A major conference is to take place (19-21 Oct) in Rio de Janeiro, Brazil, inviting all WHO member states to commit to solid policies to improve social determinants of health. Ahead of this, the world's leading expert in this field, Professor Sir Michael Marmot (University College London, UK) -- and his colleagues Dr Jessica Allen, Dr Ruth Bell, and Professor Peter Goldblatt -- are publishing a Health Policy paper outlining the issues and challenges, with an emphasis on the WHO European Region and its new policy Health 2020.
Health (and other) inequities, sometimes substantial, exist between and within countries of all incomes. Wide inequities in the distribution of power, money, and resources account for the differing conditions of daily life within a population, and inequities in health are noted in men and women, children and elderly people, and people of working and childbearing age.
This new paper refers to Professor Marmot's previous work in 2008 as the author of the WHO report from its Commission on Social Determinants of Health (CSDH). Since then, progress has been made in various countries: Brazil has set up its own CSDH. Costa Rica is attempting a whole government approach to improving health inequity, while Australia collaborated with the WHO Pacific region to formulate its own plans. India, with initiatives such as the rural employment guarantee scheme, and the extension of the right to education, has also made substantial progress. Within Europe, Norway has established policies to address the social gradient in health, while in the UK, a public health white paper has been issued by the government, putting reduction of health inequalities at the centre of its health strategy. Included in the aims are improvements in education and lifelong learning, and minimum income for healthy living. Denmark and Slovenia have also produced national strategies based on the social determinants of health and on October 14, 2011, ten health ministers from the countries in southeastern Europe, signed the Banja Luka pledge, which commits to health in all policies and highlights tackling health determinants (http://www.euro.who.int/seeforum2011 ).
The WHO European region, led by director Zsuzsanna Jakab, has set up a European review of social determinants and the health divide, also to be led by Professor Marmot. The review will publish its conclusions and recommendations in 2012. Its interim findings are reported in this Health Policy paper. The authors say that there need be no trade off between health equity and health improvement, saying both are important. They add: "In all regions, the global financial crisis has added urgency to consideration of dramatic financial inequities, within and between countries, which preceded it. As standards of living decrease in many countries, and government revenues are tightened, we would argue that it is even more urgent that the distributional effects of all policies are taken into account in policy decision making."
The European interim findings show vast differences in life expectancy within and between the 53 diverse countries in the WHO European Region. Women live longer than men in all the countries in the region. Men in Russia have life expectancy of 61 years, 1 year shorter than that in India, compared with 81 years in Iceland. Women in Kazakhstan have life expectancy of just less than 73 years compared with 85 years in France. Female life expectancy at birth was 4 years lower (and male 7 years lower) in the 12 countries that joined the European Union after May, 2004, than in the 15 countries that were members before that date. Societal transformations in the former Commonwealth of Independent States is thought to be a cause of inequity in central and eastern Europe. Maternal mortality across Europe also varies widely, from below 5 per 100,000 livebirths in countries such as Norway and Iceland to 70 for Kyrgyzstan. In a study of 16 European countries, inequality in mortality based on educational level was greatest in countries in central and eastern Europe, and lowest in Italy, Spain, and Sweden. The authors note that morbidity, disability, and mental illness are key issues that account for much loss of healthy life in Europe and globally. The apparent female advantage in health (for life expectancy) diminishes greatly when these non-fatal measures of ill health become the focus.
Discussing the need for a European review, the authors say it is necessary to address the unacceptably large health divide between countries and in some cases growing health inequity within countries. There is also a need for new evidence, and a growing interest in local action on social determinants of health. Finally, action in this area contributes to the production of other social benefits such as wellbeing, improved education, lower crime rates, more sustainable communities and improved social integration.
The authors say: "On one side some governments and other stakeholders seem to have embraced this agenda and recognised the need for action across the whole of government on the key social determinants of health…On the other side, many observers take a less positive view of progress. Social determinants of health have barely penetrated the global agenda—for example, health equity is hardly a consideration in trade talks; governments are too diverted by the global financial crisis and their domestic economic problems to give focus to health equity; and the default position of people in the health sector is to focus on health services and prevention of specific diseases."
They conclude: "The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again…Social cohesion, an educated population, good employment and working conditions, and policies that foster processes of social inclusion will be good for health and good for society as a whole."
In a linked Comment, Ms Jakab and Professor Marmot outline the goals of the WHO European Region Health 2020 policy: to achieve better and more equitable health for the people of Europe through greater awareness, improved governance, and working collaboratively across the region with common strategic goals. They say: "To accelerate knowledge sharing, innovation and enhanced citizen participation in health is important to achieve better, more equitable health."
They conclude: "As representatives of the global community gather in Rio de Janeiro, Brazil, in October, 2011, for the World Conference on Social Determinants of Health, there will be the opportunity to take important steps to make the CSDH's call for a global movement on health equity a reality. We hope that the European review and the momentum created by Health 2020 in the European region will be an important contributor to that global movement."
For Professor Sir Michael Marmot, University College London, UK: please contact Ms Felicity Porritt, Senior media advisor T) 44-7739419219 ) m.marmot@ucl.ac.uk / felicity.porritt@googlemail.com (Professor Marmot will be at the Rio Summit)
For Ms Zsuzsanna Jakab, Director, WHO European Region, please contact Senior Media Advisor Ms Viv Taylor Gee T) 45-51162096 or e-mail via Mirona Erikson, Regional Directors Office: mer@euro.who.int
Journal
The Lancet