1. ‘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

2. 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

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

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

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

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

7. 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

8. 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, figures are preliminary

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

10. Trends in ODA to agriculture compared to total ODA
Constant 2002
US$ billions
Source:
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% ( ), 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

11. 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

12. 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

13. 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

14. 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

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

16. 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: /100,000

17. 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: , 2006

18. Source: Heckman 2006

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

20. 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, , 2004
Age under 6 months in 1998
Poorest families
(Source: Rivera et al.,JAMA, 2004)

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

22. Female: Male ratio

23. 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…)

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

25. 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

26. 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

27. 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

28. 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

29. 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

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