closing the gap in a generation - bvsde desarrollo … · closing the gap in a generation ......

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


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







Gender Equity



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







Gender Equity



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







Gender Equity



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)


Healthy PlacesFair Employment Social Protection





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.


Healthy Places Fair Employment

Social Protection Universal Health Care




Gender Equity



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


Healthy Places Fair Employment

Social Protection Universal Health Care




Gender Equity



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







Gender Equity



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

Global MovementGlobal Movement

““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

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%

Leastreduction

14%

UNICEF

Reduction 42%

Reduction 33%

Reduction 47%

Reduction 51%

Reduction 49%

EMPOWERMENTEMPOWERMENT–– MATERIALMATERIAL–– PSYCHOSOCIALPSYCHOSOCIAL–– POLITICALPOLITICAL

Dreams ?Dreams ?

www.who.int/social_determinants/en

A world where social

justice is taken

seriously

closing the gap in a generation - bvsde desarrollo … · closing the gap in a generation ......

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