‘Social Determinants of Health: global context and challenges’ Michael Marmot Director: IISH UCL Chair: Commission on Social Determinants of Health International Conference on Health for Development ‘Rights, Facts and Realities’ Buenos Aires 15th August 2007

Outline Inequalities between and within countries Solid Facts: Europe Solid Facts: global context Globalisation Employment Early child development Women and gender equity Health systems Social Exclusion Priority Public Health Conditions Commission on Social Determinants of Health

Mortality over 25 years according to level in the occupational hierarchy: Whitehall (Marmot & Shipley, BMJ, 1996)

Prevalence of stunting by deciles of living conditions in Mexico 1999 Lowest Highest Living conditions Juan Rivera Cuernevaca

TRENDS IN LIFE EXPECTANCY From Human Development Report 2005 Table 10 page 253 Human Development Report 2005

THE SOLID FACTS: OMS.SECOND EDIT. 10 MESSAGES THE SOCIAL GRADIENT STRESS EARLY LIFE SOCIAL EXCLUSION WORK UNEMPLOYMENT SOCIAL SUPPORT ADDICTION FOOD TRANSPORT

Outline Inequalities between and within countries Solid Facts: Europe Solid Facts: global context Globalisation Employment Urbanisation Early child development Women and gender equity Health systems Social Exclusion Priority Public Health Conditions Commission on Social Determinants of Health

Net financial flows: developing economies, 1993-2005 At minimum, the present net capital flow from developing to developed countries must be reversed if poorer countries are to grow, develop and adopt policies that enhance health equity via the SDH. (Ron Labonte – CSDH GKN) Source: United Nations Dept. of Economic and Social Affairs, 2006. 2005 figures are preliminary

Net financial flows, by region and all developing and transition economies, 1993-2005 Source: United Nations Dept. of Economic and Social Affairs, 2006. 2005 figures are pre-liminary. “Sub- Saharan Africa” excludes Nigeria, South Africa

Trends in ODA to agriculture compared to total ODA Constant 2002 US$ billions Source:http://dfid-agriculture-consultation.nri.org/summaries/wp9.pdf Yet levels of aid to the agricultural sector have lagged behind social spending (aid to health and education) in recent years. Between 2000 and 2004, while total USAID assistance to African agriculture rose from $459 million to $514 million, USAID´s Bureau for Africa health budget rose from $295 million to $474 million. Overall, while the agricultural share of total bilateral ODA declined from 13 to 9% (2000-2003), health-related aid grew by 115%. (data from Seb) What is needed is a total quantum of aid that allows for an adequate balance of investment to both productive and social spending, if growth, poverty reduction, and health are to be coherently - and sustainably - addressed (Maxwell, 2005; Addison, Mavrotas & McGillivray, 2005). OECD data reported by DFID 2004

Outline Inequalities between and within countries Solid Facts: Europe Solid Facts: global context Globalisation Employment Urbanisation Early child development Women and gender equity Health systems Social Exclusion Priority Public Health Conditions Commission on Social Determinants of Health

ILO World Employment Report 2004 - 2005 Half of the world’s 2.8 billion workers living below US$2 a day poverty line 550 million workers are living on under the US$1 a day poverty line ILO World Employment Report 2004 - 2005

High demand / low control Effort-Reward Imbalance Adjusted hazard ratios for cardiovascular mortality by levels of work stress# Whitehall II study Nmax=812 (73 deaths); mean follow-up 25,6 years * * Tertiles 1 = low; 2 = intermediate; 3 = high #adj. for age, sex, occupational group, smoking, physical activity, SBP, total chol., BMI * p < .05 High demand / low control Effort-Reward Imbalance Source: M. Kivimäki et al. (2002), BMJ, 325: 857

Outline Inequalities between and within countries Solid Facts: Europe Solid Facts: global context Globalisation Employment Urbanisation Early child development Women and gender equity Health systems Social Exclusion Priority Public Health Conditions Commission on Social Determinants of Health

Percentage of urban population living in “slums” in different countries From KNUS report 2007 Figure 1

Homicide in Rio de Janeiro, by Neighbourhood Coast Gini: 0.45 Poverty: 6.21 Slum residence: 12.4 Homicide rate: 72.25/100,000 Harbor Gini: 0.61 Poverty: 22.7 Slum residence: 30.69 Homicide rate: 211.17/100,000

Early child development ‘Investing in disadvantaged young children is a rare public policy initiative that promotes fairness and social justice and at the same time promotes productivity in the economy and in society at large.’ James J. Heckman. Science, 312:1900-1901, 2006

Source: Heckman 2006

Prevalence of stunting by deciles of living conditions in 1999 and 2006: Mexico Lowest Highest Living Conditions Slide: adapted from Rivera, J.

IMPACT OF PROGRESA-OPORTUNIDADES IN MEXIC0 ON GROWTH AND ANAEMIA Increase in height (cm) from baseline in 1998 to 2000 Prevalence of Anaemia in 1999 and 2000 Intervention (starting 1998) % 1.1 cm Crossover Intervention (starting 1999) Rivera et al JAMA, 291, 2563-2570, 2004 1999 2000 Age under 6 months in 1998 Poorest families (Source: Rivera et al.,JAMA, 2004)

Female: Male ratio Source: Safaa El-Kogali, 2005 ( quoting Engendering Development, World Bank, 2001. Original data from: Parliamentary data from WISTAT(1998); income data from World Bank( 1999d));

Female: Male ratio

Female: Male ratio See how gender improves along certain provision lines, but not along political inclusion and participation lines – EXCEPT IN THE POOREST GROUP OF COUNTRIES (POSSIBLY RELATED TO CONFLICT AND THE INCREASE IN FEMALE HEADED HOUSHEOLDS…)

Health Systems Health systems promote health equity when their design, operations and management specifically consider the circumstances and needs of socially disadvantaged populations

Social Exclusion Processes driving inclusion/exclusion are embedded in unequal power relationships Unequal distribution of capabilities i.e. resources and rights, unequal power to act

Who is out of school? Female, rural, poor, mother with no education Urban Poorest 20% Page 11 of EFA report summary, figure 1.4 Mother with some education Characteristics of out-of-school children 80 countries, EFA report 2007, UNESCO

Outline Inequalities between and within countries Solid Facts: Europe Solid Facts: global context Globalisation Employment Urbanisation Early child development Women and gender equity Health systems Social Exclusion Priority Public Health Conditions Commission on Social Determinants of Health

Socioeconomic inequalities in male cirrhosis of the liver mortality: Australian manual and non-manual workers 1992: manual 2 times mortality rate of non-manual 2002: manual 2.5 times mortality rate of non-manual Mortality per 100,000 Age standardised Najman et al 2007

COMPARISON OF SMOKING PREVALENCE BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS SMOKING RATE RATIO BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS Bobak et al in ‘Tobacco control in developing countries’ ed: Jha & Chaloupka, 2000

OBESITY PATTERNS ACROSS THE DEVELOPING WORLD % (Popkin, Development Policy Review, 2003)