Taking action on the Social Determinants of Health...

Taking action on the Social Determinants of Health Michael Marmot

Thanks to Ruth Bell www.instituteofhealthequity.org

The Commission on Social Determinants of Health (CSDH) – Closing the gap in a generation

Strategic Review of Health Inequalities in England:

The Marmot Review – Fair Society Healthy Lives

Review of Social

Determinants of Health and

the Health Divide in the

WHO European

Region

• Social justice • Material, psychosocial,

political empowerment • Creating the conditions

for people to have control of their lives

www.who.int/social_determinants

Key principles

Prenatal Pre-school School Training Employment Retirement

Family building

Accumulation of positive and negative effects on health and wellbeing

Life course stages

Male life expectancy at birth, local authorities 2008-10

70

72

74

76

78

80

82

84

86

0 30 60 90 120 150

Life expectancy (years)

Local authority rank - based on Index of Multiple Deprivation

Inequalities in male life expectancy within local authority areas, 208-2010

Largest inequalities Smallest inequalities Westminster 16.9 (84) Barking & Dagenham 5.2 (77) Stockton-on-Tees 15.3 (78) Newham 5.0 (76) Middlesbrough 14.8 (76) Isle of Wight 4.9 (79) Wirral 14.6 (77) Herefordshire Cty UA 4.8 (79) Darlington 14.6 (77) Wokingham 3.5 (82) Newcastle -u-Tyne 13.7 (77) Hackney 3.1 (77) Figures in parentheses show life expectancy of the area

Female life expectancy at birth, local authorities 2008-10

70

75

80

85

90

95

0 30 60 90 120 150

Life expectancy (years)


“Fair Society, Healthy lives” themes

Country Year Life

expectancy

Highest Israel 2009 80 Iceland 2009 80 Sweden 2010 80 Switzerland 2007 80 Lowest Ukraine 2010 65 Republic of Moldova 2010 65 Kyrgyzstan 2009 65 Belarus 2009 65 Kazakhstan 2009 64 Russian Federation 2009 63

Male life expectancy – WHO European Region

Source: WHO HFA database

Female life expectancy – WHO European Region

Source: WHO HFA database

Country Year Life

expectancy

Highest Spain 2009 85 France 2008 85 Italy 2008 85 Switzerland 2007 85 Lowest Ukraine 2010 75 Russian Federation 2009 75 Turkey 2008 74 Kazakhstan 2009 74 Republic of Moldova 2010 74 Uzbekistan 2005 73 Kyrgyzstan 2009 73

Years of life spent free of disability, women in selected European countries 2009

Source: EC health indicators

Differences between women and men in years spent free of disability, selected European countries 2009

Source: EC health indicators

Absolute inequality in males death rates by level of education

Mackenbach et al 2008

Remaining life expecancy at 30 years of age for women and men based on educational level, 1991 -2010: Sweden

Women Men Age Age

Post secondary education

Secondary education

Lower secondary

6

4.1

3,2

5

Trends in probability of survival in men by education: Russian Federation

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

45 p20 = probability of living to 65 yrs when aged 20 yrs

University

Less than secondary

Source: Murphy et al 2006

Prenatal Early Years Working Age Older Ages

Family building


LIFE COURSE STAGES

MACROLEVEL CONTEXT

WIDER SOCIETY SYSTEMS

Perpetuation of inequities

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

Differences in PISA scores by attending preschool for more than one year before and after accounting for socioeconomic background

OECD PISA 2009 database

0 20 40 60 80 100 120 140

Israel Belgium France

Italy Switzerland

Denmark United Kingdom

Turkey Lithuania

Serbia TFYR Montenegro

Netherlands Ireland

Slovenia

Before accounting for socioeconomic background After accounting for socioeconomic background

0 10 20 30 40 50 60

Romania Latvia

Bulgaria Lithuania

Italy Greece

Spain Poland

Portugal Luxembourg

Hungary United Kingdom

Malta Estonia

Switzerland Ireland

Slovakia France

Belgium Netherlands

Germany Austria

Czech Republic Sweden Finland Cyprus

Slovenia Denmark

Norway Iceland

Poverty rate

Before social transfers After social transfers

Child poverty rates <60% median before and after social transfers 2009

Source: EU SILC

Country ranking: equality in child wellbeing - material, education, and health

Source: UNICEF Report Card 9, ranking 24 OECD countries by their performance in each of three dimensions of inequality in child well-being

Score Country 8 Denmark, Finland, Netherlands, Switzerland 7 Iceland, Ireland, Norway, Sweden 6 Austria, France, Germany, Poland, Portugal,

Canada 5 Belgium, Czech Republic, Hungary,

Luxembourg, Slovakia, Spain, United Kingdom 3 Greece, Italy, United States

Country comparison on average rank in four dimensions of child wellbeing – material, health, education, behaviours & risks, in early 2000s and late 2000s

UNICEF 2013

Children achieving a good level of development at age five, local authorities 2011: England

40

45

50

55

60

65

70

75

80

0 30 60 90 120 150

Good level of development

at age 5 %


Source: LHO (2012)

Birmingham Brighter Futures • Children and young people; • Physical health, literacy and numeracy, behaviour,

emotional health, social literacy, and job skills. • Specific programmes: Family Nurse Partnership

(FNP), Incredible Years Parenting Programme, Promoting Alternative Thinking Strategies (PATHS), Triple P Parenting Programme.

Per cent 5 year olds achieving ‘good development score’,* Birmingham LA, West Midlands & England

*in personal, social and emotional development and communication, language and literacy

Source: Department for Education: preliminary data

%


Family building


LIFE COURSE STAGES

MACROLEVEL CONTEXT



Unemployment rates by education and country of origin in selected countries

Source: Eurostat database

Psychosocial stress and occupational class

SHARE -11 European Countries Wahrendorf, Dragano and Siegrist 2011

Salavecz et al 2010

Risk of poor health by effort-reward imbalance at work: European countries


Family building


LIFE COURSE STAGES

MACROLEVEL CONTEXT



Wider Society

• Social exclusion • Social protection across the life course • Communities

Relation between social welfare spending and all cause mortality in 18 EU countries, 2000

Stuckler D et al. BMJ 2010;340:bmj.c3311

Social Protection

Each 100 USD per capita greater social spending reduced the effect on suicides by: 0.38%, active labour market programmes 0.23%, family support 0.07%, healthcare 0.09%,unemployment benefits

Spending> 190 USD no effect of unemployment on suicide

Source: Stuckler et al 2009 Lancet


Family building


LIFE COURSE STAGES

MACROLEVEL CONTEXT



Macrolevel context: Economic Issues Sustainability and environment

Changes in self-reported health and access to health care in Greece between 2007 and 2009, adjusted estimates

Source: Kentikelenis et al, 2011


Family building


LIFE COURSE STAGES

MACROLEVEL CONTEXT



London Health Inequalities Strategy

London HI Strategy: 5 strategic objectives:

1. Empowering individuals and communities 2. Equitable access to high quality heath and

social care services 3. Income inequality and health 4. Health, work, and well-being 5. Healthy places

Strengthening Communities: Merseyside Fire & Rescue Service

•Promoting healthier, safer communities’

•Community fire safety team – follow up to home safety checks •Youth programmes •Community fire stations

•On site free gyms •Gardens & gardening projects •Community rooms

Local areas using 6 areas Fair Society Healthy Lives in local strategies:

Malmö, Sweden • Commission for a Socially Sustainable Malmo,

chaired by Sven-Olof Isaacson, March 2011 • to translate the findings of the CSDH into a form

suitable to address social determinants and health inequalities in Malmo

• Report March 2013

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

Income, employment, housing and health • Unemployment, low incomes and poor

housing contribute to worse health; • These problems are more likely to occur

among particular groups within the population and among those already on low incomes.

Projected relative AHC income poverty rates under current policies and without the coalition government’s tax and benefits reforms: UK

Institute for Fiscal Studies, 2011

•A Fair Society

Taking action on the Social Determinants of Health...

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