Global and National Action on SDH Michael Marmot UCL Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2010 Web-based Meeting 11th Dec 2009

Lessons from International Efforts

Empowerment as a means – material, psychosocial, political Social justice Empowerment as a means – material, psychosocial, political Creating the conditions for people to take control of their lives www.who.int/social_determinants

CSDH – three principles of action Monitoring, Training, Research Structural drivers of those conditions at global, national and local level Conditions in which people are born, grow, live, work and age

CSDH – three Linked Areas for Action Monitoring, Training, Research Structural drivers of those conditions at global, national and local level Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Conditions in which people are born, grow, live, work and age

Tools: Health impact assessment?

CSDH – Areas for Action Health Equity in all Policies Good Global Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Market Responsibility Health and the distribution of health is a marker of a societal wellbeing; Implications for health and the distribution of health of economic, social and political action; Collective action - health, education, employment, trade, transport, environment, housing, welfare… Gender Equity Political empowerment – inclusion and voice

Wider determinants

EXPENDITURE ON MEDICAL CARE PER CAPITA IN US AND UK UNITED STATES: US$ 6,096 UNITED KINGDOM: US$ 2,560 (adjusted for purchasing power) (Human Development Report 2007/2008)

HEALTH DIFFERENCES BETWEEN ENGLAND AND THE US 55-64 year olds % Prevalence data Table 3 from JAMA paper page 2041 US population suffer more diabetes, hypertension, heart disease, heart attacks, stroke, lung disease and cancer. Biggest difference is in diabetes – US rates are twice as high. Heart disease Diabetes Cancer Source: Banks, Marmot, Oldfield and Smith; JAMA 2006 10

Not just the poor. A gradient

Life expectancy at age 25 by education, United States, 1988 - 1998 Years of school completed: LE at age 25 Overcoming Obstacles to Health: P.15 Fig 2.a For both men and women, more education often means longer life.* College graduates can expect to live at least five years longer than individuals who have not finished high school. * This chart describes the number of years that adults in different education groups can expect to live beyond age 25. For example, a 25-year-old man with 12 years of schooling can expect to live 50.6 more years and reach an age of 75.6 years. Source: National Longitudinal Mortality Study, 1988–1998. Source: Robert Wood Johnson Foundation, Commission to build a Healthier America, 2008

The slope of the gradient is not fixed

Life expectancy at birth by socioeconomic deprivation US (male and female combined) (Singh & Siahpush, 2006)

Real earnings growth (%) for men and women working full time by decile, 1980 - 2005 OECD 2008

Real earnings growth (%) for men and women working full time by decile, 1980 - 2003 OECD 2008

Proportion relatively poor pre and post welfare state redistribution Poverty % 54% 49% 50% 71% 24% 71% 72% 62% 63% 59% 44% Proportion of each population below poverty threshold before and after welfare state redistribution and the size of poverty reduction in 11 countries around year 2000 Poverty threshold = 60% of median equivalent disposable income. Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network 17

Recognition by elected officials?

Gordon Brown, Prime Minister, UK “I am pleased to announce that Sir Michael Marmot has agreed to undertake a new review of health inequalities in England…” “… the health inequalities we are talking about are not only unjust, …they also limit the development and the prosperity of communities, whole nations and even continents.” “…in today’s global society, when our understanding of ill-health and our ability to prevent and treat disease is greater than ever before, the defining challenge is of course to make the benefits of our collective expertise available to all.” Gordon Brown, Prime Minister, UK at Closing the Gap Conference, 6th Nov 2008 “…and we will learn from other countries along the way…” Gordon Brown, Prime Minister, UK at Closing the Gap Conference, 6th Nov 2008

Alan Johnson, Secretary of State, DH, 6th Nov 2008 “I have asked Professor Sir Michael Marmot, drawing on the excellent evidence of the WHO’s social determinants of health commission, to lead a review, based on the best global evidence on how we can do more to tackle health inequality in this country.” Alan Johnson, Secretary of State, DH, 6th Nov 2008 Closing the Gap Conference, London Or: “I want Michael Marmot to ask in his review whether it is possible in this country to eradicate health inequality, and what actions we as a government and society have to take to make this happen.”

Building on health inequalities agenda in the UK 1998 - Acheson Inquiry into Inequalities in Health; 1999 – national strategy for health in England – Saving Lives: our healthier nation – commitment to tackling health inequalities 2002 – Treasury led cross cutting review on health inequalities 2003 – Tackling health inequalities - Programme for action

Identify evidence to underpin future policy and action; Show how evidence can be translated into practice; Advise on possible objectives and measures, build on experience of the current PSA target on infant mortality and life expectancy; Publish a report to contribute to development post-2010 health inequalities strategy. (Feb 2010)

Indicators and the economic case

Whole of government

Equality & health equity in all policies. Reduce health inequalities and improve health and well-being for all. Policy Goals Create an enabling society that maximises individual and community potential. Ensure social justice, health and sustainability are at heart of policies. Policy objectives 1) Give every child the best start in life. 2) Enable all children, young people & adults to maximise their capabilities & control their lives. 3) Create fair employment & decent work for all. 4) Ensure healthy standard of living for all. 5) Create and develop healthy and environmentally sustainable places & communities. 6) Strengthen the role and impact of ill-health prevention. Policy mechanisms Equality & health equity in all policies. Effective evidence-based delivery systems.

Working across government Department for Transport Department for Children, Schools and Families Department of Work and Pensions Department of Energy and Climate Change Department of Communities and Local Government Ministry of Justice Department for Environment, Food and Rural Affairs Department for Culture, Media and Sport Opposition parties

Understanding of the problem?

LIFE EXPECTANCY IN LONDON BOROUGH OF CAMDEN: MEN Cycle from Hampstead in the north of Camden to UCL in the south. Travel from area where life expectancy for men is 81 years; within 30 min by bike life expectancy drops by eleven years to 70 years.

Life expectancy at birth for selected London electoral wards, 2002-06 Haringey Tottenham Green LE for men: 71 years “A programme of addressing inequalities in health was initiated in England by the Acheson report "Independent inquiry into inequalities in health": http://www.archive.official-documents.co.uk/document/doh/ih/ih.htm which triggered a series of key policy documents that have brought health inequalities forward as a cross-government priority. Government-wide targets known as PSA or Public Service Agreement targets set in 2001, aim for faster improvement in health outcomes in the fifth of areas with the worst health and deprivation indices (in life expectancy, death from heart disease and stroke, and cancers). These areas are known as “Spearhead Authorities” (See Figure 3 below for London)”. Kensington & Chelsea Queens Gate ward: LE for men: 88 years. Areas in blue are known as “Spearhead Authorities” (data from London Health Observatory)

Local level?

Equality & health equity in all policies Policy Mechanisms Equality & health equity in all policies Health Impact Assessments Equality legislation Cross and all government approach Evidence based delivery systems National and local levels

Framework for indicators and targets Establish potential targets and indicators of outcome, output and process Underpin the areas of action on social determinants in short, medium and long term Provide a rigorous basis to facilitate performance improvement of national & local government and its agencies and hold them to account Provide the basis for: setting national targets and indicators assisting local agencies in their development of local targets on a nationally comparable basis

A fairer society

Final Report Launched and available online 11 February 2010 For further information www.ucl.ac.uk/gheg/marmotreview