Addressing Inequities in Health: Social Determinants & Action

1. Is it my job as a NCD programme manager to make the world a fairer place?Acting on the social determinants of health Dr Kumanan Rasanathan Department of Ethics, Equity, Trade and Human Rights WHO, Geneva rasanathank@who.int 17 August 2010

2. Life expectancy at birth (men) (WHO World Health Report 2006; Hanlon,P.,Walsh,D. & Whyte,B.,2006)

4. Outline • Inequities in NCD • Why address inequities? • What are the social determinants of health • What can be done? • Addressing social determinants in delivery of interventions • Addressing social determinants through intersectoral action • Conclusion

5. What are inequities? Unfair, avoidable and remediable differences in health between groups

6. 5 developed DMF indices world developing 0 trends in dental decay 1980 – 2002 Inequities in diabetes and oral health trends 160 140 projections for diabetes millions of cases 2000  2030 120 100 Courtesy G.Galea 80 60 40 20 Developed Developing 0 20-44 45-64 65+ 20-44 45-64 65+ developed 2000 2030 developing 2000  2030

7. Inequities in diabetes Source: QIAN R-L et al, Chinese Diabetes Journal (Chinese National Diabetes Survey 1996), courtesy G.Galea

8. by socio-economic group and country level of economic development Source: David et al in Blas E, Sivasankara Kurup eds. Equity, social determinants and public health programmes. Geneva: WHO; 2010: 199-217. • In low income countries, the difference between Q1 & Q5 is two times, where as in upper middle income countries, the difference is not very significant

9. Why address inequities? • They are unfair and avoidable • Without doing so, major public health targets cannot be achieved • We know more about causes and how to address inequities

10. “Medicine is a social science and politics is nothing but medicine writ large!" (Virchow, 1847)

11. What are the social determinants of health?

12. What are the social determinants of health? "The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon….Together, the structural determinants and conditions of daily life constitute the social determinants of health." (WHO Commission on Social Determinants of Health, 2008)

14. Commission on Social Determinants of Health • Overarching Recommendations • Improve Daily Living Conditions • 2. Tackle the Inequitable Distribution of Power, Money, and Resources • 3. Measure and Understand the Problem and Assess the Impact of Action.

16. What can be done about inequities? • Measurement of differential performance along continuum of care • Addressing points that cause inequities in health systems • Linking to action on social determinants at local and municipal levels • Providing information about inequities in health system and social determinants at local level • Need disadvantaged groups to progress more rapidly than advantaged

17. Social determinants in health programmes: framework for analysis http://whqlibdoc.who.int.ezproxy.auckland.ac.nz/publications/2010/9789241563970_eng.pdf

18. COMPARATIVE RESULTS Inequities in social determinants in Chile Highest third Middle third Worst tertile El rango del país se ha dividido en tercios, por lo que el color verde refleja una posición en el mejor tercio, el amarillo en el tercio intermedio y el rojo en el peor tercio. Courtesy J.Vega

19. Public health programmes need to address social determinants and health equity Beneficiaries Adherers Participants Total reached Target Population Total Population Population not benefitting

20. Treatment of colon cancer in NZ • Maori patients • less likely to undergo extensive lymph node clearance • more likely to die during the postoperative period • less likely to receive chemotherapy for stage III disease • more likely to experience a delay of at least 8 weeks before starting chemotherapy Source: Hill S et al, Cancer Journal, 2010, available online doi:10.1002/cncr.25127

21. Population attributable fraction - selected risk factors Source: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491

22. Financial crises and heart disease Source: D Stuckler, C M Meissner and L P King. Can a bank crisis break your heart? Courtesy G Galea After correcting for prior economic change, inflation levels, population education levels, urbanization, and dependency ratios as well as period- and country-effects

23. Health in All Policies “…government objectives are best achieved when all sectors include health and well-being as a key component of policy development…” Adelaide Statement on Health in All Policies, 2010

24. Examples of Health in All Policies • Tobacco control • Urban planning • Cash transfers and social protection • Regulation of energy dense, low nutrition food • Environmental protection • Early child development • Employment and education policies • With equity lens

25. United Kingdom “Despite 10 years of the largest public spending increases on health since the creation of the NHS, and rising prosperity levels generally, people in England living in the poorest neighbourhoods will, on average, die seven years earlier than others living in the richest parts of Britain, the study finds. The report, entitled Fair Society, Healthy Lives, says the government will fail to meet its promise to reduce the 10% mortality gap between deprived areas and the rest of the UK. For men in poor areas the gap has widened by 2%, and for women the figure is 11%.” Source: Guardian, 2010

26. NZ Ethnic Health Inequities 1951-2006 Tobias M, Blakely T, Matheson D, Rasanathan K, Atkinson J. Changing trends in indigenous inequalities in mortality: lessons from New Zealand. Int J Epidemiol. 2009 Dec;38(6):1711-1722.

27. New Zealand Causes of Ethnic Standardised Rate Differences in NCD Tobias M, Blakely T, Matheson D, Rasanathan K, Atkinson J. Changing trends in indigenous inequalities in mortality: lessons from New Zealand. Int J Epidemiol. 2009 Dec;38(6):1711-1722.

28. New Zealand “The recent narrowing in ethnic mortality inequality… has occurred in tandem with rapid economic recovery—including a marked reduction in many indicators of social inequality…[and] also coincided with the reorientation of the health sector It is difficult…to demonstrate causality between health policy changes and trends in health [inequities]…there is little international evidence on the contribution of health systems per se to ethnic [inequities] in health… The New Zealand experience implies that action by the health sector alone is necessary but not sufficient to address health [inequities].” Tobias M, Blakely T, Matheson D, Rasanathan K, Atkinson J. Changing trends in indigenous inequalities in mortality: lessons from New Zealand. Int J Epidemiol. 2009 Dec;38(6):1711-1722.

29. Brazil “Aquino et al. presented their study on the FHS impact on infant mortality. Their findings show that the FHS contributed to a decrease in infant mortality rates. The FHS effects were greater in areas with the highest infant mortality rates and the lowest human development indexes before the program was begun, suggesting that the FHS can contribute to decreases in health social inequities in Brazil.” Aquino R, de Oliveira NF, Barreto ML. Impact of the family health program on infant mortality in Brazilian municipalities. Am J Public Health. 2009 Jan;99(1):87-93.

30. Conclusion • Health inequities in NCD are avoidable and remediable • Without addressing inequities, unlikely to make progress on NCD targets • NCD programme managers can: • Measure inequities in NCD and disseminate this knowledge • Act to ensure their own programmes do not worsen inequities • Design interventions on risk factors considering social determinants • Look to achieve greater progress for disadvantaged groups • Advocate for broader intersectoral policies to address the social determinants

31. A world where social justice is taken seriously www.who.int/social_determinants/en