The Commission on Social Determinants of Health

Dr Sharon FrielPrincipal Research Fellow, University College London &

Fellow, National Centre for Epidemiology and Population Health, The Australian National University

Ireland, 12-13th January 2009

Closing the Gap in a Generation: Health Equity through Action on

the Social Determinants of Health

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

Balanda and Wilde, Institute of Public Health, Ireland 2001

Occupational class gradients in health

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Perc

en

tage d

iffe

ren

ce (

%)

Mortality differencebetween highest andlowest occupationalclasses

Age standardised all cause mortality, 15-64 years 1999-2003, England and Wales

Romeri et al, 2006

Under 5 mortality rates, select countries, by household wealth

0

50

100

150

200

Indonesia Brazil India Kenya

Poorest fifth 2nd poorest fifth Middle fifth2nd richest fifth Richest fifth

Und

er 5

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Victora et al, 2003

Building knowledge and leadership

Producing policy and institutional change

Building policy interest, communities of practice

Commissioners

Knowledge networks

Country partners

Civil society

Global institutions

WHO integration

March 2005 – August 2008

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

Health equity as a development outcome

CSDH Thematic Areas

Ageing

MigrationAid

Mental Health

Environment

Alcohol

Food & Nutrition

Rural Settings

Psychosocial

Medical Education

Education

Violence

Indigenous Peoples

Conflict

Women & Gender Equity

Social Exclusion

Globalisation

Health Systems

Urban Settings PPHC

Employment Conditions

Early Child Development

Measurement & Evidence

Knowledge Networks

www.who.int/social_determinants

““This ends the debate decisively. Health care is This ends the debate decisively. Health care is an important determinant of health. Lifestyles an important determinant of health. Lifestyles are important determinants of health. But it is are important determinants of health. But it is factors in the social environment that determine factors in the social environment that determine access to health services and influence lifestyle access to health services and influence lifestyle choices in the first place.”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:

Commission on Social Determinants of Health, 2008

Structural determinantsthe 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

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

0

5

10

15

20

25

30

35

Men Women

Pe

rce

nt

Permanent

Fixed termtemporary

Non-fixed termtemporary

No contract

Artazcoz et al, 2005

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).

Reorientation of health care– Primary health care – Disease prevention – Health promotion

Progressive building of universal health care services organised around PHC

Policy Challenge

“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.

2. Tackle the unequal distribution of power, money and resources

Health Equity in all Policies,

Systems and Programmes

Fair Financing

Good Global Governance

Market Responsibility

Gender Equity

Political empowerment – inclusion and

voice

Policy Challenges

Health CareEMERGING KEY ISSUES

Overseas development assistance from donor countries relative to per capita wealth, 1961-2002

Family policy generosity and child poverty

Lundberg et al, 2007

Power and Governance

ParticipatoryProcesses

Health equity at

the table

HEiPSP

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20

40

60

80

100

120

140

Su

icid

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ate

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100,0

00.

0 1 2 3 4 5 6Total Number of Cultural Factors Present

Cultural Factors:

Self-government

Land claim participation

Health services

Education

Cultural facilities

Police/fire services

Aboriginal Youth Suicide by Cultural Factors Present

Chandler & Lalonde, 1998

No data, no problem, no action

3. Measure, evaluate, expand the knowledge base, improve skills and raise awareness

Claire Delperdange

Monitoring and Evaluation

• Stratified data• Measures of health inequity• Surveillance system• Different types of data /

knowledge

The power of data

Glasgow (deprived) 54

India 61

Korea 65

Poland 71

Mexico 72

Cuba 75

US 75

UK 76

Glasgow (affluent) 82

Life expectancy at birth (men)

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 08-• World Health Assembly 09

Building a Global Movement for Action on the Social Determinants of Health and Health

Equity

www.who.int/social_determinants

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……