Inequities In Health: A Global Perspective Dr Ann Hemingway Oct 2009

2 Definitions Inequalities in health are: Differences in the prevalence or incidence of health problems between individual people of higher and lower socio-economic status. Inequities in health are these differences but articulated as being preventable, unjust and wrong. Kunst A. & Mackenbach J. (1994) Measuring Socio-economic Inequalities in Health WHO monograph WHO CSDH (2008) Commission on the social determinants of health final report WHO: Europe

3 Explanations for inequities in health The artefact explanation The social selection/illness explanation The behavioural explanation The materialist/structuralist explanation

4 Epidemiological Transition Some countries experiencing double burden of disease Also demographic transition Non-communicable diseases Communicable diseases

5 Why Reduce Health Inequities? Public health programs that reduce inequities in health can be cost effective Conditions that lead to marked health disparities are detrimental to all members of a society Inequities in health are undesirable to the extent that they are unfair or unjust Disparities in health are avoidable to the extent that they stem from policy options such as welfare benefits, health care funding, regulation of business and labour and tax policies Woodward A. & Kawachi I Why reduce health inequalities J. Epid Comm Health 54 p

6 The Social Determinants of Health: The Evidence (WHO 2003) 1. The social gradient

Stress Social and psychological circumstances can cause long term stress and early death. Insecuri ty Low Self Esteem Social Isolatio n Lack of control Lack of supporti ve friendshi ps Continui ng anxiety Poor mental health Feeling a failure

Early Life A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime Poor circumstances during pregnancy Deficiencies in nutrition Maternal stress/risk of smoking + misuse of drugs/alcohol Insufficient exercise and inadequate Prenatal care

Poverty and Social Exclusion Life is short where its quality is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives. The stress of poverty and social exclusion are particularly harmful during pregnancy, to babies, children and older people. Increases risks of divorce/se paration Increases the risk of becoming disabled Increases the risk of becoming chronicall y ill Increases the risks of developing an addiction

Stress in the workplace People who have more control over their work have better health. Risk of suffering with CHD related to degree of control at work –high degree of control = 1 (Marmot et al 1997)

Unemployment Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death.

Social Support Friendship, good social relations and strong supportive networks improve health at home, at work and in the community. Those who get less social and emotional support are more likely to experience depression and a greater risk of pregnancy complications. In addition poor close relationships can lead to worse mental and physical health.

Addiction Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting.

Food Because global market forces control food supplies, healthy food is a political issue. A good diet and adequate food supply are central to promoting health and well being.

Transport Healthy sustainable transport means less driving and more walking and cycling, backed up by better public transport. Healthy transport also encourages social interaction in the street and greater social cohesion.

16 Housing No matter which country in the world you live in your housing affects your health and well being either directly through damp, cold, heat or infestation. But also indirectly by affecting your status and the stability of your home environment.

17 Life Expectancy And Mortality Rates, By Country Development Category (2000)

18 Source WHO (2005) World health statistics 2005 Geneva p 9 Global Distributional Inequity Under Five Mortality Rate, WHO 2003

19 Health Challenges: Maternal Mortality 210 m women become pregnant annually 20 m experience pregnancy-related illness 500,000 die from complications of pregnancy or childbirth. Lifetime risk of dying in pregnancy in Africa is 1 in 12 versus 1 in 4,000 in Europe

20 Health Challenges: HIV/AIDS TB Malaria 3 million people died of AIDS in More than 12 million children were orphaned. TB is the leading infectious cause of death globally, and is a major and growing public health challenge. Interaction with HIV. Malaria causes 1 million deaths p.a. 40% of the world at risk of malaria. Primary cause of mortality in under 5s

21 Health Challenges: Mental Illness 13% of Disease Burden caused by neuropsychiatric disorders <1% of health budgets in developing countries Source: WHO 2009

22 Chronic diseases: Cardiovascular disease and global health Cardiovascular disease thought to be a quintessential `western disease` is fast becoming a threat in developing countries. It now causes four times as many deaths in mothers in developing countries than do childbirth and HIV/AIDS combined The INTERHEART study found that 90% of heart disease is avoidable World Heart Federation (2006)

23 source: ONS, 2000 Rates of limiting long-standing illness among adults, Britain, 2000

24 CHD and inequalities There is a strong correlation between CHD risk and deprivation, the poorest members of society in the UK now suffer a risk three times the rates of those who are better off. One in three children in the UK grow up in relative poverty, a higher proportion that any other European member state.

25 Coronary Heart Disease the UK`s biggest single killer Despite reductions in death rates CHD is the biggest single cause of premature death in the UK. One in four British men and one in five British women die from CHD. The UK has one of the highest rates of CHD in the European Union (NHF 2004). National Heart Forum (2004) campaign policy document NHF

26 Poverty Gender Water and sanitation War and refugees Equity and human rights Other influences on the Determinants of Health

27 Final recommendations from the WHO Commission on the Social Determinants of Health Sept 2008 Improve daily living conditions Tackle the inequitable distribution of power, money and resources Measure and understand the problem and assess the impact of action

28 Health System Issues Access to services Governance and structures Policy processes Public/private mix and roles Professional staffing Type of health care offered Urban vs. rural vs. peri-urban Chronic versus acute care Cure vs. care balance Home based versus institutional Referral systems Care paths and integration of care Financing

29 Selected Countries: Levels And Sources Of Health Finance Source: WHO (2006) World Health Report. Working Together for Health. (annex tables 2 and 3, pp ) WHO, Geneva

s Changing wider context Re-emergence of a focus on the wider determinants of health WHO and Tobacco Commission on Social Determinants of Health Policy-making processes: Focus on Evidence-based policy-making NGOs and advocacy WHO 2000 Report on health system performance

31 Globalisation Ill-health does not need a visa Rising influence of commercial interests such as pharmaceutical/media/food multinationals Worth of top 5 companies is 2 x total GDP of sub-Saharan Africa

32 Globalisation International regulation challenges Effects of conflict on health Changing user expectations about community and individual rights Shrinking of professional world Increasing international migration of human resources

33 International trade – unlocking the potential for human development Until the lions have their historians declares an African proverb tales of hunting will always glorify the hunter. The same is true of global trade, for enthusiasts rapid expansion over the last two decades has been an unmitigated blessing. Under the right conditions it has potential to reduce poverty, narrow inequality and overcome economic injustice. For many of the worlds poorest people these conditions have yet to be created. (UN Human Development Report (2005), Aid trade and security in an unequal world, UNDP)

34 Contextual Issues Global economic and political shifts Crises – natural and artificial and Aid Urbanisation Environmental degradation and global warming Technology in health care including genetic medicine and telemedicine Changing health needs: Ageing populations Non Communicable Diseases growing Major Communicable Diseases including existing (AIDS etc) and emerging ones such as avian flu Neglected diseases

35 Aid in the 21 st century The people of this country are distant from the troubled areas of the earth and it is hard for them to comprehend the plight and consequent reactions of the long suffering peoples and the effect of those reactions on their governments in connection with our efforts to promote peace in the world. The truth of the matter is that …….. requirements are so much greater than her present ability to pay that she must have substantial additional help or face economic, social and political deterioration of a very grave character. George C Marshall

36 With these words US Secretary of State George Marshall outlined his plan for European reconstruction in 1947, over the next three years the US transferred $13 billion in aid to Europe, equivalent to more than 1% of US GDP. This was done partly for reasons of moral conviction but also by the recognition that US prosperity and security depended on European recovery.

37 At the end of the 1960`s the Commission on International Development argued for donors to contribute 0.7 of GDP by Many countries have committed to delivering this but none have done it. An average % of 0.22 was achieved in For Sub-Saharan Africa per capita aid fell from $24 in 1990 to $12 in 1999, in 2003 it was just below the 1990 level.

38 New donors are appearing though including the former soviet union countries with the Czech Republic being the most generous at 0.1% GDP. The russian government is also working with the UN to create and aid agency called RUSAID. However overall aid commitments remain unmet and the aid that is offered is often unstable, inconsistent, and often transitory.

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40 Tackling Health Inequalities: Status Report On The Program For Action 2005 (UK, DOH) A continuing widening of inequalities as measured by infant mortality and life expectancy at birth in line with the trend Reductions in childhood poverty and improvements in housing have occurred. Some signs of narrowing of the gap in relation to heart disease mortality and to a lesser extent cancer

41 UK Life Expectancy The latest data (2005) indicate that since the baseline (1997) the relative gap in life expectancy between England as a whole and the fifth of local authorities with the worst life expectancy has increased for men and women. For males the gap increased by nearly 2%, for females by 5%

42 UN Millennium Development Goals (MDG) Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop a global partnership for development

s Changing wider context Re-emergence of wider determinants of health as policy issues Policy-making processes WHO 2000 Report on health system performance Millennium Development Goals Recognition of growing Human Resource crisis

44 Countries With A Critical Shortage Of Health Service Providers (Doctors, Nurses And Midwives) Source: WHO (2006) World Health Report Fig 1.5

45 Source WHO (2005) World health statistics 2005 Geneva p 9 Global Distributional Inequity Under Five Mortality Rate, 2003

46 Growing Human Resource Crisis Global shortage e.g.: 334,000 additional midwives needed in next 10 years Global inequities Losses due to complex reasons Ability of richer countries to plunder poorer health systems Quality and morale of existing staff affected – vicious circle

47 Interestingly…….. The final report of the WHO CSDH over arching recommendations focus on Improving daily living conditions The inequitable distribution of power, money and resources, and: Measuring and understanding the problem and the impact of action Health care is mentioned (particularly primary health care) but not as the main answer to the problems of inequities in health

Dr Ann Hemingway