The Commission on Social Determinants of Health Dr Sharon Friel Principal Research Fellow, University College London & Fellow, National Centre for Epidemiology and Population Health, The Australian National University Ireland, th January 2009 Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health

Dramatic inequities dominate global health today

Global Programme on Evidence for Health Policy, 2000 data

A social gradient in health exists within countries

All Ireland Health Inequalities Balanda and Wilde, Institute of Public Health, Ireland 2001

Age standardised all cause mortality, years , England and Wales Romeri et al, 2006

Under 5 mortality rates, select countries, by household wealth Under 5 mortality per 1000 Victora et al, 2003

Building knowledge and leadership Producing policy and institutional change Building policy interest, communities of practice Commissioners Knowledge networks Country partners Civil society Global institutions WHO integration March 2005 – August 2008

The development of society can be judged by: the quality of its populations’ health the fairness in distribution of health, and the degree of protection provided from disadvantage due to ill-health Marmot 2006 Harveian Oration Health equity as a development outcome

CSDH Thematic Areas Ageing Migration Aid Mental Health Environment Alcohol Food & Nutrition Rural Settings Psychosocial Medical Education Education Violence Indigenous Peoples Conflict Women & Gender Equity Social Exclusion Globalisation Health Systems Urban Settings PPHC Employment Conditions Early Child Development Measurement & Evidence Knowledge Networks

“This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place.” Dr Margaret Chan, the DG of the WHO, at the launch of the CSDH Final Report in Geneva 28 th August 2008 Photo: WHO/Chris Black

The Social Determinants of Health The poor health of the poor, the social gradient in health within countries and the marked inequities between countries are caused by: Commission on Social Determinants of Health, 2008 Structural determinants the unequal distribution in power, money, goods and services, globally, nationally and locally Conditions of daily life The consequent unfairness in the immediate circumstances in people’s lives - access to schools, education, health care, conditions of work and leisure, their homes, communities, towns or cities

CSDH three overarching recommendations : 1. Improve daily living conditions 2. Tackle the unequal distribution of power, money and resources 3. Measure and understand the problem and assess the impact of action

Early Life Over 200 million children under 5 are not reaching their developmental potential Grantham-McGregor et al. Lancet 2007

Effects of nutritional supplementation and psychosocial stimulation on stunted children in a 2 year study, Jamaica Granthan-McGregor et al 1991

Urban health challenges Communicable and non-communicable diseases HIV/AIDS Road traffic injuries Urban violence and crime Substance abuse and illicit drug use Underweight and overweight KNUS report 2007

Policy Challenge Sustainable urbanisation –Urban governance and planning for health –Viable rural living –Environmentally sensitive

Employment and Working Conditions

Regional variation in the percentage of people in work living on US$2/day or less ILO, 2008

Cost of a Standard Healthy Living Basket as a percentage of Weekly Household Income, 2005 Friel et al, Standard of healthy living on the Island of Ireland. FSPB

Precarious employment and mental health Artazcoz et al, 2005

Economic and social policies matter for health and health equity

Health Care Every year, 100 million people are forced into poverty by health care costs (ILO 2005).

Reorientation of health care –Primary health care –Disease prevention –Health promotion Progressive building of universal health care services organised around PHC Policy Challenge

“in a world that is so divided by inequalities in wealth and opportunity, it is easy to forget that we are part of one humanity” Desmond Tutu in HDR, Tackle the unequal distribution of power, money and resources

Health Equity in all Policies, Systems and Programmes Fair Financing Good Global Governance Market Responsibility Gender Equity Political empowerment – inclusion and voice Policy Challenges

Health Care EMERGING KEY ISSUES Overseas development assistance from donor countries relative to per capita wealth,

Family policy generosity and child poverty Lundberg et al, 2007

Power and Governance Participatory Processes Health equity at the table HEiPSP

Cultural Factors: Self-government Land claim participation Health services Education Cultural facilities Police/fire services Aboriginal Youth Suicide by Cultural Factors Present Chandler & Lalonde, 1998

No data, no problem, no action 3. Measure, evaluate, expand the knowledge base, improve skills and raise awareness Claire Delperdange

Monitoring and Evaluation Stratified data Measures of health inequity Surveillance system Different types of data / knowledge The power of data Glasgow (deprived)54 India61 Korea65 Poland71 Mexico72 Cuba75 US75 UK76 Glasgow (affluent)82 Life expectancy at birth (men)

Monitoring and Evaluation Knowing the impact on health equity Tools to assess the impact of policy and programmes

Improved human capacity Training needs medical, other health and non-health curricula workforce competencies Funding for evidence generation Push-pull factors: underlying determinants Public awareness and concern

Sustaining Action Launch Final Report August 08 Regional Committee meetings 08 International Conference 08 National and regional commissions 08- World Health Assembly 09 Building a Global Movement for Action on the Social Determinants of Health and Health Equity

… Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death…