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Closing the Gap:
tackling health inequalities
Michael Marmot
Copenhagen
May 2013
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 Euro
Region
Social determinants of health
CSDH (2008)
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
Why we need to tackle health inequalities
• Moral responsibility
• Much can done in countries at all levels
• Financial difficulties are not a barrier
Concepts, Values and Principles
• Social justice
– Health equity
– Intergenerational equity
– Gender equity
• Human rights
• Life course approach
– Social arrangements,
institutions and policies
– Conditions of daily life
• Vulnerability and
exclusionary processes
• Empowerment
• Social inequities
• Social gradient in health
• Mutual responsibility
• Evidence
Absolute inequality in males death rates by
level of education
Mackenbach et al 2008
Remaining life expecancy at 30 years of age for women and men based on educational level, 1991 -2010: Sweden
Women Men Age Age
Post secondary
education
Secondary
education
Lower secondary
6
4.1
3,2
5
Trends in probability of survival in men by
education: Russian Federation
0.4
0.45
0.5
0.55
0.6
0.65
0.7
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Calendar year
45
p 2
0
45 p20 = probability of living to 65 yrs when aged 20 yrs
University
Less than secondary
Source: Murphy et al 2006
Life expectancy and disability-free life expectancy at birth
by neighbourhood income deprivation, 1999-2003
Life expectancy for men at age 25 by
education, 2008-10
30
35
40
45
50
55
60
65
EE HU RO BG PL HR CZ SI PT FI DK MT NO IT SE
ISCED 0-2 ISCED 5-6 Total
Life expectancy at 25 (years)
Malta
Denmark Finland
Portugal
Slovenia
Czech Republic
Croatia
Poland
Bulgaria Romania
Hungary Estonia
ISCED 0-2 Pre-primary, primary and lower secondary education
ISCED 4-6 Tertiary education
Sweden Italy
Norway
Source: Eurostat Database
Life expectancy for women at age 25
by education, 2008-10
30
35
40
45
50
55
60
65
BG RO HU HR EE PL CZ DK MT SI PT NO FI SE IT
ISCED 0-2 ISCED 5-6 Total
Life expectancy at 25 (years)
Sweden Finland Norway
Portugal Slovenia Denmark
Czech Republic
Poland Croatia
Hungary Romania
Bulgaria
Source: Eurostat Database
Italy Malta
Estonia
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
Links between socioeconomic status and factors
affecting child development, 2003-4
Source: Department for Children, Schools and Families
Early child care and education
• Parenting and family support
– Perinatal services
– Care before and during pregnancy
– Help for new mothers
• Pre-school education and care
• Primary, secondary and tertiary education and
training
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
Country comparison on average rank in four dimensions of
child wellbeing – material, health, education, behaviours &
risks, in early 2000s and late 2000s
UNICEF 2013
Report Card 11
Differences in PISA scores by attending preschool for more
than one year before and after accounting for socioeconomic
background
OECD PISA 2009 database
0 20 40 60 80 100 120 140
Israel
Belgium
France
Italy
Switzerland
Denmark
United Kingdom
Turkey
Lithuania
Serbia
TFYR Montenegro
Netherlands
Ireland
Slovenia
Before accounting for socioeconomic background
After accounting for socioeconomic background
0 10 20 30 40 50 60
Romania
Latvia
Bulgaria
Lithuania
Italy
Greece
Spain
Poland
Portugal
Luxembourg
Hungary
United Kingdom
Malta
Estonia
Switzerland
Ireland
Slovakia
France
Belgium
Netherlands
Germany
Austria
Czech Republic
Sweden
Finland
Cyprus
Slovenia
Denmark
Norway
Iceland
Poverty rate
Before social transfers After social transfers
Child poverty rates <60%
median before and after
social transfers 2009
Source: EU SILC
Gross enrolment ratio in pre-primary education
(%) (selected countries) year ending 1999 & 2009
0,0
10
20
30
40
50
60
70
80
90
100
1999
2009
Source: Unicef statistical tables
Access to preschool by wealth: CEE/CIS
Areas for improving outcomes:
• Child Development – Cognitive
– Communication & language
– Social & emotional
– Physical
• Parenting – Safe and healthy environment
– Active learning
– Positive parenting
• Parent’s lives – Mental wellbeing
– Knowledge & skills
– Financially self-supporting
Children achieving a good level of development at age five, local
authorities 2011: England
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
Source: LHO (2012)
Birmingham Brighter Futures
• Aims to improve the lives of all the city's children
and young people;
• Focus on improving children’s physical health,
literacy and numeracy, behaviour, emotional
health, social literacy, and job skills.
• Specific programmes relevant to early years
include: Family Nurse Partnership (FNP),
Incredible Years Parenting Programme,
Promoting Alternative Thinking Strategies
(PATHS), Triple P Parenting Programme.
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
%
Integrated approach across the social
determinants
• Family income
• Parental leave arrangements,
• Availability & affordability of childcare at
particular ages and stages
• Aligning policy - child care and education,
employment, housing and transport
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
Employment and working conditions have
powerful effects on health and health equity
When these are good they can provide:-
• financial security
• paid holiday
• social protection benefits such as sick pay, maternity leave, pensions
• social status
• personal development
• social relations
• self-esteem
• protection from physical and psychosocial hazards
… all of which have protective and positive effects on health
(CSDH Final Report, WHO 2008)
Occupational stress in European countries
0
10
20
30
40
50
Very low Low High Very high
Effort rewardimbalance
Low control
Per cent
Occupational class
Unemployment rates by education and country of
origin in selected countries
Source:
Eurostat
database
Unemployment and Mortality 1% rise in
unemployment
associated with:
- 0.8% ↑Suicide
- 0.8% ↑Homicide
- 1.4% ↓Traffic
death
No effect on all-
cause mortality
Source: Stuckler et al 2009 Lancet
Changes in adult
unemployment and in age-
standardised suicide rates
(age 0–64 years) in old (pre-
2004) and new European
Union Member States
(Stuckler et al Lancet 2011) 2007 is the index year, and y-axis values represent
proportional change relative to that year
Unemployment
Suicides
Social Protection
Each 100 USD per
capita greater social
spending reduced the
effect on suicides by: 0.38%, active labour
market programmes
0.23%, family support
0.07%, healthcare
0.09%,unemployment
benefits
Spending> 190 USD no effect of
unemployment on suicide
Source: Stuckler et al 2009 Lancet
Older ages
• People in professional and managerial
classes reach the same level of disability as
those in routine and manual classes about
15 years later.
• Professional and managerial classes have
less illness in their 70s than ‘routine and
manual’ classes 15 years earlier
Source: English Longitudinal Study of Ageing (ELSA)
Spending on basics as % of income rises
steeply among poorer groups
Spending on basics as % of income
2008/9 Percentage point change in
spending as % of income
2004/5-2008/9
Poorest 48.3 12.5
2nd 34.4 2.2
3rd 27.6 -1.5
4th 22.6 -4.1
Richest 16.4 -7.1
All 29 .7 0.7
Source: English Longitudinal Study of Ageing (ELSA)
ELSA: well-being by access to amenities and
services (number of access problems) and age
,0
10,0
20,0
30,0
40,0
50,0
60,0
Age: 50-64 Age: 65-74 Age: 75+
% a
bo
ve
thre
sho
ld
Elevated depressive symptoms
by access to services/amenities
and age in wave 4
No
problem
1 access
problem
>=2 access
problems
15,0
20,0
25,0
30,0
Age: 50-64 Age: 65-74 Age: 75+
Mea
n s
core
(p
oss
ible
ran
ge:
5-3
5)
Life satisfaction by access to
services/amenities and age in
wave 4
No
problem
1 access
problem
>=2 access
problems
Source: English Longitudinal Study of Ageing (ELSA)
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
Macrolevel context:
Economic Issues
Sustainability and environment
Evidence from previous economic downturns
suggests that population health will be affected:
• More suicides and attempted suicides; possibly more
homicides and domestic violence
• Fewer road traffic fatalities
• An increase in mental health problems, including
depression, anxiety and lower levels of wellbeing
• Worse infectious disease outcomes such as TB +
HIV
• Negative longer-term mortality effects
• Health inequalities are likely to widen
Trends in the numbers of suicides and unemployment
claimants in England, 2000-10, by sex.
Barr B et al. BMJ 2012;345:bmj.e5142 ©2012 by British Medical Journal Publishing Group
Excess suicides and suicide attempts due to
economic reasons in Italy
De Vogli et al, JECH 2012
Annual average concentrations of particulate matter, in
the capital city in 2009* and change since 2005
Source: WHO Health for All database 2012
0 10 20 30 40 50 60 70
Iceland
Estonia
Ireland
Finland
Denmark
Sweden *
Switzerland
United Kingdom
Greece **
Poland
Albania
Serbia
Romania *
Bulgaria
Bosnia and Herzegovina
Turkey
2005 Particulate matter 2009*
Higher
concentrations
of particulate
matter
Lower
concentrations
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
Wider Society
• Social exclusion
• Social protection across the life course
• Communities
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
Welfare generosity and non employment by
education in 26 European countries
van der Wel, Dahl & Thielen 2011, data from EU SILC (2005)
Increasing generosity Increasing generosity
Primary
Tertiary
Secondary
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
Health inequalities and policy strategies
• Health inequalities are not inevitable;
• Not just a responsibility of the health care sector;
• There is no ‘magic bullet’
• Whole of society, whole of government
• Identify the challenges that Malmö is facing regarding social
differences and health inequalities
• Present evidence based strategies on how to reduce health
inequalities in Malmö – Child development
– Democracy and influence in society
– Social and economic conditions • Final report 2013
The Malmö commission
Commission for a Socially Sustainable Malmö (slide courtesy of Anna Balkfors)
Malmö, Sweden
• Commission for a Socially Sustainable Malmo,
chaired by Sven-Olof Isaacson, March 2011
• to translate the findings of the CSDH into a form
suitable to address social determinants and health
inequalities in Malmo
• Report March 2013
73 27% 100%
59% 84% 25
Geographic differences: Malmö
Education
General election
50 11% 61% Child poverty
25 7 % 32% Smoking
38 35% 75% Employment rate
22 70
Lowest Highest Differences
6.4 74.6 yrs 81 yrs
Life expectancy
Source: Välfärdsredovisningen för Malmö 2011, City of Malmö, (slide courtesy of Anna Balkfors)
Malmö: Six areas for action
• Children and young people´s livings conditions
• Living environment and urban planning
• Education
• Income and employment
• Health services’
• Changes in processes for socially sustainable development
London Health Inequalities Strategy
London HI Strategy: 5 strategic objectives:
1. Empowering individuals and communities
2. Equitable access to high quality heath and
social care services
3. Income inequality and health
4. Health, work, and well-being
5. Healthy places
Starting at the beginning:
early years care and education
Linden Children’s Centre,
Aug 2009
Bromley by Bow Centre
Review of health inequalities in England post
2010: Consultation in North West of England
• Values: shape our goals
• Nature of society not just programs and services
e.g. income inequality.
• Measurement: reflect what we want to achieve
• Journey and the destination e.g. local ownership,
collaborative working
A world where
social justice
is taken seriously
INTERNATIONAL INSTITUTE FOR
SOCIETY AND HEALTH
For further information email:
UCL Health and Society
Summer School
8-12 July 2013
www.ucl.ac.uk/healthandsociety/
