Transcript No Slide Title

The Commission on Social Determinants of Health
Closing the Gap in a Generation:
Health Equity through Action on the
Social Determinants of Health
Dr Sharon Friel
Principal Research Fellow, University College London &
Fellow, National Centre for Epidemiology and Population Health, The
Australian National University
Ireland, 12-13th January 2009
Dramatic inequities dominate global
health today
Global Programme on Evidence for Health Policy, 2000 data
A social gradient in health exists
within countries
All Ireland Health Inequalities
70 0
60 0
50 0
M o r t ali t y d if f e r e nc e
40 0
30 0
b e t w e e n h ig h e st a n d
l o w e st o c c u p a t io n a l
20 0
c l a ss e s
10 0
e
ea s
d is
o ry
ra t
s pi
Re
I nj
ur
ie s
&p
oi
d is
ry
a to
cul
C ir
so n
i ng
ea s
e
nce
r
Ca
se
is e
a
sd
io u
ect
I nf
l ca
us e
so
f de
a th
0
Al
Pe rc entage diffe ren ce (% )
O cc up ati ona l cla s s g rad ien ts i n he alth
Balanda and Wilde, Institute of Public Health, Ireland 2001
Age standardised all cause mortality, 15-64 years
1999-2003, England and Wales
Romeri et al, 2006
Under 5 mortality per 1000
Under 5 mortality rates, select countries, by
household wealth
200
150
100
50
0
Indonesia
Brazil
Poorest fifth
2nd richest fifth
Victora et al, 2003
India
2nd poorest fifth
Richest fifth
Kenya
Middle fifth
Producing policy and
institutional change
Building policy interest,
communities of practice
Building knowledge and
leadership
Commissioners
Knowledge networks
Country partners
Civil society
Global institutions
WHO integration
March 2005 – August 2008
Health equity as a development outcome
The development of society can be judged by:
• the quality of its populations’ health
• the fairness in distribution of health, and
• the degree of protection provided from
disadvantage due to ill-health
Marmot 2006 Harveian Oration
CSDH Thematic Areas
Environment
Education
Aid
Migration
Globalisation
Ageing
Women &
Gender Equity
Rural
Settings
Alcohol
Early Child Development
Social
Exclusion
Knowledge
Networks
Urban Settings
Conflict
Employment Conditions
Food & Nutrition
Mental
Health
Health Systems
Measurement & Evidence
Violence
PPHC
Psychosocial
Medical Education
Indigenous Peoples
www.who.int/social_determinants
“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 28th August 2008
Photo: WHO/Chris Black
The Social Determinants of Health
The poor health of the poor, the social gradient in health
within countries and the marked inequities between
countries are caused by:
Structural determinants
the unequal distribution in power, money, goods and services,
globally, nationally and locally
Conditions of daily life
The consequent unfairness in the immediate circumstances
in people’s lives - access to schools, education, health care,
conditions of work and leisure, their homes, communities,
towns or cities
Commission on Social Determinants of Health, 2008
CSDH three overarching recommendations:
1. Improve daily living conditions
2. Tackle the unequal distribution of power, money
and resources
3. Measure and understand the problem and assess
the impact of action
Early Life
Over 200 million children under 5 are not
reaching their developmental potential
Grantham-McGregor et al. Lancet 2007
Effects of nutritional supplementation and psychosocial
stimulation on stunted children in a 2 year study, Jamaica
Granthan-McGregor et al 1991
Urban health challenges
Communicable and non-communicable diseases
HIV/AIDS
Road traffic injuries
Urban violence and crime
Substance abuse and illicit drug use
Underweight and overweight
KNUS report 2007
Employment and Working Conditions
Regional variation in the percentage of people
in work living on US$2/day or less
ILO, 2008
Cost of a Standard Healthy Living Basket as a percentage
of Weekly Household Income, 2005
Friel et al, 2005. Standard of healthy living on the Island of Ireland. FSPB
Precarious employment and mental health
35
Percent
30
25
Permanent
20
Fixed term
temporary
Non-fixed term
temporary
No contract
15
10
5
0
Men
Artazcoz et al, 2005
Women
Economic and social policies
matter for health and health equity
Health Care
Every year, 100 million people are forced into
poverty by health care costs (ILO 2005).
Policy Challenge
Reorientation of health care
– Primary health care
– Disease prevention
– Health promotion
Progressive building of universal health care
services organised around PHC
2. Tackle the unequal distribution of
power, money and resources
“in a world that is so divided by inequalities in
wealth and opportunity, it is easy to forget that
we are part of one humanity”
Desmond Tutu in HDR, 2007.
Policy Challenges
Good Global
Governance
Political
empowerment
– inclusion and
voice
Gender Equity
Health Equity in all
Policies,
Systems and
Programmes
Fair Financing
Market
Responsibility
Overseas development assistance from donor
countries relative to per capita wealth, 1961-2002
EMERGING KEY ISSUES
Health Care
Family policy generosity and child poverty
Lundberg et al, 2007
Power and Governance
Participatory
Processes
HEiPSP
Health equity
at
the table
Aboriginal Youth Suicide by Cultural Factors
Present
140
Cultural Factors:
Suicide Rate per 100,000.
120
Self-government
100
Land claim
participation
80
60
Health services
40
Education
20
Cultural facilities
0
0
1
2
3
4
5
Total Number of Cultural Factors Present
Chandler & Lalonde, 1998
6
Police/fire services
3. Measure, evaluate, expand the
knowledge base, improve skills
and raise awareness
No data, no problem, no action
Claire Delperdange
Monitoring and Evaluation
Life expectancy at birth (men)
•
•
•
•
Glasgow (deprived)
The power of
India
data
Korea
Poland
Mexico
Stratified data
Measures of health inequity Cuba
US
Surveillance system
UK
Different types of data /
Glasgow (affluent)
knowledge
54
61
65
71
72
75
75
76
82
Monitoring and Evaluation
Knowing the impact on
health equity
• Tools to assess the impact of policy and
programmes
Improved human capacity
• Training needs
• medical, other health and non-health curricula
• workforce competencies
• Funding for evidence generation
• Push-pull factors: underlying determinants
• Public awareness and concern
Sustaining Action
•
•
•
•
•
Launch Final Report August 08
Regional Committee meetings 08
International Conference 08
National and regional commissions 08World Health Assembly 09
Building a Global Movement for Action on the
Social Determinants of Health and Health
Equity
Social justice is a
matter of life and
death. It affects the
way people live,
their consequent
chance of illness,
and their risk of
premature death…
www.who.int/social_determinants