closing the gap in a generation - epi2008.com.br 23_09_11h45_pdf... · social protection health...

Closing the gap in a Closing the gap in a

generationgenerationMichael MarmotMichael Marmot

UCLUCL

Chair of WHO Commission on Social Chair of WHO Commission on Social Determinants of HealthDeterminants of Health

World Congress of Epidemiology

Porto Alegre, Brazil

Keynote lecture

September 2008

OutlineOutline

Inequities and the social gradientInequities and the social gradient

Convergence of challenges;Convergence of challenges;

Addressing the challenges Addressing the challenges –– taking action taking action

on the social determinants of health on the social determinants of health

Between country inequitiesBetween country inequities……

Life expectancy 43 years shorter for women in Life expectancy 43 years shorter for women in

Zambia (43) than for women in Japan (86) Zambia (43) than for women in Japan (86) (WHO (WHO

2008)2008)

The lifetime risk of maternal death is one in The lifetime risk of maternal death is one in

eight in Afghanistan; it is only 1 in 17 400 in eight in Afghanistan; it is only 1 in 17 400 in

Sweden Sweden (WHO et al 2007)(WHO et al 2007)

Within country inequitiesWithin country inequities……

Life expectancy 17 years shorter for black Life expectancy 17 years shorter for black

men Washington DC than for white men in men Washington DC than for white men in

nearly Montgomery County.nearly Montgomery County.

Maternal mortality 3Maternal mortality 3--4 times higher among 4 times higher among

the poor compared to the rich in Indonesia.the poor compared to the rich in Indonesia.

Deaths rates (age standardized) for all causes of death by Deaths rates (age standardized) for all causes of death by

deprivation twentieth, ages 15deprivation twentieth, ages 15--64, 199964, 1999--2003, England and Wales2003, England and Wales

males

females

The dashed lines are average mortality rates for men and women inEngland and Wales

women

men

Romeri et al 2006

Difference in adult mortality between least and most deprived neDifference in adult mortality between least and most deprived neighbourhooighbourhoo

in UK more than 2.5 times.in UK more than 2.5 times.

Cardiovascular deaths of people aged 45 Cardiovascular deaths of people aged 45 -- 64 64

and social inequalities: Porto Alegre, Braziland social inequalities: Porto Alegre, Brazil

0

50

100

150

200

250

300

350

400

High Medium

high

Medium

low

Low ALL

CVD deaths Attributable CVD deaths

CVD deathsper 100,000

inhabitants

Socioeconomic level of districts

45% all premature CVD deaths in Porto Allegre caused by socioeconomic inequality

Premature mortality by CVD 2.6 times higher in lowest compared to highest districtsby socioeconomic level

(Source: Bassanesi, Azambuja & Achutti, Arq Bras Cardiol, 2008)

Dramatic inequalities dominate global Dramatic inequalities dominate global

health health

A social gradient in health exists in all A social gradient in health exists in all

countries and within citiescountries and within cities

0

50

100

150

200

Uganda

2000/01

India

1998/99

Turkmenistan

2000

Peru 2000 Morocco

2003/04

Poorest Less poor Middle Less rich Richest

Under 5 mortality per 1000 live births by wealth Under 5 mortality per 1000 live births by wealth

quintilequintile

Gwatkin et al 2007, DHS data

Average U5M for high income countries is 7/1000

OutlineOutline

Inequities and the social gradientInequities and the social gradient



on the social determinants of health on the social determinants of health

Double burden of diseaseDouble burden of disease

-- communicable and noncommunicable and non--

communicablecommunicable

Source: World Health Statistics, WHO, 2008

Projected deaths by cause for high-, middle,and low-income countries

CVD

CVD

CVD

Proportion of population aged 60 or overProportion of population aged 60 or over

0

5

10

15

20

25

30

35

1950 1975 2007 2025 2050

World More developed regions Less developed regions

%

Source: World Population Ageing 2007, UNDESA

Climate change Climate change –– adds urgency to take adds urgency to take

action on SDHaction on SDH

OutlineOutline

So whatSo what’’s news new……??



on the social determinants of healthon the social determinants of health

Economic and social policies Economic and social policies

matter for health and health matter for health and health

equityequity

Health Equity as a Development Outcome

Participation

Voice

Agency

Empowerment

PsychosocialMaterial

Political

Health Equity

Daily Living Conditions Early life

Physical and social environments

Working conditionsSocial Protection

Health Care

Structural Drivers

Societal norms and valuesSocial Inequities

Governance and FinancingEconomic Growth and Social Policy

WHO Commission on Social Determinants WHO Commission on Social Determinants

of Healthof Health

2005 2005 --20082008

�� CommissionersCommissioners�� 9 Knowledge 9 Knowledge

NetworksNetworks�� Country PartnersCountry Partners�� Civil society workCivil society work�� Global initiativeGlobal initiative�� WHO integration WHO integration Set up by the World Health Organisation

www.who.int/social_determinants

Conditions in which people are

born, grow, live, work and age

Structural drivers of those conditions

at global, national and local level

CSDH CSDH –– Areas for ActionAreas for Action

Monitoring, Training, Research

Early child development and

education

Healthy Places

Fair Employment

Social Protection

Universal Health Care

Health Equity in all Policies

Fair Financing Good Global

Governance

Market

Responsibility

Gender Equity

Political empowerment

– inclusion and voice


Proportion relatively poor pre and Proportion relatively poor pre and

post welfare state redistributionpost welfare state redistribution

05

1015202530354045

Finla

ndNorw

aySw

eden

Belgiu

mG

erm

any

Netherla

nds

Italy

Spain

Canada

UK US

poverty rates post tax & transfers poverty reduction by income redistribution

71% 71% 72%

Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data,

CSDH Nordic Network

62% 63% 59%

54%49%

44%50%

24%

Po

ver

ty %

Taxation in East Asia (left) and subTaxation in East Asia (left) and sub--Saharan Saharan

Africa (right), 1970Africa (right), 1970––79, 198079, 1980––89, and 199089, and 1990––9999

Cobham 2005

direct

sales

trade

East Asia sub Saharan Africa

0

20

40

60

80

100

S Asia Latin

America and

Caribbean

E Asia and

Pacif ic

Sub-

Saharan

Africa

Mid-east and

N Africa

Europe and

C Asia

Industrialised

economies

%

1980-85

1986-90

1991-95

1996-98

Proportion of tariffs in total revenue by region,1980-1998

Source: GKN 2007

Low income countries are relatively more reliant on import tariffs for public revenue. Trade liberalization has reduced the availability of tariff revenues since 1970s

Trends in development assistance, G7 and Trends in development assistance, G7 and

selected comparison countries,1985 selected comparison countries,1985 -- 20062006

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

UK

USA

Japan

Italy

Germany

Canada

France

Denmark

Sweden

Norway

Netherlands

Source: OECD, Development database on Aid from DAC Members

0.7

% GNI


education

Healthy Places

Fair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity




Child survival and early child developmentChild survival and early child development

Physical, cognitive/language, Physical, cognitive/language,

social/emotionalsocial/emotional

Poor selfPoor self--rated health at age 50+ and accumulation of rated health at age 50+ and accumulation of

sociosocio--economic risk factors over life course economic risk factors over life course –– Russian Russian

menmen

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

MEN WOMEN

O 1 2 3No. of risk factors

Risk factors:

•Ever hungry to bed aged 15 yr

•Elementary /vocational education

•Adult household income below median

Odd

s R

atio

fo

r P

oor

Hea

lth

(Nicholson et al 2005)


education

Healthy Places

Fair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity





education

Healthy PlacesFair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity




Global slum upgradingGlobal slum upgrading

Cost estimate: less than US$ 100 billion.Cost estimate: less than US$ 100 billion.

Finance on shared basis, for instance byFinance on shared basis, for instance by

–– international agencies and donors (45%),international agencies and donors (45%),

–– national and local governments (45%), andnational and local governments (45%), and

–– households themselves (10%), helped by households themselves (10%), helped by

micromicro--credit schemes. credit schemes.

Slum upgrading in IndiaSlum upgrading in India

Slum upgrading in Ahmadabad, India, cost only Slum upgrading in Ahmadabad, India, cost only

US$ 500/household. US$ 500/household.

community contributions of US$ 50/household.community contributions of US$ 50/household.

Following the investment in these slums, there Following the investment in these slums, there

was improvement in healthwas improvement in health

–– decline in waterborne diseases, decline in waterborne diseases,

–– children started going to school, children started going to school,

–– women were able to take paid work, no longer having women were able to take paid work, no longer having

to stand in long lines to collect water.to stand in long lines to collect water.


education

Healthy Places

Fair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity





education

Healthy Places

Fair Employment Social Protection




Governance

Market

Responsibility

Gender Equity




Regional variation in the percentage of people in Regional variation in the percentage of people in

work living on US$ 2/day or lesswork living on US$ 2/day or less

0

10

20

30

40

50

60

70

80

90

100

1997 2002 2007

World

Central & South EastEurope & CIS

East Asia

South East Asia &Pacific

South Asia

Latin America &Caribbean

Middle East

North Africa

Sub-Saharan Africa

2007 figures are preliminary estimateILO 2008

Gender inequities in labour conditions: lost pay or lost job promotions or difficulty retaining jobs

36

4349

25

36

28

0

20

40

60

Unable to get paid leave Did not have access tohealth insurance through

job

Job difficulties* because ofneed to care for sick

children

women men

% o

f pare

nts

* Job difficulties: lost pay or lost job promotions or difficulty retaining jobs. Adapted from Heymann (2006), Forgotten Families. Average percentages basedon selected countries.


education

Healthy Places

Fair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity





education

Healthy Places

Fair Employment

Social Protection Universal Health Care



Governance

Market

Responsibility

Gender Equity




Building social protection for the elderlyBuilding social protection for the elderly

–– materialmaterial

–– psychosocialpsychosocial

Minimum income for healthy living Minimum income for healthy living –– Morris et al.Morris et al.

–– DietDiet

–– Physical activity/body and mindPhysical activity/body and mind

–– Psychosocial relations/social connections/activePsychosocial relations/social connections/active

mindsminds

–– Getting aboutGetting about

–– Medical careMedical care

–– HygieneHygiene

–– HousingHousing

Psychosocial relations/social connections/active mindsPsychosocial relations/social connections/active minds

TelephoneTelephone

Stationery, stampsStationery, stamps

Gifts to Gifts to

grandchildren/othersgrandchildren/others

Cinema, sports, etcCinema, sports, etc

Meeting friends, Meeting friends,

entertainingentertaining

TV set and licenceTV set and licence

NewspapersNewspapers

Holidays (UK)Holidays (UK)

Miscellaneous, Miscellaneous,

hobbies, gardening hobbies, gardening

etcetc

Morris et al 2007

Weekly disposable incomes for Weekly disposable incomes for

people over 65, England 2007people over 65, England 2007

State State

pensionpensionPension Pension

credit credit

guarantee*guarantee*

Minimum Minimum

income for income for

healthy healthy

living **living **

Single Single

personperson££87.3087.30 ££119.05119.05 ££131.00131.00

CoupleCouple ££139.60139.60 ££181.70181.70 ££208.00208.00

*Rent, mortgage and council tax may be paid after further means testing** people 65+ living independently in the community; excludes rent, mortgageand council tax

Morris et al 2007 IJE

Social pensions in selected low and Social pensions in selected low and

middle income countriesmiddle income countries

CountryCountry Age Age eligibleeligible

Universal Universal or means or means testedtested

Monthly Monthly

amountamount

(US$)(US$)

% of % of

pop 60+pop 60+

% of % of people people

60+ 60+

receivingreceiving

BangladeshBangladesh 57+57+ MM US$ 2US$ 2 6%6% 16% 16% (age 57+)(age 57+)

IndiaIndia 65+65+ MM US$ 4US$ 4 8%8% 13%13%

ThailandThailand 60+60+ MM US$ 8US$ 8 11%11% 16%16%

BotswanaBotswana 65+65+ UU US$ 27US$ 27 5%5% 85%85%

Lesotho Lesotho

Since 2004 universal social pension Since 2004 universal social pension

scheme for all aged 70+ years scheme for all aged 70+ years

costs 1.43% of GDPcosts 1.43% of GDP

benefit level is about the same as the benefit level is about the same as the

national poverty line (about US$ national poverty line (about US$

21/month). 21/month).

Monthly disbursement through post office Monthly disbursement through post office

network in rural and urban areas network in rural and urban areas

(McKinnon, 2007)


education

Healthy Places

Fair Employment

Social Protection




Governance

Market

Responsibility

Gender Equity




Universal Primary Health Care Universal Primary Health Care

Community basedCommunity based

Disease preventionDisease prevention

Health promotion Health promotion –– using social using social

determinants frameworkdeterminants framework

EMPOWERMENTEMPOWERMENT

–– MATERIALMATERIAL

–– PSYCHOSOCIALPSYCHOSOCIAL

–– POLITICALPOLITICAL

WhatWhat’’s next?s next?

WHO taking the leadWHO taking the lead

Building capacityBuilding capacity

AdvocacyAdvocacy

ResearchResearch

TrainingTraining

OptimismOptimism

Under 5 mortality rate: change 1990 Under 5 mortality rate: change 1990 --

20062006

6

27

27

29

83

46

160

10

53

55

55

123

79

187

0 50 100 150 200

Industrialized countries

CEE/CIS

Latin America & Caribbean

East Asia & Pacific

South Asia

Middle East & North Africa

Sub-Saharan Africa

Reduction 40%

Least

reduction

14%

UNICEF

Reduction 42%

Reduction 33%

Reduction 47%

Reduction 51%

Reduction 49%

Trends in U5M by wealth quintile: Trends in U5M by wealth quintile:

BangladeshBangladesh

128

110

97

76 72 72

122

85 81

135

10697

147

127

98

141 140

121

50

70

90

110

130

150

1996/97 1999/2000 2004

Average Richest 4th 3rd 2nd Poorest

Relative inequ: 1.86 1.93 1.69

Absolute inequ: 65 67 50(DHS data)

www.who.int/social_determinants/en

A world

where social

justice is

taken

seriously

closing the gap in a generation - epi2008.com.br 23_09_11h45_pdf... · social protection health...

Documents