closing the gap in a generation - bvsde desarrollo … · closing the gap in a generation ......
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Closing the gap in a Closing the gap in a generationgeneration
Michael MarmotMichael MarmotUCLUCL
Chair of WHO Commission on Social Chair of WHO Commission on Social Determinants of HealthDeterminants of Health
Santiago, ChileSeptember 2008
Social Justice
Empowerment•Material•Psychosocial•political
Creating conditions forpeople to lead flourishinglives
OutlineOutline
Inequities and the social gradientInequities and the social gradientConvergence 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 neighbourhooighbourhooin 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 and social inequalities: Porto AllegreAllegre, Brazil, Brazil
050
100150200250300350400
High Mediumhigh
Mediumlow
Low ALL
CVD deaths Attributable CVD deaths
CVD deathsper 100,000inhabitants
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
Uganda2000/01
India 1998/99
Turkmenistan2000
Peru 2000 Morocco2003/04
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 gradientConvergence 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
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-, middleand 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
Inequities and the social gradientInequities and the social gradientConvergence of challenges;Convergence of challenges;Addressing the challenges Addressing the challenges –– taking action taking action on the social determinants of healthon the social determinants of health
Conceptual FrameworkConceptual Framework
SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES
SOCIOECONOMIC& POLITICAL
CONTEXT
Governance
Policy
Macroeconomic
Social
Health
Cultural and Societal norms
and values
Education
Occupation
Income
Gender
Ethnicity / Race
Social PositionMaterial Circumstances
Social Cohesion
Psychosocial Factors
Behaviours
Biological Factors
Health Care System
DISTRIBUTION
OF HEALTH
ANDWELL-BEING
WHO Commission on Social Determinants WHO Commission on Social Determinants of Healthof Health
2005 2005 --20082008
CommissionersCommissioners9 Knowledge 9 Knowledge NetworksNetworksCountry PartnersCountry PartnersCivil society workCivil society workGlobal initiativeGlobal initiativeWHO integration WHO integration
Set up by the World Health Organisationwww.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
Conditions in which people are born, grow, live, work and age
Structural drivers of those conditions at global, national and local level
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 GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Proportion relatively poor pre and Proportion relatively poor pre and post welfare state redistributionpost welfare state redistribution
05
1015202530354045
Finland
Norway
Sweden
BelgiumGerm
any
Netherlands
Italy
SpainCanada 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%
Pove
rty
%
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
Debt service and development assistance, by Debt service and development assistance, by region, 2000 region, 2000 -- 20032003
(Labonte & Shrecker, 2007, data from World Bank)
Global aid and global needGlobal aid and global need
Over 60% of the total increase in ODA Over 60% of the total increase in ODA between 2001 and 2004 went to between 2001 and 2004 went to Afghanistan, the Democratic Republic of Afghanistan, the Democratic Republic of Congo, and IraqCongo, and IraqThese three countries account for less These three countries account for less than 3% of the developing worldthan 3% of the developing world’’s poor. s poor. Much of the ODA increase in 2005 can be Much of the ODA increase in 2005 can be accounted for by debt relief to Iraq and accounted for by debt relief to Iraq and Nigeria.Nigeria.
Donor countries Donor countries honourhonour existing existing commitments by increasing aid to 0.7% of commitments by increasing aid to 0.7% of GDP; expand the Multilateral Debt Relief GDP; expand the Multilateral Debt Relief Initiative; and coordinate aid use through a Initiative; and coordinate aid use through a social determinants of health frameworksocial determinants of health framework
CSDH FR 2008
The Growing Gap: per capita aid from donor The Growing Gap: per capita aid from donor countries relative to per capita wealth, 1960countries relative to per capita wealth, 1960--20002000
Randel et al 2004
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Health equity impact assessment in Health equity impact assessment in economic agreements economic agreements Flexibility in agreements Flexibility in agreements A responsible private sectorA responsible private sector
Johannesburg water pricingJohannesburg water pricing
R -R 1R 2R 3R 4R 5R 6R 7R 8R 9
R 10
1 11 21 31 41 51 61 71 81 91 101
Consum ption (kl/m onth)
Actual Tariffs (Rand/kl) Johannesburg
Ideal for hh of 10
Current – favoursricher consumers
Ideal – subsidises poorer consumers
Source: GKN 2007
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Levels of wages of women Levels of wages of women compared to men in selected areascompared to men in selected areas
70
73
76
80
80
81
60 65 70 75 80 85
4 areas in sub Saharan Africa
8 areas in Latin America &Caribbean
10 areas in transition
22 Industrialized areas
6 areas in East Asia & Pacific
4 areas in Middle East & N Africa
UNICEF 2006
Percentage of women who have a say in decision Percentage of women who have a say in decision ––making about their own health care, selected low and making about their own health care, selected low and
middle income countriesmiddle income countries
0
1020
3040
50
6070
8090
100Bu
rkin
a Fa
so
Sene
gal
Nig
eria
Mal
awi
Cam
eroo
n
Gui
nea
Mor
occo
Ethi
opia
Zam
bia
Bang
lade
sh
Leso
tho
Keny
a
Rw
anda
Gha
na
Arm
enia
Tanz
ania
Moz
ambi
que
Rep
. of M
oldo
va
Mad
agas
car
Egyp
t
Boliv
ia
Col
ombi
a
Eritr
ea
Indo
nesi
a
Philip
pine
s
Jord
an
%
DHS data CSDH FR
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Child survival and early child developmentChild survival and early child developmentPhysical, 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
00.5
11.5
22.5
33.5
44.5
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 Rat
io fo
r Poo
r Hea
lth
(Nicholson et al 2005)
Early child development and education
Healthy PlacesFair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
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.
Early child development and education
Healthy Places Fair Employment
Social Protection Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Employment conditions: Employment conditions: Five Five ““dimensionsdimensions”” of global scopeof global scope
Unemployment Unemployment
Precarious employment Precarious employment
Informal employment and informal jobsInformal employment and informal jobs
Child Child labourlabour
Slavery / bonded Slavery / bonded labourlabour
EMCONET
FAIR EMPLOYMENTFAIR EMPLOYMENTFreedom from coercionFreedom from coercion
Job securityJob security
Fair incomeFair income
Job protection and social benefitsJob protection and social benefits
Respect and dignity at workRespect and dignity at work
Workplace participationWorkplace participation
Enrichment and lack of alienationEnrichment and lack of alienation
EMCONET
Deaths from workplace exposure to dangerous Deaths from workplace exposure to dangerous substances, various countries and regionssubstances, various countries and regions
0
20,000
40,000
60,000
80,000
100,000
120,000
MEC LAC FSE OAI SSA EME IND CHN
Num
ber o
f dea
ths
in 2
001
ILO, 2005
Forced Forced LabourLabour by trafficking by trafficking (minimum estimation)(minimum estimation)(ILO)(ILO)
Trafficking Trafficked as % of total(absolute number) forced labour
Industrialized economies 270,000 74.8Transition economy 200,000 94.3Asia and Pacific 1,360,000 14.3Latin America and Caribbean 250,000 19.0Sub-Saharan Africa 130,000 19.6Middle East and North Africa 230,000 88.1TOTAL 2,440,000 19.8
EMCONET
Informal economyInformal economy
Women are much more Women are much more likely than men to be in likely than men to be in the informal economy. In the informal economy. In developing countries, the developing countries, the majority of economically majority of economically active women work in the active women work in the informal economy. informal economy. Social protection in old Social protection in old age for workers in the age for workers in the informal economyinformal economy
0102030405060708090
100
Brazil Kenya India
women men
% non-agricultural labor forceIn the informal economy, 1991-1997
Source: Chen 2001
Prevalence of poor mental health in manual Prevalence of poor mental health in manual workers by type of contract: Spainworkers by type of contract: Spain
0
5
10
15
20
25
30
35
Permanent
Fixed termtemporaryNon-fixed termtemporaryNo contract
Source: Artazcoz et al 2005
%
0
0.51
1.5
22.5
33.5
4
4.5
No report of iso strain 1 report 2 reports
under 4546-55
Hazard Ratios of incident CHD by Iso-Strain (phase 1 and 2 of Whitehall II); split by age group
Chandola et al. European Heart Journal (2008)
Coronary heart disease and work stress,Whitehall II study
What must be doneWhat must be done
Make full and fair employment a central Make full and fair employment a central goal of national and international goal of national and international economic policy making;economic policy making;Safe, secure and fairly paid work, year Safe, secure and fairly paid work, year round; healthy workround; healthy work--life balance;life balance;Improve working conditions Improve working conditions –– material material hazards, workhazards, work--related stress, health related stress, health damaging behavioursdamaging behaviours
CSDH Final Report 2008
Early child development and education
Healthy Places Fair Employment
Social Protection Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
FAMILY POLICY GENEROSITY AND FAMILY POLICY GENEROSITY AND CHILD POVERTYCHILD POVERTY
SWENOR
SWINET
ITAIRE
GERFRA
FIN
CAN
BELAUT
AUS UK
USA
0
5
10
15
20
25
0 10 20 30 40 50 60 70 80 90 100
–– Countries with generous Countries with generous family policies have lower family policies have lower child poverty rateschild poverty rates
–– This association is mainly This association is mainly due to policies that support due to policies that support dual earner familiesdual earner families
–– The contribution may be The contribution may be direct through the amount direct through the amount of benefits paid, or indirect of benefits paid, or indirect by supporting two earners by supporting two earners and thereby raising the and thereby raising the market income of the market income of the household household
Povety Povety (%)(%)
Family Policy Family Policy Generosity (%)Generosity (%)
Source: Lundbrg et al 2007 CSDH Nordic Network
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
TelephoneTelephoneStationery, stampsStationery, stampsGifts to Gifts to grandchildren/othersgrandchildren/othersCinema, sports, etcCinema, sports, etcMeeting friends, Meeting friends, entertainingentertaining
TV set and licenceTV set and licenceNewspapersNewspapersHolidays (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 pensionpension
Pension 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 taxMorris et al 2007 IJE
Social pensions in selected low and Social pensions in selected low and middle income countriesmiddle income countries
85%85%5%5%US$ 27US$ 27UU65+65+BotswanaBotswana
16%16%11%11%US$ 8US$ 8MM60+60+ThailandThailand
13%13%8%8%US$ 4US$ 4MM65+65+IndiaIndia
16% 16% (age 57+)(age 57+)
6%6%US$ 2US$ 2MM57+57+BangladeshBangladesh
% of % of people people 60+ 60+ receivingreceiving
% of % of pop 60+pop 60+
Monthly Monthly amountamount(US$)(US$)
Universal Universal or means or means testedtested
Age Age eligibleeligible
CountryCountry
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good GlobalGovernance
Market Responsibility
Gender Equity
Political empowerment – inclusion and voice
CSDH CSDH –– Areas for ActionAreas for Action
Universal Primary Health Care Universal Primary Health Care Community basedCommunity basedDisease preventionDisease preventionHealth promotion Health promotion –– using social using social determinants frameworkdeterminants framework
Catastrophic health expenditure and impoverishment due Catastrophic health expenditure and impoverishment due to outto out--ofof--pocket health expenditure, by WHO regionpocket health expenditure, by WHO region
Source: World Health Statistics, WHO, 2008
0 30 60 90
Number of people (millions)
Eastern Mediterranean
African
Europe
South-East Asia
Americas
Western pacific
People Impoverished
People suffering catastrophic health expenditure
Health outcomes (HALE) positively associated with public Health outcomes (HALE) positively associated with public spending as a proportion of total health expenditurespending as a proportion of total health expenditure
Source: Koivusalo & Mackintosh (eds) 2005
WhatWhat’’s next?s next?Global Conference in London 2008 to promote Global Conference in London 2008 to promote uptakeuptakeSri Lanka 2009, practical uptakeSri Lanka 2009, practical uptakeCountries translate findings into programmes, Countries translate findings into programmes, Brazil, Chile, UK, Canada, Argentina?, India?Brazil, Chile, UK, Canada, Argentina?, India?WHO resolutionWHO resolutionECOSOC Agenda ECOSOC Agenda -- ? Core Development Goal? Core Development GoalGlobal Report on Social Determinants and Global Report on Social Determinants and Health equity Health equity Capacity building Capacity building –– Research and TrainingResearch and Training
““This ends the debate decisively. Health This ends the debate decisively. Health care is an important determinant of health. care is an important determinant of health. Lifestyles are important determinants of Lifestyles are important determinants of health. But it is factors in the social health. But it is factors in the social environment that determine access to environment that determine access to health services and influence lifestyle 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
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%
Leastreduction
14%
UNICEF
Reduction 42%
Reduction 33%
Reduction 47%
Reduction 51%
Reduction 49%