Closing the gap in a generation: Health equity through action on the social determinants of health

Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others.

A girl born today can expect to live for more than 80 years if she is born in some countries – but less than 45 years if she is born in others. Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen.

These inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces.

Social and economic policies have a determining impact on whether a child can grow and develop to its full potential and live a flourishing life, or whether its life will be blighted. Increasingly the nature of the health problems rich and poor countries have to solve are converging. The development of a society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health.

In the spirit of social justice, the Commission on Social Determinants of Health was set up by the World Health Organization (WHO) in 2005 to marshal the evidence on what can be done to promote health equity, and to foster a global movement to achieve it.

As the Commission has done its work, several countries and agencies have become partners seeking to frame policies and programmes, across the whole of society, that influence the social determinants of health and improve health equity. These countries and partners are in the forefront of a global movement.

The Commission calls on the WHO and all governments to lead global action on the social determinants of health with the aim of achieving health equity. It is essential that governments, civil society, WHO, and other global organizations now come together in taking action to improve the lives of the world’s citizens. Achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it.

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EXECUTIVE SUMMARY
A new global agenda for health equity

Our children have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality. But poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

It does not have to be this way and it is not right that it should be like this. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. Reducing health inequities is, for the Commission on Social Determinants of Health (hereafter, the Commission), an ethical imperative. Social injustice is killing people on a grand scale. ...

Table of Contents
EXECUTIVE SUMMARY 1
PART 1: SETTING THE SCENE FOR A GLOBAL APPROACH TO HEALTH EQUITY 25
Chapter 1: A New Global Agenda – the Commission on Social Determinants of Health 26
Chapter 2: Global Health Inequity – the Need for Action 29
Chapter 3: Causes and Solutions 35
PART 2: EVIDENCE, ACTION, ACTORS 41
Chapter 4: The Nature of Evidence and Action 42
Assembling the evidence 42
The Commission’s conceptual framework 42
Judging the evidence 43
The Commission’s key areas for action and recommendations 43
Implications for different actors 44
Contextualizing the recommendations 46
PART 3: DAILY LIVING CONDITIONS 49
Chapter 5: Equity from the Start 50
Action towards a more equitable start in life 51
Changing the mindset 51
A comprehensive approach to early childhood in practice 52
The scope of education 56
Barriers to education 58
Educating girls 59
Chapter 6: Healthy Places Healthy People 60
Action to build a flourishing living environment 63
Participatory urban governance 63
Improving urban living conditions 63
Urban planning and design that promotes healthy behaviours and safety 66
Land rights 69
Rural livelihoods 69
Rural infrastructure and services 70
Rural-urban migration 71
The natural environment 71
Chapter 7: Fair Employment and Decent Work 72
Creating fair employment and decent work 76
A supportive international environment 76
Fair representation of workers in developing the national policy agenda 77
Safe and decent work standards 80
Precarious work 80
Improving working conditions 82
Chapter 8: Social Protection Across the Lifecourse 84
Action towards universal social protection 87
Universal social protection systems across the lifecourse 87
The generosity of social protection systems 90
Targeting 90
Extending social protection systems to excluded groups 91
Chapter 9: Universal Health Care 94
Actions for universal health care 96
Universal Primary Health Care 96
Primary Health Care – community engagement and empowerment 96
Prevention and promotion 97
Using targeted health care to build universal coverage 99
Health-care financing – tax and insurance 100
Aid for the health workforce 105
PART 4: POWER, MONEY, AND RESOURCES 109
Chapter 10: Health Equity in All Policies, Systems, and Programmes 110
Building a coherent approach to health equity 111
Health equity as a marker of societal progress 111
Policy coherence – mechanisms to support health equity in all policies 112
Government policy impact on health equity 114
Action within the health sector 116
Institutional strengthening 116
The health sector as a catalyst beyond government 118
Chapter 11: Fair Financing 120
Actions for fair financing 123
Progressive taxation 123
Tax in a globalized world 124
Development assistance for health 126
A social determinants of health framework for aid 126
Debt relief 129
Future debt responsibility 129
Fair allocation 130
Chapter 12: Market Responsibility 132
Actions for market responsibility 135
Health equity impact assessment in economic agreements 136
Flexibility in agreements 136
A responsible private sector 142
Chapter 13: Gender Equity 145
Action towards improving gender equity for health 147
Legislation 147
Gender mainstreaming 148
Including women’s economic contribution in national accounts 150
Education and training 151
Economic participation 152
Sexual and reproductive health and rights 153
Chapter 14: Political Empowerment – Inclusion And Voice 155
Action towards fairness in voice and inclusion 158
Legislation for political empowerment – rights and agency 158
Fair participation in policy-making 160
Bottom-up approaches to health equity 162
Chapter 15: Good Global Governance 166
Actions for good global governance 170
Health equity – a global goal 170
Multilateral coherence 170
The Millennium Development Goals 171
Champions for global health governance 173
PART 5: KNOWLEDGE, MONITORING, AND SKILLS: THE BACKBONE OF ACTION 177
Chapter 16: The Social Determinants of Health: Monitoring, Research, and Training 178
Action towards enhanced capacity for monitoring, research, and intervention 179
Birth registration systems 179
National health equity surveillance systems 180
A global health equity surveillance system 184
Expanding the knowledge base 186
Training and education on the social determinants of health 188
PART 6: BUILDING A GLOBAL MOVEMENT 193
Chapter 17: Sustaining Action Beyond the Commission on Social Determinants of Health 194
Foundations for sustained action 194
An unfinished agenda 196
Goals and targets for health equity 196
Milestones towards health equity – short- to medium-term deliverables 198
ANNEX A: LIST OF ALL RECOMMENDATIONS 200
COMMISSIONER BIOGRAPHIES 207
REFERENCES 208
ACRONYMS 225
LIST OF BOXES, FIGURES AND TABLES 227
INDEX 232

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