Closing the gap in a generation Health equity through action on the social determinants of health Commission on Social Determinants of Health FINAL REPORT | EXECUTIVE SUMMARY

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The Commission calls for closing the health gap in a generation 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.

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.

The social determinants of health and health equity The Commission, created to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it, is a global collaboration of policy- makers, researchers, and civil society led by Commissioners with a unique blend of political, academic, and advocacy experience. Importantly, the focus of attention embraces countries at all levels of income and development: the global South and North. Health equity is an issue within all our countries and is affected significantly by the global economic and political system.

The Commission takes a holistic view of 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 but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.

The global community can put this right but it will take urgent and sustained action, globally, nationally, and locally. Deep inequities in the distribution of power and economic arrangements, globally, are of key relevance to health equity. This in no way implies ignoring other levels of action. There is a great deal that national and local governments can do; and the Commission has been impressed by the force of civil society and local movements that both provide immediate local help and push governments to change.

And of course climate change has profound implications for the global system – how it affects the way of life and health of individuals and the planet. We need to bring the two agendas of health equity and climate change together. Our core concerns with health equity must be part of the global community balancing the needs of social and economic development of the whole global population, health equity, and the urgency of dealing with climate change.

A new approach to development The Commission’s work embodies a new approach to development. Health and health equity may not be the aim of all social policies but they will be a fundamental result. Take the central policy importance given to economic growth: Economic growth is without question important, particularly for poor countries, as it gives the opportunity to provide resources to invest in improvement of the lives of their population. But growth by itself, without appropriate social policies to ensure reasonable fairness in the way its benefits are distributed, brings little benefit to health equity.

Traditionally, society has looked to the health sector to deal with its concerns about health and disease. Certainly, maldistribution of health care – not delivering care to those who most need it – is one of the social determinants of health. But the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics. Action on the social determinants of health must involve the whole of government, civil society and local communities, business, global fora, and international agencies. Policies and programmes must embrace all the key sectors of society not just the health sector. That said, the minister of health and the supporting ministry are critical to global change. They can champion a social determinants of health approach at the highest level of society, they can demonstrate effectiveness through good practice, and they can support other ministries in creating policies that promote health equity. The World Health Organization (WHO), as the global body for health, must do the same on the world stage.

Closing the health gap in a generation The Commission calls for closing the health gap in a generation. It is an aspiration not a prediction. Dramatic improvements in health, globally and within countries, have occurred in the last 30 years. We are optimistic: the knowledge exists to make a huge difference to people’s life chances and hence to provide marked improvements in health equity. We are realistic: action must start now. The material for developing solutions to the gross inequities between and within countries is in the Report of this Commission.



Three principles of action

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’s overarching recommendations

Improve Daily Living Conditions Improve the well-being of girls and women and the circumstances in which their children are born, put major emphasis on early child development and education for girls and boys, improve living and working conditions and create social protection policy supportive of all, and create conditions for a flourishing older life. Policies to achieve these goals will involve civil society, governments, and global institutions.

Tackle the Inequitable Distribution of Power, Money, and Resources In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.

Measure and Understand the Problem and Assess the Impact of Action Acknowledging that there is a problem, and ensuring that health inequity is measured – within countries and globally – is a vital platform for action. National governments and international organizations, supported by WHO, should set up national and global health equity surveillance systems for routine monitoring of health inequity and the social determinants of health and should evaluate the health equity impact of policy and action. Creating the organizational space and capacity to act effectively on health inequity requires investment in training of policy-makers and health practitioners and public understanding of social determinants of health. It also requires a stronger focus on social determinants in public health research.

These three principles of action are embodied in the three overarching recommendations above. The remainder of the Executive Summary and the Commission’s Final Report is structured according to these three principles.





1. Improve Daily Living Conditions The inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. This inequity is seen in the conditions of early childhood and schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment in which people reside. Depending on the nature of these environments, different groups will have different experiences of material conditions, psychosocial support, and behavioural options, which make them more or less vulnerable to poor health. Social stratification likewise determines differential access to and utilization of health care, with consequences for the inequitable promotion of health and well-being, disease prevention, and illness recovery and survival.


Equity from the start

What must be done

A comprehensive approach to the early years in life requires policy coherence, commitment, and leadership at the international and national level. It also requires a comprehensive package of ECD and education programmes and services for all children worldwide.

Commit to and implement a comprehensive approach to early life, building on existing child survival programmes and extending interventions in early life to include social/emotional and language/cognitive development.

• Set up an interagency mechanism to ensure policy coherence for early child development such that, across agencies, a comprehensive approach to early child development is acted on.

• Make sure that all children, mothers, and other caregivers are covered by a comprehensive package of quality early child development programmes and services, regardless of ability to pay.

Expand the provision and scope of education to include the principles of early child development (physical, social/emotional, and language/cognitive development).

• Provide quality compulsory primary and secondary education for all boys and girls, regardless of ability to pay. Identify and address the barriers to girls and boys enrolling and staying in school and abolish user fees for primary school.

Early child development (ECD) – including the physical, social/emotional, and language/cognitive domains – has a determining influence on subsequent life chances and health through skills development, education, and occupational opportunities. Through these mechanisms, and directly, early childhood influences subsequent risk of obesity, malnutrition, mental health problems, heart disease, and criminality. At least 200 million children globally are not achieving their full development potential. This has huge implications for their health and for society at large.

Evidence for action Investment in the early years provides one of the greatest potentials to reduce health inequities within a generation. Experiences in early childhood (defined as prenatal development to eight years of age), and in early and later education, lay critical foundations for the entire lifecourse. The science of ECD shows that brain development is highly sensitive to external influences in early childhood, with lifelong effects. Good nutrition is crucial and begins in utero with

adequately nourished mothers. Mothers and children need a continuum of care from pre-pregnancy, through pregnancy and childbirth, to the early days and years of life. Children need safe, healthy, supporting, nurturing, caring, and responsive living environments. Preschool educational programmes and schools, as part of the wider environment that contributes to the development of children, can have a vital role in building children’s capabilities. A more comprehensive approach to early life is needed, building on existing child survival programmes and extending interventions in early life to include social/ emotional and language/cognitive development.


Effects of combined nutritional supplementation and psychosocial stimulation on stunted children in a 2-year intervention study in Jamaicaa.






Baseline 6 mo 12 mo 16 mo 24 mo


a Mean development scores (DQ) of stunted groups adjusted for initial age and score compared with a non-stunted group adjusted for age only, using Griffiths Mental Development Scales modified for Jamaica. Reprinted, with permission of the publisher, from Grantham-McGregor et al. (1991).


Supplemented and stimulated





Healthy Places Healthy People

What must be done

Communities and neighbourhoods that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological well-being and that are protective of the natural environment are essential for health equity.

Place health and health equity at the heart of urban governance and planning.

• Manage urban development to ensure greater availability of affordable housing; invest in urban slum upgrading including, as a priority, provision of water and sanitation, electricity, and paved streets for all households regardless of ability to pay.

• Ensure urban planning promotes healthy and safe behaviours equitably, through investment in active transport, retail planning to manage access to unhealthy foods, and through good environmental design and regulatory controls, including control of the number of alcohol outlets.

Promote health equity between rural and urban areas through sustained investment in rural development, addressing the exclusionary policies and processes that lead to rural poverty, landlessness, and displacement of people from their homes.

• Counter the inequitable consequences of urban growth through action that addresses rural land tenure and rights and ensures rural livelihoods that support healthy living, adequate investment in rural infrastructure, and policies that support rural-to-urban migrants.

Ensure that economic and social policy responses to climate change and other environmental degradation take into account health equity.

Where people live affects their health and chances of leading flourishing lives. The year 2007 saw, for the first time, the majority of human beings living in urban settings. Almost 1 billion live in slums.

Evidence for action Infectious diseases and undernutrition will continue in particular regions and groups around the world. However, urbanization is reshaping population health problems, particularly among the urban poor, towards non-communicable diseases, accidental and violent injuries, and deaths and impact from ecological disaster.

The daily conditions in which people live have a strong influence on health equity. Access to quality housing and shelter and clean water and sanitation are human rights and basic needs for healthy living. Growing car dependence, land- use change to facilitate car use, and increased inconvenience of non-motorized modes of travel, have knock-on effects on local air quality, greenhouse gas emission, and physical inactivity. The planning and design of urban environments has a major impact on health equity through its influence on behaviour and safety.

The balance of rural and urban dwelling varies enormously across areas: from less than 10% urban in Burundi and Uganda to 100% or close to it in Belgium, Hong Kong Special Administrative Region, Kuwait, and Singapore. Policies

and investment patterns reflecting the urban-led growth paradigm have seen rural communities worldwide, including Indigenous Peoples, suffer from progressive underinvestment in infrastructure and amenities, with disproportionate levels of poverty and poor living conditions, contributing in part to out- migration to unfamiliar urban centres.

The current model of urbanization poses significant environmental challenges, particularly climate change – the impact of which is greater in low-income countries and among vulnerable subpopulations. At present, greenhouse gas emissions are determined mainly by consumption patterns in cities of the developed world. Transport and buildings contribute 21% to CO2 emissions, agricultural activity accounts for about one fifth. And yet crop yields depend in large part on prevailing climate conditions. The disruption and depletion of the climate system and the task of reducing global health inequities go hand in hand.

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