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Health inequalities are present throughout the world, and require action at the societal level – globally, nationally and locally. They are not confined to poor health for people in poor countries and to good health for populations living in wealthy countries. Inequalities in health are linked to social gradients in health within most countries.
Examples of global health inequalities between countries are:
- The risk of a baby dying between birth and one year of age is 2 per 1000 live births in Iceland and over 120 per 1000 live births in Mozambique;
- In Afghanistan, the lifetime risk of a maternal death is one in 11; in Europe, the lowest is one in 31 800.
Examples of health inequalities within countries outside the EU are:
- In Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births, while the infant mortality rate of babies born to mothers with at least secondary education is under 40 per 1000;
- Life expectancy at birth among indigenous Australians is substantially lower (59.4 for males and 64.8 for females) than that of non-indigenous Australians (76.6 and 82.0, respectively);
During WHO’s World Conference on Social Determinants of Health, held in Rio de Janeiro, Brazil on 19–21 October 2011, the Rio Political Declaration on Social Determinants of Health got finalized and adopted.
The Declaration expresses global political commitment to implement an approach that addresses the social determinants of health in order to reduce health inequities and achieve other global priorities. It will help to build momentum within WHO Member States to develop dedicated national strategies and action plans.
The Declaration resonates with and strengthens the process of developing a new European policy for health and well-being, Health 2020, by recognizing the vital importance of the social determinants of health and the needs:
- to reduce health inequities;
- to strengthen governance for health and development;
- to strengthen health systems to support the provision of equitable universal coverage of health care;
- to maintain and further expand public health capacity, including capacity for intersectoral action on the social determinants; and
- to work for equity through the inclusion of health in the policies of all sectors.
In March 2005, a WHO Commission on Social Determinants of Health (CSDH) was set up by Dr JW Lee, the former Director-General of WHO, to bring together evidence on what can be done to achieve better and more fairly distributed health worldwide, and to promote a global movement to achieve this. The CSDH was chaired by Sir Michael Marmot.
The CSDH had a three year directive to gather and review evidence on what needs to be done to reduce health inequalities within and between countries and to put together recommendations for action. Building partnerships with countries committed to comprehensive, cross-government action to tackle health inequalities was integral to this. The CSDH was a global process, bringing together hundreds of researchers and practitioners from universities and research institutions, government ministries, and international and civil society organizations.
‘Knowledge networks’ collected evidence on policies and interventions to improve health and reduce health inequities across a number of areas including: early child development, employment conditions, globalization, women and gender equity, urban settings, social exclusion, health systems, measurement, and priority public health conditions.
The CSDH built further evidence-gathering partnerships through two regional networks (the Nordic and Asian networks) and with researchers in additional key areas, such as ageing, indigenous peoples, food and nutrition, violence and conflict, and the environment.
In 2008 the CSDH published its final report called “Closing the gap in a generation: Health equity through action on the social determinants of health“. As outlined in the report, the 3 overarching recommendations of the Commission are to:
1. Improve Daily Living Conditions
Improve the well-being of girls and women and the circumstances in which their children are born, put major emphasis on early child development and education for girls and boys, improve living and working conditions and create social protection policy supportive of all, and create conditions for a flourishing older life. Policies to achieve these goals will involve civil society, governments, and global institutions.
2. Tackle the Inequitable Distribution of Power, Money, and Resources
In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.
3. Measure and Understand the Problem and Assess the Impact of Action
Acknowledging that there is a problem, and ensuring that health inequity is measured – within countries and globally – is a vital platform for action. National governments and international organizations, supported by WHO, should set up national and global health equity surveillance systems for routine monitoring of health inequity and the social determinants of health and should evaluate the health equity impact of policy and action. Creating the organizational space and capacity to act effectively on health inequity requires investment in training of policy-makers and health practitioners and public understanding of social determinants of health. It also requires a stronger focus on social determinants in public health research.
The final report of the CSDH is available here (in Chinese, English, Portuguese, French, Russian and Spanish).
More information about the WHO Commission on Social Determinants of Health can be found here.
Reports of the different Knowledge Networks are accessible here.
There are various international and global organisations that strive for health equity. Below you can find an overview of several actors, including a short description and a reference to their websites.
The mission of the International Union for Health Promotion and Education (IUHPE) is to promote global health and to contribute to the achievement of equity in health between and within countries of the world.
The goals of the IUPHE are:
- Greater equity in the health of populations between and within countries of the world;
- Effective alliances and partnerships to produce optimal health promotion outcomes;
- Broadly accessible evidence-based knowledge and practical experience in health promotion;
- Excellence in policy and practice for effective, quality health promotion; and
- High levels of capacity in individuals, organisations and countries to undertake health promotion activities.
Health Action Partnership International c.i.c. (HAPI) is an international health partnership bringing together leading professionals and organisations from across the world to improve the effectiveness of action to address the social and economic determinants of health, and to build capacity in countries to tackle health inequity.
- Provides technical assistance to countries who wish to develop capacity, systems and mechanisms to promote health;
- Provides high quality consultants with appropriate skills and experience to assess assets and needs, give capacity and offer advice;
- Matches individuals, organisations and regions who wish to develop long-term exchange and learning relationships;
- Provides project management on projects working with a range of partners across countries to ensure effective outcomes.
- Building of the global movement for health equity: from Santiago to Rio and beyond. Michael Marmot, Jessica Allan, Ruth Bell, Peter Goldblatt. The Lancet, Health Policy, October 19, 2011 DOI:10.1016/S0140-6736(11)61506-7
- Closing the Gap in a Generation: Health equity through action on the social determinants of health. Global Review final report by the WHO Commission on Social Determinants of Health, WHO (2008)