Social Determinants and universal health

coverage
Professor Sir Michael Marmot

International Conference on Universal Health Coverage
Lima, Peru


Universal Health Coverage and Action on
Social Determinants
UHC and SDH are complementary:
both are essential to population
health;
Every sector is a health sector
Health and well being as outcomes



BENEFITS FROM GOVERNMENT HEALTH SERVICE
EXPENDITURE, AVERAGE FOR 21 COUNTRIES
0
2
4
6
8
10
12
14
16
Less Same More
Number of countries*
Source: Reaching the Poor, eds:Gwatkin,D.R. Wagstaff,A. Yazbeck A.S. The World Bank, 2005

*Number of countries where lowest quintile receives less, the same, or more
benefit compared with the highest income quintile

Use of maternal and child health services by
highest /lowest economic quintiles, 50+countries
*medical treatment;
ARI=acute respiratory infections
Source: Gwatkin et al 2005 DHS data
Cardiovascular deaths of people aged 45 - 64 and
social inequalities: Porto Alegre, Brazil
0
50
100
150
200
250
300
350
400
High Medium
high
Medium
low
Low ALL
CVD deaths Attributable CVD deaths
C
V
D

d
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0

i
n
h
a
b
i
t
a
n
t
s

Socioeconomic level of districts
Bassanesi, Azambuja & Achutti, Arq Bras Cardiol, 2008
Social patterning of diabetes by education and by
monthly income, Buenos Aires, Argentina
Fleisher et al 2008
Trends in under five mortality by household
wealth quintile: Bangladesh

Source: DHS data from http://www.measuredhs.com/
Under five mortality per 1000 live births by
mothers education: Peru 2000 and 2012
106
43
76
33
35
20
0
20
40
60
80
100
120
2000 2012
No education Primary Secondary or higher
(U5M for the ten years preceding the survey) Source: measuredhs.com

Prevalence of stunting by family income and
year of survey: Brazil

Victora et al 2011, Monteiro et al 2010
The Commission on
Social Determinants of
Health (CSDH) Closing
the gap in a generation
Strategic Review of Health
Inequalities in England:
The Marmot Review Fair
Society Healthy Lives
Review of Social
Determinants of Health and
the Health Divide in the
WHO European Region
Michael Marmot

Health inequities
persist

within and between
countries
The health divide in male life expectancy
The health divide and
health inequities, males
The health divide in male life
expectancy
Persistence of health inequities in Sweden
The health divide and
health inequities, males
Persistence of health inequities in Sweden
The widening of health inequities in
the Russian Federation
Life expectancy by GDP, 2010 (or latest available)
Michael Marmot

Health inequities are:
unnecessary
avoidable
unjust
Areas for action emphasizing priorities

The review grouped its
recommendations into
four themes

Action is needed on
all four themes.
Preliminary action
A first step for any country wishing to address
inequities in health and its social determinants is to
examine and understand the extent to which current
policies are addressing or considering inequities

Recommendation 4(c) - Undertake regular reporting
and public scrutiny of inequities in health and its social
determinants at all governance levels, including
transnational, country and local.

Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Michael Marmot

Support


Good Quality Parenting
Family Building
Gender equity



Children achieving a good level of development at age five, local
authorities 2011

40
45
50
55
60
65
70
75
80
0 30 60 90 120 150
Good level
of development
at age 5
%
Local authority rank - based on Index of Multiple Deprivation
Country ranking: equality in child wellbeing -
material, education, and health
Source: UNICEF Report Card 9, ranking 24 OECD countries by their
performance in each of three dimensions of inequality in child well-being
Score Country
8 Denmark, Finland, Netherlands, Switzerland

7 Iceland, Ireland, Norway, Sweden

6 Austria, France, Germany, Poland, Portugal,
Canada

5 Belgium, Czech Republic, Hungary,
Luxembourg, Slovakia, Spain, United Kingdom

3 Greece, Italy, United States
Child poverty rate at <50% median income
25.5
23.1
18.8
14.5
12.1
7.3
7.3
6.1
4.7
0 5 10 15 20 25 30
Romania
United States
Latvia
Poland
United Kingdom
Austria
Sweden
Norway
Iceland
per cent of children living in relative poverty
Per cent children living in a household in which disposable income, when adjusted for
family size and composition, is less than 50% of the national median income
(Unicef Innocenti Report Card 10)
Enrolment in preschool (ages 3-5) and reading in 6
th

grade: selected countries in Latin America
Tinajero 2010
Per cent 5 year olds achieving good development
score,* Birmingham LA, West Midlands & England
*in personal, social and emotional development
and communication, language and literacy
Source: Department for Education: preliminary data

%
Michael Marmot

Provide universal
good quality


Early years child care
Education
Work
Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Key contribution of work and employment
Participation in labour market
Appropriate income
Avoidance of adverse hazards
Positive psychosocial environment

Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Michael Marmot

Adequate social protection
Social Inclusion
Equity at older ages



Michael Marmot

Adequate social protection
Social Inclusion
Equity at older ages



Action across
the Social Gradient
Self reported health by education and social
expenditures: 18 EU countries
0
0.05
0.1
0.15
0.2
0.25
Predicted
probability
of poor
health
Net Total Social Expenditures in PPP's
Primary
Minimum
Maximum
0
0.05
0.1
0.15
0.2
0.25
Predicted
probability
of poor
health
Primary
Secondary
Tertiary
Net Total Social Expenditures in PPP's
Source: Dahl & van der Wel, data from EU SILC 2005
Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Michael Marmot

Action across the life-course
Build resilience
Reduce exclusion
Strengthen communities
Prenatal Early Years Working Age Older Ages
Family building
Accumulation of positive and negative
effects on health and wellbeing
LIFE COURSE STAGES
MACROLEVEL CONTEXT
WIDER SOCIETY SYSTEMS
Perpetuation of inequities
Michael Marmot
Quality Housing
Safe Communities
Universal Health Care
Safeguard future generations
Local areas using 6 areas
Fair Society Healthy Lives
in local strategies:



Priorities agreed by 65 Health and Well-being
Boards Local Government England
Kings Fund 2013
5
7
9
23
28
49
0
10
20
30
40
50
60
Prevention Inequality Ageing Mental
health
Unhealthy
behaviours
Marmot
Principles
Monitoring social determinants of health
Early years
An indicator of early child development across the
interconnected domains of physical, social/behavioural
and cognitive/language
Youth
An indicator of involvement in education/training and/or
employment during adolescence
Adult life
An indicator of resources to live a life with dignity and
participate in society
Older ages
Social isolation

The role of health professionals
WORKFORCE EDUCATION AND TRAINING
WORKING WITH INDIVIDUALS & COMMUNITIES
WORKFORCE INSTITUTIONS - the role of the
health care sector as an employer
WORKING IN PARTNERSHIP
WORKFORCE AS ADVOCATES
Do something... do more... do better

If countries have very little in place in terms of
policies on social determinants of health,
some action matters.
Where policies do exist, they can be improved
to deal with large and persistent health
inequities
There is scope to do better on inequities in the
richest countries of Europe.

Michael Marmot

Health is a human right
Do something
Do more
Do better