Addressing health inequalities:

Lessons from the Commission on Social

Determinants of Health
Professor Sir Michael Marmot
UCL

Lima, Peru
Policy workshop
September 2011
 European
Review of
Health
Inequalities
and the
Health
Divide

The Commission on Strategic Review of Health

Social Determinants of Inequalities in England:
Health (CSDH) – Closing
The Marmot Review – Fair
the gap in a generation
Society Healthy Lives
CSDH – three principles of action
Structural drivers of those conditions
at global, national and local level

Conditions in which people are

born, grow, live, work and age

Monitoring, Training, Research

 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global
Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
• Empowerment
– Material
– Psychosocial
– political
• Every sector is a health sector
– Health and well being as outcomes
World Health Assembly Resolution
May 2009

• All member states:

– Tackle health inequities through action on the social
determinants of health
– Impact of polices and programmes on health inequities;
– Health equity in global development goals
"Public health can be grateful for backing from the
Commission on Social Determinants of Health. I
agree entirely with the findings. The great gaps in
health outcomes are not random. Much of the
blame for the essentially unfair way our world
works rests at the policy level."
Dr Margaret Chan, 62nd World Health Assembly,
May 2009

Photos:WHO/Cédric Vincensini
• Translating the CSDH recommendations into
different country/regional contexts
•
 A Fair Society

Conditions in which
individuals and
communities have control
over their lives
Life expectancy and disability-free life expectancy at birth
by neighbourhood income deprivation, 1999-2003
 Fair Society, healthy Lives: 6 Policy Objectives

A. Give every child the best start in life

B. Enable all children, young people and adults to maximise
their capabilities and have control over their lives
C. Create fair employment and good work for all
D. Ensure healthy standard of living for all
E. Create and develop healthy and sustainable places and
communities
F. Strengthen the role and impact of ill health prevention
• Policies in one area have effects in other areas;

• Need to have coherent policies;

• Effects on health, and the distribution of health

• Health inequalities between and within countries:
the social gradient in health
 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global

Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
Equity from the start – lifecourse
approach
• Early child development (ECD) has a determining
influence on subsequent life chances and health

• Physical, social/emotional, language/cognitive

development

• Child development is socially determined and, in

turn, is a determinant of health across the life
course
Links between socioeconomic status and factors
affecting child development, 2003-4

Source: Department for Children, Schools and Families

Source: Heckman 2006
• Success in promoting early child development
does not depend on a society being wealthy

• The cost of effective programmes varies with the

wage structure of a society

CSDH ECD KN Final Report

Improving outcomes for children

• Generous government income transfers;

• Employment policies
– Policies facilitating maternal employment and
education;
– Policies facilitating the reconciliation of work and family
life;
• Increasing children’s access to reasonable
QUALITY early childhood care and education.

Kamerman & Gabel 2006, UNICEF

 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global

Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
Area effects

• Social support/social cohesion/sense of

community
• Built environment – green spaces, transport...
• Good urban design can encourage social
cohesion
 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global

Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
Prevalence of poor mental health in manual workers by type
of contract: Spain

% 35

30
Permanent
25
Fixed term
20 temporary
15 Non-fixed term
temporary
10 No contract
5

Source: Artazcoz et al 2005

Work

• Stress in the workplace

increases the risk of
disease
ODDS RATIO* OF METABOLIC SYNDROME BY EXPOSURE TO
ISO-STRAIN: WHITEHALL II PHASES 1 TO 5
Odds Ratio
3

2.5

1.5

0.5

0
No exposure 1 exposure 2 exposures 3 or more
Exposure to Iso-strain exposures

*Adj. for age, employment, grade and health behaviours

Chandola, Brunner & Marmot, BMJ, 2006

 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global

Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
 Relation between social welfare spending and all
cause mortality in 18 EU countries, 2000

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

Copyright ©2010 BMJ Publishing Group Ltd.

 Proportion relatively poor pre and
post welfare state redistribution
Poverty %

poverty rates post tax & transfers poverty reduction by income redistribution

45
40
35 54%
30 49% 50%
71% 71% 72% 62% 63% 59% 44% 24%
25
20
15
10
5
0

US
UK
ly

n
ay

da
y
en
d

um

s
an

ai
an

nd

I ta
rw

na
ed

Sp
i

m
nl

lg

la
No

Ca
Sw

er
Fi

Be

er
G

th
Ne

Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data,
CSDH Nordic Network 2008
FAMILY POLICY GENEROSITY AND CHILD POVERTY

Poverty
(%)

Family Policy Generosity (%)

Source: CSDH Nordic Network 2008
• Minimum income for health living
 CSDH – Areas for Action

Health Equity in all Policies

Fair Financing Good Global

Governance
Early child development and
education
Healthy Places
Fair Employment
Market Social Protection
Responsibility Universal Health Care
Gender Equity

Political empowerment
– inclusion and voice
Cost-Related Access Problems in the Past Year, by Income
(Adjusted) percent
experienced at least one
of three problems**

Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—
insurance status.
* Indicates significant within-country differences with below-average income (p < 0.05).
** Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
• Local action
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
Malmo

• 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
 A Fair Society
Conditions in which
individuals &communities:

Have control over their

lives
and

Participate fully in society

Website www.marmotreview.org