Jessica Allen

WHO European review of social determinants of health and the health divide

The European region has seen remarkable heath gains in those populations that have experienced progressive improvements in the conditions in which people are born, grow, live, and work. However, inequities, both between and within countries, persist. The review reported here, of inequities in health between and within countries across the 53 Member States of the WHO European region, was commissioned to support the development of the new health policy framework for Europe: Health 2020. Much more is understood now about the extent, and social causes, of these inequities, particularly since the publication in 2008 of the report of the Commission on Social Determinants of Health. The European review builds on the global evidence and recommends policies to ensure that progress can be made in reducing health inequities and the health divide across all countries, including those with low incomes. Action is needed--on the social determinants of health, across the life course, and in wider social and economic spheres--to achieve greater health equity and protect future generations.

Social determinants of mental health.

Abstract A persons mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood, older childhood and adolescence, during family building and working ages, and through to older age. Action throughout these life stages would provide opportunities for both improving population mental health, and for reducing risk of those mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number of other physical health conditions, these actions would also reduce inequalities in physical health and improve health overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of governance and across sectors can make a positive difference.

Social Determinants of Health Equity

Language is important. The call for papers in this supplement was entitled health equity. Yet the call asked for papers that address disparities in health. In the United States, disparities, most often, has been used to refer to racial/ethnic differences in health, or more commonly health care. We note that the call in this supplement expands the focus and highlights differences by socioeconomic status and geographic location, among others. By tradition, in the United Kingdom we have used the term inequalities to describe the differences in health between groups defined on the basis of socioeconomic conditions. To reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviors. Much of the evidence describing this was set out in the World Health Organization Global Commission on the Social Determinants of Health.1 In fact, so close is the link between social conditions and health, that the magnitude of health inequalities is an indicator of the impact of social and economic inequalities on people’s lives. Health then becomes an important further cause for concern about the rapid increase in inequalities of wealth and income in our societies. Increasingly, we are using the language of health inequity to describe those health inequalities that, though avoidable, are not avoided and hence are unfair. Two particular issues stand in the way before we can act on knowledge of social determinants of health to address health equities: lifestyle drift and overconcentration on health care.2 Lifestyle drift describes the tendency in public health to focus on individual behaviors, such as smoking, diet, alcohol, and drugs, that are undoubted causes of health inequities, but to ignore the drivers of these behaviors—the causes of the causes. Too often health is equated only with health care. Lack of access to health care has dominated the debate in the United States because of egregious inequities in access, despite spending far more on health care than any other country. A recent study by the Commonwealth Fund found that compared with other countries the US health system performed relatively poorly in terms of cost, equity, and efficiency.3 The Veterans Health Administration, however, does have a strong focus on equity. The Office of Health Equity ensures that the health care provision for veterans provides equitable care appropriate for the individual’s circumstance and irrespective of geography, gender, race/ethnicity, age, culture, or sexual orientation. There is importance, too, in incorporating socioeconomic factors into provision of equitable access and care. The Office of Health Equity also brings an equity focus into organizational discussions of policy, decision-making, resource allocation, practice, and performance plans throughout the Veterans Health Administration—a health equity in all policies approach that could be extended to other relevant organizations and stakeholders. Universal access to high quality care and a focus on equitable outcomes, then, is central to challenging health inequities. So too is challenging inequities in social conditions which lead to health inequalities. Attempts have been made to apportion determinants of health status of populations—see Figure 1, showing the relatively significant proportion of inequity attributed to social determinants. FIGURE 1— Estimates of the contribution of the main drivers of health status. The Robert Wood Johnson Foundation in the United States also sets out how social factors have as much, or even more impact on health as the medical care system, and it urges leaders across the United States to shift funding priorities to emphasize 3 areas essential to improving the nation’s health: Increasing access to early childhood development programs; revitalizing low-income neighborhoods; and broadening the mission of health care providers beyond medical treatment.5 Important goals, too, for the Veterans Health Administration. In our English review of health inequalities, in 2010, we enlisted the help of 80 or so experts and set out a large evidence base, which demonstrated the most important influences on health and health inequalities.6 We made recommendations in six priority areas. None was in health care because there is evidence of reasonably equitable, universal access to health care in England. The six priority areas were: quality of experiences in the early years, education and building personal and community resilience, good quality employment and working conditions, having sufficient income to lead a healthy life, healthy environments, and priority public health conditions—taking a social determinants approach to tackling smoking, alcohol, and obesity. At the heart of our approach is the finding that health inequalities are not limited to poor health for the worst off, or the most socially disadvantaged. There is a striking social gradient in health and disease running from top to bottom of society.7 The social gradient has now been shown to be widespread across the world in countries at low, middle, and high income.6 Figure 2 shows this gradient in England for life expectancy and healthy life expectancy. FIGURE 2— Life expectancy and disability-free life expectancy (DFLE) at birth by neighborhood income and deprivation: 1999–2003. There has been considerable progress in the recognition and adoption of the social determinants of health approach to health equity. Internationally, organizations such as the United Nations have expressed their broad commitment to health equity through action on the social determinants, and the European Union and World Health Organization have also acted on the social determinants of health and adopted this approach at the heart of their health improvement and health equity strategies. There have also been advancements at the national level—in many countries national governments have acted. There have been some great strides by local governments and authorities too. In England, 75% of local authorities have adopted this approach. However, and it is a significant however, there are many further challenges to greater health equity and to the social determinants of health.

Building of the global movement for health equity: from Santiago to Rio and beyond

Health inequalities are present throughout the world, both within and between countries. The Commission on Social Determinants of Health drew attention to dramatic social gradients in health within most countries and made proposals for action. These inequalities are not inevitable. The purpose of this article is to report on activity that has taken place worldwide after the report by the Commission on Social Determinants of Health. First, we summarise the global situation. Second, we summarise an interim report of the emerging findings from an independent review of social determinants and the health divide, which was commissioned by the WHO European region. The world conference on social determinants of health will be held in Rio de Janeiro, Brazil, in October, 2011. This summit provides an opportunity to galvanise support, prioritise action, and respond to the call by the Commission on Social Determinants of Health for social justice as a route to a fair distribution of health.

Global action on the social determinants of health

Action on the social determinants of health (SDH) is required to reduce inequities in health. This article summarises global progress, largely in terms of commitments and strategies. It is clear that there is widespread support for a SDH approach across the world, from global political commitment to within country action. Inequities in the conditions in which people are born, live, work and age, are however driven by inequities in power, money and resources. Political, economic and resource distribution decisions made outside the health sector need to consider health as an outcome across the social distribution as opposed to a focus solely on increasing productivity. A health in all policies approach can go some way to ensure this consideration, and we present evidence that some countries are taking this approach, however given entrenched inequalities, there is some way to go. Measuring progress on the SDH globally will be key to future development of successful policies and implementation plans, enabling the identification and sharing of best practice. WHO work to align measures with the sustainable development goals will help to forward progress measurement.

Core intended learning outcomes for tackling health inequalities in undergraduate medicine

BackgroundDespite there being a concerted effort in recent years to influence what doctors can do to tackle health inequalities in the UK, there has been limited policy focus on what undergraduate students need to learn at medical school in preparation for this. This project led by members of the Health Inequalities Group of the Royal College of General Practitioners in collaboration with the Institute of Health Equity, University College London sought to fill this gap.DiscussionWe conducted a Delphi poll using our teaching and stakeholder networks. We identified 5 areas for learning focusing on key knowledge and skills. These were population concepts, health systems, marginalised patient groups, cultural diversity and ethics.SummaryThese intended learning outcomes about health inequalities represent the best available evidence to date for colleagues seeking to develop core undergraduate medical curricula on the topic.