alcohol binging High SES Average SES Low SES Smoking Overwt or obese Physical inactivity Source: Canadian Institute for Health Information, Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada, 2008 Self rated Health

11 Is change possible?

12 Sweden: Life Expectancy at age 30 by level of education, , women Compulsory Upper secondary Post-secondary Slide: Vagero Source: SCB

13 The widening trend in mortality by education in Russia, elementary university 45 p Calendar year 45 p20 = probability of living to 65 yrs when aged 20 yrs Source: Murphy et al, AJPH, 96, , 2006

14 Trends in U5M by wealth quintile: Bangladesh Average Richest 4th 3rd 2nd Poorest / / Relative inequ: bsolute inequ: (DHS data)

15 Outline Health inequities within and between countries The social gradient in health Social determinants of health and health inequity Action on SDH societal well being Principles of action on the SDH Action on SDH areas for action

16 Inequalities in health that are avoidable are inequitable Tackling health inequities is a matter of social justice

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

18 Outline Health inequities within and between countries The social gradient in health Social determinants of health and health inequity Action on SDH societal well being Principles of action on the SDH Action on SDH areas for action

19 CSDH three principles of action Structural drivers of those conditions at global, national and local level Conditions in which people are born, grow, live, work and age Monitoring, Training, Research

20 Outline Health inequities within and between countries Action on SDH societal well being Principles of action on the SDH Action on SDH areas for action

21 CSDH three principles of action Structural drivers of those conditions at global, national and local level Conditions in which people are born, grow, live, work and age Monitoring, Training, Research

22 National monitoring systems health equity and the social determinants of health Global health equity surveillance system

23 CSDH three Linked Areas for Action Structural drivers of those conditions at global, national and local level Early child development and education Conditions Healthy in which Places people are born, grow, Fair Employment live, work and age Social Protection Universal Health Care Monitoring, Training, Research

24 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

25 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

26 Intersectoral linkage for health and health equity

27 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

28 Bretton Woods 2 international 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 agenda Place equality of influence at the heart of decision-making CSDH FR

29 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

30 FAMILY POLICY GENEROSITY AND Povety (%) USA AUS IRE SWI UK CHILD POVERTY NET CAN AUT BEL GER FRA ITA FIN SWE NOR Family Policy Generosity (%) Countries with generous family policies have lower child poverty rates This association is mainly due to policies that support dual earner families The contribution may be direct through the amount of benefits paid, or indirect by supporting two earners and thereby raising the market income of the household Lundberg et al 2007 CSDH NEWS group

31 Proportion relatively poor pre and post welfare state redistribution Poverty % poverty rates post tax & transfers 71% 71% 72% 62% 63% 59% poverty reduction by income redistribution 54% 49% 44% 50% 24% Finland Norway Sweden Belgium Germany Netherlands Italy Spain Canada UK US Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network

32 Recognising global role High income countries and global role Debt and overseas development assistance Implications of trade and trade agreements for global health and health equity

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

34 Taxation in East Asia (left) and sub-saharan Africa (right), , 79, , 89, and trade sales direct East Asia sub Saharan Africa Cobham 2005

35 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

36 CSDH Areas for Action Health Equity in all Policies Market Responsibility Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

37 Aboriginal Youth Suicide by Factors Present Suicide Rate per 100, Total Number of Cultural Factors Present Cultural Factors: Self-government Land claim participation Community Control: Health services Education Cultural facilities Police/fire services Chandler & Lalonde, 1998

38 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

39 Early child development and education Early life survival and development Physical, language/cognitive and social/emotional development

40 Sure Start Local Programmes: England Effect of SSLP versus non SSLP Child development Mean difference Child positive social behaviour Independence 0.45 (p value 0.01) 0.32 (p value less than 0.001) Parenting Negative parenting (p value less than 0.001) Home learning environment 1.3 ((p value less than 0.001)

41 Gaps in average maths scores among 15 year olds by father s education: selected OECD countries Difference in maths score low to high education Difference in maths score medium to high education Sweden US Canada unweighted OECD average OECD 2008

42 Intergenerational mobility across the earnings distribution Lowest income quintile 3rd quintile Highest income quintile 2nd quintile 4th quintile Probability for son of being in the same income quintile as the father 0.5 Sweden UK US Welfare dependency is transmitted across generations OECD 2008

43 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

44 Rates of mortality from transportation injury in nine European countries, by level of education, 1990s Figure from Mackenbach 2006

45 Impact of heat wave in Europe Country France Germany Spain Italy UK Netherlands Portugal Belgium (2003) Excess Deaths* *number of deaths over and above what would normally be expected for the month of August., source: INSERM 2005 in Environment Alert Bulletin, UNEP

46 Elderly Loss of autonomy Social isolation Living directly below roof of a building Living in cities - heat island effect (Brucker, 2005)

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

48 Fast food consumption (1995 and Fast food consumption (1995 and 1999) in selected countries Russia Poland Hungary Czech Republic South Africa Mexico Chile Brazil Argentina Venezuela Thailand Malaysia Philippines China India Source: Eurobarometer data in Hawkes 2002 Million transa

49 Fast food chains more common in deprived areas: England and Scotland Mean number of fast food outlets* per people (most deprived Macdonald et al (least deprived) Index of multiple deprivation quintile (*McDonald s, Burger King, KFC and Pizza Hut)

50 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

51 FAIR EMPLOYMENT Freedom from coercion Job security Fair income Job protection and social benefits Respect and dignity at work Workplace participation Enrichment and lack of alienation CSDH EMCONET 2007

52 Prevalence of poor mental health in manual workers by type of contract: Spain % Permanent Fixed term temporary Non-fixed term temporary No contract 5 0 Source: Artazcoz et al 2005

53 The Iso-strain strain concept of stress at work Socially isolated (no supportive co-workers or supervisors) High strain (High demands and low control)

54 Coronary heart disease and work stress, Whitehall II study Hazard Ratios of incident CHD by Iso-Strain (phase 1 and 2 of Whitehall II); split by age group under No report of iso strain 1 report 2 reports Chandola et al. European Heart Journal (2008)

55 PAR* for coronary heart disease (fatal CHD/non fatal MI/definite angina) 50 PAR % 40 Each domain Combined Full adjustment PAR for all combined * 30% 95% CI 10%-46% adjusted for other predictors DCS ERI Justice Combined Full adjustment *Population attributable risk odds ratios adjusted for age, sex, employment grade 29% 95% CI 9%-45% J Head et al,2007

56 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

57 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

58 Building social protection for the elderly material psychosocial

59 Minimum income for healthy living Morris et al. Diet Physical activity/body and mind Psychosocial relations/social connections/active minds Getting about Medical care Hygiene Housing

60 Psychosocial relations/social connections/active minds Telephone Stationery, stamps Gifts to grandchildren/others Cinema, sports, etc Meeting friends, entertaining TV set and licence Newspapers Holidays (UK) Miscellaneous, hobbies, gardening etc Morris et al 2007

61 *Rent, mortgage and council tax may be paid after further means testing ** people 65+ living independently in the community; excludes rent, mortgage and council tax Morris et al 2007 IJE Weekly disposable incomes for people over 65, England 2007 Single person State pension Pension credit guarantee* Minimum income for healthy living ** Couple

62 CSDH Areas for Action Health Equity in all Policies Fair Financing Market Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Good Global Governance Gender Equity Political empowerment inclusion and voice

63 Health sector Access, availability, acceptability, quality Exemplar of good practice major employer Stewardship Health equity in all policies

64 Universal Primary Health Care Community based Disease prevention Health promotion using social determinants framework

65 Health-adjusted life expectancy (HALE) and private spending as a percentage of total health spending (2000) Healthy life expectancy: years Private as % of total health expenditure Koivusalo & Mackintosh (2005)

66 Catastrophic health expenditure and impoverishment due to out-of of-pocket health expenditure, by WHO region Eastern Mediterranean African People Impoverished People suffering catastrophic health expenditure Europe South-East Asia Americas Western pacific Number of people (millions) Source: World Health Statistics, WHO, 2008

67 Moving forward Global Conference in London Nov 6/ to promote uptake announcement of review of health inequalities in England Sri Lanka 2009, practical uptake in SE Asia Countries translate findings into programmes, Brazil, Chile, UK, Canada, Argentina?, India? WHO resolution ECOSOC Agenda -? Core Development Goal Global Report on Social Determinants and Health equity Capacity building Research and Training

68 Global movement

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71 I am pleased to announce that Sir Michael Marmot has agreed to undertake a new review of health inequalities in England And we will learn from other countries along the way Gordon Brown, Prime Minister, UK at Closing the Gap Conference, 6th Nov 2008

72 Optimism?

73 Under 5 mortality rate: change Sub-Saharan Africa Middle East & North Africa South Asia East Asia & Pacific Latin America & Caribbean CEE/CIS Industrialized countries Reduction 40% 79 Reduction 42% 83 Reduction 47% Reduction 51% Reduction 49% 123 Reduction 33% Least reduction 14% UNICEF

74 Closing the Gap in a Generation A world where social justice is taken seriously