Economic arguments can – and have been – made for taking action to improve health. The Commission on Macroeconomics and Health2 put forward an economic case for investing in control of major infectious diseases in developing countries. Some economists have argued, to the contrary, that increases in life expectancy in developing countries have contributed to population growth, which wipes out the rise in GDP per capita brought about by productivity gains.Reference Acemoglu and Johnson3 However, while wealthier nations tend, on average, to have healthier populations, there are important outliers. The United States ranks second in GDP per capita at US$41,890 (behind Luxembourg)4 but 29th in life expectancy for men (77.4 years for the period 2000–2005).4 Chile, Costa Rica and Cuba have relatively high life expectancy for men (77.9, 78.1 and 77.2 years respectively) compared with many countries at similar relatively low levels of GDP per capita.4 Economic growth has the potential to bring great social benefits for population health,Reference Deaton5 but the link between a nation’s wealth and the health of its population depends on factors such as how a nation spends its wealth and how the wealth is distributed.6
Economic analyses of the costs of health inequities have been carried outReference Mackenbach, Meerding and Kunst7, 8 and show that health inequities are immensely costly in economic terms. Investments in care and education of young children – key areas for action explored by the Commission9 – will not only have long term benefits for population health but will also benefit society economically.Reference Heckman10 Notwithstanding the economic debate, the Commission calls for action to be taken on the social determinants of health, not for gains in economic efficiency, but to improve population health and the distribution of health. Better health and more equitably distributed health are ends in themselves.
The scale of the global health inequities with which the Commission is concerned is immense. Life expectancy for women in Zambia is 43 years, in Japan it is twice as long, 86 years. Within both rich and poor countries there are inequities in health and life expectancy. Life expectancy for men in the deprived suburb of Calton in Glasgow, Scotland, is 28 years less than for men living 13 km away in affluent Lenzie,Reference Hanlon, Walsh and Whyte11 Men in Calton have a shorter life expectancy than the average for men in India, where 80% of the population lives on $2 a day.4 The differences in life expectancy for men between Calton and Lenzie show how powerful social determinants of health can be.
However, it is not only the difference between the worst off and the best off that concerns the Commission. The gradient in health that runs from the bottom to the top of society is well documented.Reference Marmot12 The lower the socioeconomic position, the worse the health, and even those in the middle of the social hierarchy have worse health and a lower life expectancy than those at the top. The significance of the social gradient in health for overall population health is that if policies only target the poorest 10% of the population, they miss most of the health problems. The mortality of the under fives in developing countries gives the starkest illustration of the health gradient. In Uganda, the death rate of children under 5 years old in the poorest fifth of households is 192 per 1000 live births, in the next poorest quintile the figure is 173, in the middle quintile 164, in the second richest quintile 136 and in the richest fifth of households in Uganda it is 106 deaths per 1000 live births.Reference Gwatkin, Rutstein, Johnson, Suliman, Wagstaff and Amouzou13 Compare these data against an average death rate for under fives in high income countries of seven deaths per 1000 live births.
Health inequities arise from the differential exposures and vulnerabilities of people to material, psychosocial, and biological hazards according to the socially conditioned circumstances in which they are born, grow, live, work and age. For a substantial number of the world’s population, material deprivation – characterised by lack of clean water, food, sanitation, adequate shelter, and basic health care – drives poor health outcomes. At the same time, there are more deaths globally from non-communicable disease than from communicable diseases.14 Also, in countries at all stages of development, whether or not basic human needs are met, the position within the social hierarchy is associated with relative deprivation, which drives health inequities. Differential conditions of daily life are driven by the wider social, economic and political context, governance at national and global levels, and biases, norms and values operating within societies.Reference Solar and Irwin15 This framework for understanding the causes of health inequities led to the development of the Commission’s principles of action to tackle health inequities6, Reference Marmot, Friel, Bell, Houweling and Taylor16 which are:
(1) improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age;
(2) tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally;
(3) measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.
The Commission drew its three overarching recommendations for action from these three principles, and arranged its full set of recommendations as follows.
Daily living conditions
• Equity from the start
• Healthy places
• Fair employment and decent work
• Social protection
• Universal health care
Power, money and resources
• Health equity in all policies, systems and programmes
• Fair financing
• Market responsibility
• Gender equity
• Political empowerment – inclusion and voice
• Good global governance
Monitoring, research and training
Power, money and resources
The Commission was challenged, before, during and after its deliberations, to prioritise its recommendations. Yet the Commission resisted, wishing to avoid the ‘one size fits all’ trap that might be implied by such a prioritisation. The broad set of recommendations resulting from the Commission’s global evidence could never serve as a prescription for policies to suit every country context. Rather, the aim was to set out the evidence and provide recommendations that could be translated by countries to suit their own circumstances. Nevertheless, positioning health equity as a measure of performance in economic and social development at global, national and local level is a radically transformational recommendation. It implies establishing health equity as a core global development goal and measuring progress as improvements in health and well being across societies. The world economic crisis, and the opportunities for rethinking global structures of governance and finance that the economic crisis has opened up, make such a transformation seem less visionary and more plausible than it seemed even a few months ago. Health equity impact assessments are a tool that the Commission recommends should be institutionalised in every policy across sectors, including trade, finance, employment, education, health, housing, environment and transport to ensure coherence in gearing global and national systems towards health equity.6
Fair financing – within and between countries
In countries at all stages of economic development, creating the conditions for health equity requires a commitment to increase and maintain public expenditure to fund policies across the range of the social determinants of health, from early child development and education, through living and working conditions to health care.6 Poverty levels are influenced by the availability of jobs, the extent to which jobs pay a healthy living wage and by the generosity of redistributive social welfare payments. Lundberg et al.Reference Lundberg, Åberg Yngwe, Kölegård Stjärne, Björk and Fritzell17 have shown that among a number of high income countries, those countries with more generous family welfare policies – notably Sweden, Norway and Finland – have lower rates of child poverty (less than 10%) than countries such as Britain with less generous policies. This association is mainly due to policies that support dual earner families, either directly through the amount of benefits paid or indirectly by enabling two family members to work in the employment market, thus raising earned household income.Reference Lundberg, Åberg Yngwe, Kölegård Stjärne, Björk and Fritzell17 Other studies reported by Lundberg et al.,Reference Lundberg, Åberg Yngwe, Kölegård Stjärne, Björk and Fritzell17 using Luxembourg Income Study data, show that income redistribution by tax and transfers is effective a poverty reduction measure, but the extent to which poverty is reduced is a matter of policy choice. The Nordic countries have the lowest poverty rates (less than 10%) after taxes and transfers are taken into account, Belgium, Germany and the Netherlands have poverty levels of 10–15%, while Italy and Spain, together with Canada, the UK and the US, have poverty levels over 15%.Reference Lundberg, Åberg Yngwe, Kölegård Stjärne, Björk and Fritzell17
Poverty reduction through progressive taxation and welfare payments requires effective tax systems that focus on direct taxes (such as income and property taxes) rather than indirect taxes (such as trade or sales taxes).6 Many developing countries, where tax systems are relatively weak and the tax take is low because the majority of workers are in the informal sector, have relied on trade tariffs as revenue for public spending.18 High income countries have a global role in creating conditions for development of low income countries. Economic agreements between rich and poor countries that require tariff reduction may seriously reduce revenue for public policies in low income countries. The impacts of economic agreements on health equity need to be assessed and taken into consideration until other streams of revenue from direct taxation are established.6
A number of low income countries rely heavily on international aid to finance development. Donor countries need to increase the amount of aid to meet the internationally agreed commitments of 0.7% of GDP, and aid needs to be long-term, predictable and available to meet the development needs of the recipient countries through a ‘social determinants of health’ framework.6 In addition, multilateral debt relief must be stepped up and made available to more countries.
Perversely, net global financial flows have been increasingly from low income countries, particularly in sub-Saharan Africa, to high income countries, since the early 1990s, amounting to about US$500 billion in 2006.19 These net outflows from developing countries must be reversed if poorer countries are going to grow their economies and establish policies that improve people’s living and working conditions.18
Political empowerment – inclusion and voice
The Commission places material, psychosocial and political empowerment of people, communities and countries at the heart of development for health equity, meaning that people and populations need the basic material requisites for a healthy life, they need to have control over their lives and they need to participate in decision making processes.6 The impact of community empowerment on health and well being is powerfully shown by the study of youth suicides among First Nation communities in Canada.Reference Chandler and Lalonde20 The study examined aboriginal youth suicide and cultural and community factors, including self-government, land claim participation, community control of health services, education, cultural facilities and police and fire services. Over the five-year study period, a linear relationship was found between youth suicide and the number of cultural and community factors that were under the control of the aboriginal community: the fewer factors controlled by the community, the higher the rate of youth suicide.
Optimism
Do we have grounds for optimism? Sceptics say: ‘we have been here before with Alma Ata’. The declaration of Alma Ata, 1978,21 now hailed as a milestone of the twentieth century, stated that achieving the highest attainable level of health is a social goal that involves the action of economic and social sectors as well as the health sector, and it stated that the gross inequalities in health between countries and within countries are unacceptable. The intervening 30 years has been a period of successes and failures for global health and a period that has seen a tremendous growth in knowledge, technical ability, communications and wealth. The hobbling of the Alma Ata movement by the ascendancy of an approach that favoured vertical disease control and by a period of frenzied market-driven economic growth carries lessons for those concerned with health and development.Reference Irwin and Scali22 Learning from the past, and with strong allies across the political spectrum, the Commission of Social Determinants of Health carries the principles of Alma Ata forward into the 21st century with new knowledge and a clear vision: a vision of a world where social justice is taken seriously.
Acknowledgement
This article is based on a lecture given by Professor Marmot at the 20th annual conference of Academia Europaea, September 2008.
Professor M. Marmot is Head of the Department of Epidemiology & Public Health, UCL and was chair of the WHO Commission on Social Determinants of Health 2005–2008.
Ruth Bell is a Senior Research Fellow at UCL and was a member of the Secretariat of the WHO Commission on Social Determinants of Health.
