World HeALTH ORGANSATIONSocial Determinants of health.ppt

what are the determinants of health

1. 1 The Determinants of Health

2. Definition of Health 1 Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity (World Health Organization, 1948). Health is an individual right and a social justice issue. It is also a public good. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.

3. Factors Determining Health 1 Clinical care is less important than many people think whereas socioeconomic factors and the physical environment are quite influential on health and well-being. Genetic characteristics are also less significant than many people think. Whether people are healthy or not, is determined by their circumstances and environment – the social, economic and environmental conditions which affect the health of the population.

4. Why frame health in terms of societal conditions? 1 Source: Donkin, A., P. Goldblatt, J. Allen, V. Nathanson and M. Marmot (2017). "Global action on the social determinants of health." BMJ Global Health. Figure: Estimates of the contribution of the main drivers of health status. Impact: 30 - 50% or more Health care (up to 15%) Social circumstances & environmental exposure (45%) Health behaviour patterns (40%) Health care (up to 25%) Socioeconomic (50%) Environmental (10%) Genetics (15%) Mc Giniss et al (2002) Canadian Institute of Advanced Research (2012)

5. WHAT ARE THE Social Determinants of Health? 1 The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. The social determinants of health are multi-layered and range from societal to individual factors.

6. 1 Source: Dahlgren G and Whitehead M (1991) Policies and strategies to promote social equity in health. Stockholm, Institute of Future Studies. THE Social Determinants of Health

7. 1 Social Determinants of Health Conceptual Framework S Global Commission on SDH (2008) PAHO Equity Commission (2019) Dahlgren & Whitehead (1991)

8. 1 Global Commission on Social Determinants of Health Conceptual Framework (2008) SOCIOECONOMIC POLITICAL CONTEXT Governance Macroeconomic Policies Social Policies Labour market, Housing, Land Public Policies, Education, Health, Social p rotection Culture and Societal value STRUCTURAL DETERMINANTS OF HEALTH INEQUITIES INTERMEDIARY DETERMINANTS OF HEALTH SOCIOECONOMIC POSITION SOCIAL CLASS GENDER ETHNICITY (RACISM) Material Circumstances (Living and Working, Conditions, Food Availability, etc.) Behaviour s and Biological Factors Psychosocial Factors EDUCATION OCCUPATION INCOME IMPACT ON EQUITY IN HEALTH AND WELL-BEING Social cohesion & Social c apital HEALTH SYSTEM

9. PAHO Conceptual Framework on Social Determinants of Health and Health Equity (2019) 1 Source: Pan American Health Organization. Just Societies: Health Equity and Dignified Lives. Report of the Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas . Washington, D.C.: PAHO; 2019. INTERSECTIONALITY: SOCIAL AND ECONOMIC INEQUITIES, GENDER, SEXUALITY, ETHNICITY, DISABILITY, MIGRATION STRUCTURAL DRIVERS Political, Social, Cultural and Economic Structures Natural Environment, Land and Climate Change History and Legacy, Ongoing Colonialism, Structural Racism CONDITIONS OF DAILY LIFE Early Life and Education Working Life Older People Income and Social Protection Violence Environment and Housing Health Systems TAKING ACTION Governance Human Rights HEALTH EQUITY AND DIGNIFIED LIFE

10. Action recommendations 1 Global Commission on SDH (2008) – 3 overarching recommendations PAHO Equity Commission (2019 ) – 12 recommendations

11. Priority recommendations : The Global Commission 1 The World Health Organization’s Commission on Social Determinants of Health final report (2008) contains three overarching recommendations - 1 2 3 Improve daily living conditions: the circumstances in which people are born, grow, live, work, and age Tackle the inequitable distribution of power, money and resources: the structural drivers of those conditions of daily life – globally, nationally, and locally Measure and understand the problem and assess the impact of 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

12. Priority recommendations : PAHO Commission 1 The 12 recommendations include priority objectives and specific measures in the following general categories: 1 2 3 Achieving equity in political, social, cultural, and economic structures Protecting the natural environment, mitigating climate change, and respecting relationships to land Reversing the health equity impacts of ongoing colonialism and structural racism Structural drivers: Inequities in power, money, and resources

13. Priority recommendations : PAHO Commission 1 Conditions of daily life 4 5 6 Equity from the start: Early life and education Decent work Dignified life at older ages 7 8 Income and social protection Reducing violence for health equity 9 10 Improving environment and housing conditions Equitable health systems

14. 1 Priority recommendations : PAHO Commission Governance for health equity 11 12 Governance arrangements for health equity Fulfilling and protecting human rights

15. End of Module 1 Part 2 Please continue to Module 2 Part 1

16. MODULE 2 PART 1 21 st Century Health Dynamics and Inequality 2 Global Challenges and Health Dynamics

17. Learning Objectives 2 Describe some of the major global challenges impacting health 1

18. Global Challenges for Health The 21 st century brings many complex and interacting challenges. Some of the major global challenges directly and indirectly impacting health include: 2 1 2 3 4 5 6 7 Globalization Urbanization Poverty Socioeconomic inequality Food insecurity Environmental degradation Demographic transition

19. Globalization: trade, migration and industrialization 2 The world is more and more economically interconnected. Trade between countries is one indication of this. Between 1960 and 2017, the value of trade in goods and services as a share of global GDP increased from 12% to 37%. 1 The number of people travelling and migrating is increasing. 1 World Bank, World Development Indicators. Accessed https://data.worldbank.org/indicator/NE.EXP.GNFS.ZS 1

20. Globalization: trade, migration and industrialization 2 Many low- and middle-income economies have industrialized and grown significantly. Consequences for rural to urban migration, urbanization and socioeconomic change. This globalization is impacting health in multiple ways: Increases risks of global epidemics such as severe acute respiratory syndrome (SARs) and the spread of health hazards including contaminated foods and products; Rapid economic growth places pressure on the labour force, infrastructure and environment. 1

21. Urbanization 2 Urbanization is the process of the population moving from rural areas to urban areas, which leads to many changes in economic, social and physical environments. The world is rapidly becoming more urban. Between 2010 and 2050, the percentage of the world’s population living in urban areas is predicted to increase from 50% to 70%. At present, nearly 1 billion people or 33% of the urban population live in slums. 2

22. Urbanization 2 As with rapid economic growth, urbanization can place strain on infrastructure resulting in poor living conditions and an inability to properly access social services like education and medical care. Rapid, unplanned urbanization creates congestion and pollution, and has impacts on health-promoting behaviours and risk factors for non-communicable diseases (NCDs). 2

23. Economic growth, poverty and governance 2 Economic growth is the most powerful instrument for reducing poverty and improving quality of life. In 2015, 736 million people lived on less than $1.90 a day, down from 1.85 billion in 1990. 2 While poverty rates have declined in all regions, progress has been uneven. Increasingly, the majority of the world’s poor live in middle-income countries. 2 The World Bank, Understanding Poverty, accessed (page updated Apr 03, 2019): https://www.worldbank.org/en/topic/poverty/overview 3

24. Economic growth, poverty and governance 2 Health is traditionally viewed as an end product of the growth process. However, in the other direction, a healthy population is also a driver for economic growth. In many countries, the past several decades of economic growth have been accompanied by a shift in the discourse of public policy and governance towards neoliberalism. 3

25. Socioeconomic inequality 2 Interrelated to poverty, there is also socioeconomic inequality. Socioeconomic inequality relates to disparities in both economic and social resources. Large inequalities exist not only across countries, but also between population groups within each country. 4

26. Socioeconomic inequality 2 Growth in many countries has disproportionally benefited higher income groups while lower income households have been left behind. Income and wealth inequalities are fundamental causes of health inequalities. They influence other factors such as housing, alcohol use and smoking. 4

27. Socioeconomic inequality 2 Source: World Inequality Lab, World Inequality Report, 2018 Inequality is Rising or Staying Extremely High Nearly Everywhere Top 10% income shares across the world, 1980-2016 Share of National Income (%) 60 50 40 30 20 1980 1985 1990 1995 2000 2005 2010 2015 Africa Brazil China India Russia Middle-East US-Canada Global Income Inequality Europe Inequalities are on the rise and halting this trend has become a priority for policy-makers in many countries.

28. Socioeconomic inequality 2 Rising income inequality Change in real household income, OECD average Source: In It Together - Why Less Inequality Benefits All (2015) 1980 1985 1990 1995 2000 2005 2010 40% 20% 0% The gap between low income and high income earners keeps on increasing over the years Top 10% Bottom 40% Bottom 10%

29. FOOD INSECURITY 2 5 Food security exists when all people at all times have physical, social and economic access to sufficient, safe and nutritious food to meet dietary needs and food preferences for an active and healthy life. New shocks related to climate change, conflict, pests (such as locusts) and infectious diseases are hurting food production, disrupting supply chains and stressing people’s ability to access nutritious and affordable food.

30. FOOD INSECURITY 2 5 The widespread incidence of microbiological, chemical or other food safety hazards in food also continues to be a serious issue for the food system. Recent world economic reports have highlighted economic slowdowns and downturns in several economies, impacting global food security and nutrition trends.

31. Environmental degradation 2 Conserving the earth’s ecosystem on which human society depends is a precondition for economic and social development, including good health. Although human health has improved dramatically since 1950, this gain has been accompanied by unprecedented environmental degradation from human activities that now threaten both human health and life-support systems. 6

32. Environmental degradation 2 Environmental factors – polluted air, built environment hazards, agricultural practices, occupational hazards, radiation, climate change, chemical exposures and inadequate water and sanitation – were associated with 12.6 million deaths (23% of deaths worldwide) in 2012. 3 3 Prüss-Ustün, A, Wolf, J, Corvalán, C, Bos, R & Neira, M 2016, Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks, WHO, Geneva. 6

33. Environmental degradation 2 Source: Gupta, J et al. (2019). Communicating the health of the planet and its links to human health. The Lancet, Planetary Health, DOI: https://doi.org/10.1016/S2542-5196(19)30040-3 . Socioecological systems Air Land Freshwater Oceans Biodiversity Interconnectedness of Earth system Planetary Impact Global impacts on health of the planet and human health, 2018 – 50. Human Health Impact Good Stable Reversible Irreversible Low Pollinators decline; extinction of genes, species, or ecosystems Food security decrease, potential zoonoses increase Household or urban pollution and greenhouse gases Greatest cause of death and sickness; causes displacement globally globally. Loss of cheap protein and jobs Fish population declines, plastic pollution, coral bleaching, polar ice melting Impact on water security, health and jobs Pollution (including antibiotics or nano), extraction greater than recharge Impact on access to land, number of jobs Desertification, deforestation, and chemical pollution

34. Demographic transition 2 Demographic transition is the transition from high birth and death rates to lower birth and death rates as a country or region develops from an agricultural society to an industrialized economic system. Population growth: according to the United Nations, the global population is predicted to increase from 6.8 billion to 9.1 billion between 2010 and 2050. 7

35. Demographic transition 2 Other demographic processes undergoing change include women’s fertility and increasingly older populations in the developed world. This demographic transition places strain on the health care system as more people need care, especially for chronic illnesses such as NCDs. 7

36. End of Module 2 Part 1 Please continue to Module 2 Part 2

37. Learning Objectives 2 Distinguish between the underlying concepts of health inequality and health inequity 1 Explain how societal inequalities influence health outcomes 2

38. Health equity vs Health equality 2 A visual depiction of the difference between equality and equity

39. Health equity 2 The absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically. – World Health Organization, 2008 “ ” The World Health Organization defines health equity as:

40. Health inequities are avoidable – they are created by structural and political processes and decisions that affect the everyday living conditions of individuals and populations. The social inequities in health arise because of inequities in the conditions of daily life and the fundamental drivers that give rise to them: inequities in power, money and resources. THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES 2

41. THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES 2 Action on health inequities requires action across all the social determinants of health: the range of interacting factors that shape health and well-being. The Social Determinants of Health (SDH/SDOH) shape health inequities. The SDH are conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life (the latter also referred to as the social determinants of health equity/or the structural determinants of health). These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.

42. The graded relationship between social position and health, where health outcomes progressively improve with increasing social position, is known as the social gradient in health . Social position and the social gradient in health 2 To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is known as proportionate universalism . 1 Kelly MP (2010). The axes of social differentiation and the evidence base on health equity. J R Soc Med; 103:266-72. A visual representation of the social gradient in health Low Economic Status High Good Health Poor

43. Inequities in health accumulate throughout life 2 Source: World Health Organization. Review of social determinants and the health divide in the WHO European Region: final report. Copenhagen: World Health Organization, 2013. Prenatal Early years Working age Older ages Family-building Accumulation of positive and negative effects on health and well-being over the life-course Perpetuation of inequities

44. Health InEQuality MONITORING 2 Health equity is considered as a normative, aspirational concept, like the ‘right to health’. It is measured through the measurement of health inequalities – observable differences between subgroups within a population. Health inequalities can thus be measured and monitored and serve as an indirect means of evaluating health inequity. Health inequality monitoring is undertaken to provide information for policies, programmes and practices to reduce health inequity.

45. EQUITY STRATIFIERS 2 Also called “dimensions of inequality” Health inequalities tend to stem from social inequalities Equity stratifiers typically reflect social conditions There are several equity stratifiers that are used to distinguish groups and individuals: Socioeconomic status Education Place of residence (rural, urban etc.) Race or ethnicity Occupation Gender Religion

46. MAKING COMPARISONS ON A global level - GLOBAL HEALTH INEQUITY 2 Health equity has two important strands: improving average health of countries and abolishing avoidable inequalities in health within countries Two components of global inequalities: inequalities between groups within the same society, and inequalities between countries Improve mechanisms of global governance to promote health equity

47. BETWEEN-COUNTRY HEALTH INEQUALITIES 2 Between-country inequality shows variability between countries based on national averages . For example, comparing countries on the basis of national infant mortality rates Poor countries tend to have worse health outcomes compared to rich countries Levels of inequality also vary considerably even among countries with similar levels of per capita income, as we will see on the next slide

48. Life Expectancy and Income of 182 nations in the year 2015 2 Source: www.gapminder.org

49. WITHIN-COUNTRY HEALTH INEQUALITIES 2 Within-country inequality exists between subgroups within a country, based on disaggregated data and summary measures of inequality For example, comparing the difference between infant mortality rates among urban and rural subgroups

50. AGE STANDARDISED AVOIDABLE MORTALITY RATE (PER 100,000) BY DEPRIVATION DECILE, ENGLAND, 2017 2 Source: Marmot, M, Allen J. et al. (2020). Health equity in England: The Marmot review 10 years on. London: Institute of Health Equity. Deaths per 100,000 p population 600 500 400 300 200 100 1 2 3 4 5 6 7 8 9 10 Most deprived Deprivation deciles Least deprived Females Males

51. Equity stratifiers INTERSECT 2 As we have seen, income can have an impact on health equity. Other equity stratifiers like education also explain health outcomes. Education increases health literacy, which is the ability to obtain, read, understand and use health care information to make appropriate health decisions and follow instructions for treatment. Gender can make a significant difference due to social attitudes about the value of men and women. For example, parents might be more likely to take a son to get immunized than a daughter because of social customs that value men over women. Overall, the inequalities as measured by stratifiers intersect and now increasingly scientists are looking at intersectionality of multiple factors driving health inequalities. The next slides are illustrative.

52. 2 CORRELATION BETWEEN INEQUalITY AND AN INDEX OF HEALTH AND SOCIAL PROBLEMS Health and social problems are worse in more unequal countries Index of: Life expectancy Maths & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness – incl. drugs & alcohol addiction Social mobility Index of health and social problems Better Worse Japan Sweden Norway Finland Denmark Belgium Austria Germany Spain Netherlands France Canada Switzerland Italy Iceland Greece New Zealand Australia UK Portugal USA Low High Income inequality

53. Social INEQUALITIES ARE PERVASIVE AND HAVE BEEN WIDENING… 2 Source: United Nations Development Programme (UNDP), Human Development Report, 2019 Income inequality based on the top 10 percent’s income share has risen since 1980 in most regions but at different rates Share of national income (%) 60 50 40 30 20 1980 1985 1990 1995 2000 2005 2010 2015 Sub-Saharan Africa Brazil China Europe Middle-East North America India Russian Federation 57 55 41 34 61 47 55 46 2016 VALUE

54. SOCIAL DETERMINANTS OF HEALTH AND THE PATHWAYS TO HEALTH AND ILLNESS 2 The role of psycho-social mechanisms Work Psychological Early Life Genes Culture Pathophysiological Changes Organ Impairment Well-being Morbidity Mortality Brain Neuroe ndocrine and immune response Social Environment Material Factors Social Structure Health Behaviours Source: Brunner, E., & Marmot, M.G. (2006). ‘Social Organization, Stress, and Health.’ In M.G. Marmot & R.G. Wilkinson (Eds.), Social Determinants of Health. Oxford: Oxford University Press, Figure 2.2, p.9.

55. BURDEN OF INEQUITY 2 Gap in health status between poorest and richest income quintiles in 36 European countries Source: The WHO European Health Equity Status Report, 2019 Income Security & Social Protection Social and Human Capital Health Service Employment & Working Conditions Living Conditions % of the gap explained by differences in 5 factors, controlling for age & gender (based on analysis of EQLS 2003 - 2016) 10% 35% 29% 19% 7% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

56. RISING INEQUALITY IS NOT INEVITABLE 2 National policies and institutions do matter .

57. … AMENABLE TO CHANGE: POLICY ACTION 2 Micro Level: Individual interaction Mesa Level: Community Macro Level: Public Policies Globalization Environment Monitoring and follow-up of health equity and SDH Evidence on intervention to tackle social determinants of health across government. Include health equity as a goal in health policy and other social policies Policies on stratification to reduce inequalities, mitigate effects of stratification Policies to reduce exposures of disadvantaged people to health-damaging factors Policies to reduce vulnerabilities of disadvantaged people Policies to reduce unequal consequences of illness in social, economic and health terms Key dimensions and directions for policy Context-specific strategies tackling both structural and intermediary determinants Social Participation and Empowerment Intersectoral Action Framework for tackling SDH inequities (Commission on the Social Determinants of Health, 2008)

58. End of Module 2 Part 2 Please continue to Module 3