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CLOSING THE HEALTH EQUITY GAP

Policy options and opportunities for action


ISBN 978 92 4 150517 8
World Health Organization
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CLOSING THE HEALTH EQUITY GAP
Policy options and opportunities for action
WHO Library Cataloguing-in-Publication Data

Closing the health equity gap: policy options and opportunities for action.

1.Health policy. 2.Health status disparities. 3.Socioeconomic factors. 4.Social justice. I.World Health Organization.

ISBN 978 92 4 150517 8 (NLM classification: WA 525)

World Health Organization 2013

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Contents
ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

FOREWORD.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Why act to improve health equity?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The structure of this report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

SECTION 1. THE HEALTH SECTOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10


Working towards universal coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Public health programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Measuring inequities in health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Facilitating mobilization of people and groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Intersectoral action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

SECTION 2. CROSS-GOVERNMENT ACTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25


Early child development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Urban settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Globalization and increasing economic interdependence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Employment and working conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Policy and attitudes towards women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Inclusive policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Engaging civil society. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

AN EXAMPLE PROGRAMME OF ACTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

QUESTIONS AND NEXT STEPS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

THE KNOWLEDGE NETWORK REPORTS AND BOOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

1
Acknowledgements

T
his report, which highlights policy options for consideration within national discussions, was developed
in conjunction with WHO regional offices and others across the Organization who are working on the
social determinants of health and equity issues. The general approach to the report was discussed at
a seminar within WHOs Information, Evidence and Policy cluster and with WHO regional advisors
following the release of the final report of the Commission on Social Determinants of Health in August 2008. In
January 2009 the 124th session of the WHO Executive Board supported the Commissions recommendations,
and the subsequent deliberations of the Sixty-second World Health Assembly in May 2009 led to the passing
of resolution WHA62.14 on reducing health inequities through action on the social determinants of health.
This report aims to disseminate more detailed evidence-based policy options and opportunities for action by
the health sector and other sectors in order to reduce health inequities. The financial support of the United
Kingdoms Department of Health is gratefully acknowledged.

Support and guidance on the direction and finalization of this report were provided by Nick Drager, Tim Evans
and Marie-Paule Kieny. The report was coordinated by Ritu Sadana and the principal writers were Ross Gribbin
and Ritu Sadana. The material presented in this report does not necessarily represent the decisions, policy or
views of the World Health Organization or of the Commission on Social Determinants of Health. The report
primarily draws on the final reports and case studies of global knowledge networks set up by WHO to support
the Commission, and was reviewed by all knowledge networks hub leaders.

We gratefully acknowledge the contributions of knowledge network hub leaders and key members: Joan
Benach, Josiane Bonnefoy, Erik Blas, Jostacio Moreno Lapitan, Jane Doherty, Sarah Escorel, Lucy Gilson, Mario
Hernndez, Clyde Hertzman, Lori Irwin, Heidi Johnston, Michael P Kelly, Tord Kjellstrom, Ronald Labont,
Susan Mercado, Antony Morgan, Carles Muntaner, Piroska stlin, Jennie Popay, Laetitia Rispel, Vilma Santana,
Ted Schrecker, Gita Sen, Arjumand Siddiqi, and Ziba Vaghri. The report does not necessarily reflect the views of
all members of the knowledge networks. Further details and references can be found in the full reports of each
knowledge network, as listed at the end of this report.

The assistance and contributions provided by the following WHO staff are gratefully acknowledged: Anthony
Mawaya, Chris Mwikisa Benjamin Nganda (African Region); Marco Ackerman, Luiz Galvao, (Region of the
Americas); Mohamed Assai, Sameen Siddiqi, Susanne Watts (Eastern Mediterranean Region); Chris Brown,
Sarah Simpson, Erio Ziglio (European Region); Davison Munodawafa, Than Sein (South-East Asia Region);
Anjana Bhushan, Soe Nyunt-U (Western Pacific Region); and Daniel Albrecht, Avni Amin, David Evans, Meena
Cabral de Mello, Benedickte Dal, Riku Elovainio, Matthias Helbe, Ahmad Hosseinpoor, Ivan Ivanov, Evelyn
Kortum, Anand Sivansankara Kurup, Jennifer H Lee, Knut Lonnroth, Dheepa Rajan, Kumanan Rasanathan, Lori
Sloate, Eugenio Villar, and Wim Van Lerberghe (WHO Headquarters).

Evelyn Omukubi, Nuria Quiroz and Karina Reyes-Moya provided valuable secretarial and administrative
support.

The report was edited by David Bramley and Lindsay Martinez-Mackey.

2 Closing the health equity gap: Policy options and opportunities for action
Foreword

H
ealth inequities are unfair, avoidable and remediable differences in health status between countries
and between different groups of people within the same country. Health inequities are attracting
increasing attention on national and global policy agendas. Despite this, few countries have been able
systematically to reduce them. WHO convened the Commission on Social Determinants of Health in
2005 to survey the available worldwide evidence on health inequities and, most importantly, to look at the
evidence for policy options that could reverse the trend of increasing inequities.

The result has been a three-year process involving hundreds of people from all over the world and producing
over 100 publications nothing less than the most comprehensive review ever undertaken of global health
inequities and measures to address them. The Commission conclusively shows how health inequities are not
natural phenomena but rather the result of policy failure. They are thus avoidable by improving policy choices.

The final report of the Commission, released in August 2008, provides a cogent diagnosis of the problem and an
admirable survey of the range of policy interventions required. Necessarily, however, the report could not include
more than a fraction of the material collected and produced by the various work streams of the Commission.

This report is explicitly aimed at policy-makers and others interested in acting on the social determinants of
health in order to help them navigate the vast amount of work produced. It draws from the extensive work of
the nine knowledge networks set up by WHO to generate evidence for the Commission. Essentially, it brings
together a series of policy briefs, each roughly corresponding to a knowledge network and a specific social
determinant of health, which together form an overall policy brief on options for policy-makers to act on the
social determinants of health. This monograph first considers the essential role of the health sector in reducing
inequities, and then discusses how the health sector can work with other sectors that are also vital to this task. It
is thus designed for both health-sector policy-makers and those in other sectors.

This document should be seen as an input to the policy dialogue on how to implement the recommendations
of the Commission both globally and within individual country contexts. As the Director-General of WHO has
noted, when we think about the Commissions findings we must confront the paradox that, while health has
risen to prominence on the international development agenda, within most countries health matters are often
afforded lower priority than the concerns of other sectors. The World Health Assembly in May 2009 provided
a strong mandate to work together in this area, through its resolution on reducing health inequities through
action on the social determinants of health. The Rio Political Declaration on Social Determinants of Health in
October 2011 endorsed by the World Health Assembly in May 2012 further strengthens this mandate. We
hope that these policy briefs clearly show how the work of the Commission can be applied by policy-makers
now to accelerate the difficult but important journey to achieving health equity in a generation.

Marie-Paule Kieny
Assistant Director-General
Health Systems and
Innovation Cluster
World Health Organization

3
Introduction

The health equity gap is demonstrated most simply and dramatically by comparing
life expectancy at birth in different settings. A childs life expectancy depends on the
place of birth more than 80 years in Japan or Sweden but less than 50 years in many
developing countries. However, equally important are the striking discrepancies seen
worldwide within countries, with the poorest groups having higher rates of illness and
premature mortality than the richer groups. The difference in health outcomes between
a countrys most privileged groups and its most disadvantaged ones is often greater
than the differences between countries.

4 Closing the health equity gap: Policy options and opportunities for action
Why act to improve health equity?
Poor health outcomes are arise by chance (1). Social factors, and the quality of the natural
not confined to the worst-off which can be changed and environment in which people live.
populations. In countries at all controlled by policy, are largely Depending on the characteristics
levels of income, health and responsible for the differences of these environments, individual
illness follow a social gradient in the health outcomes in groups will have different
whereby those who are more different populations and groups. experiences of material conditions,
socially disadvantaged have Moreover, it is often the lack of psychosocial support, security
less access to services, suffer policies or frameworks for action and lifestyle options, which make
more illness and/or die sooner that exacerbates growing inequities them more or less vulnerable to
than people in more privileged in the distribution of goods, poor health. Social status likewise
social positions. Box 1 shows opportunities and rights. influences access to health
how health status is affected by services, with consequences for
place of residence, education, These factors are known as the disease prevention, for recovery
income or household wealth, social determinants of health. from illness and for survival.
and ethnicity or race. They are seen in every country
and across the various elements of The fact that health is
The Commission on Social society. They include the conditions significantly determined by the
Determinants of Health (referred of early childhood and schooling, social environment has profound
to below as the Commission) has the nature of employment implications for policy far beyond
put forward compelling evidence and working conditions, the the health sector, as shown in
based on a vast body of research physical form of the constructed Table 1.
that these disparities do not environment, gender inequity,

Table 1. Policy implications of the social determinants of health

POLICY IMPLICATIONS OF THE SOCIAL DETERMINANTS OF HEALTH


Health policy implications Broader policy implications
Action on disease prevention and control will leave many of the most Major health benefits can accrue from changes in the social environment.
vulnerable groups without better health prospects unless the root causes However, incorrect policy decisions may be made if the health effects
of ill-health are also tackled. The health sector has an important role have not been considered. The health implications of policy decisions
in addressing these root causes, not only in its own services but also by need to be taken into account in order to maximize opportunities for
advocating for change and through intersectoral action. health benefits and to avoid the adverse consequences of government
actions.

5
Box 1. Health and illness follow a social gradient
Health, as well as risk factors, access or coverage of services, well-being, functioning, illness and death are socially patterned across the entire spectrum
of society, from the poorest to the richest groups in populations. Data from around the world show that socially constructed gradients exist in every
country and can be described by differences in place of residence (Figure A), education (Figures B and C), income or household wealth (Figure D),
and ethnicity or race (Figures E and F). These potentially avoidable differences in health outcomes or access commonly referred to as health
inequities are due primarily to social factors. Although some differences by sex or age have biological causes, evidence indicates that up to half of
the differences between men and women, for example, are socially determined and can also be considered unfair.

Figure A. Gradient by place of residence


Under-5 mortality rate by place of residence
250
Rural
Urban
200
Rate per 1000 live births

150

100

50

0
Niger Cambodia India Egypt 2005 Honduras Rep. of Moldova
2006 2005 2005/2006 2005 2005
Source: Demographic and Health Surveys.

Figure B. Gradient by education level


Neonatal mortality rate by educational level of the mother
100
No education
90 Primary
Neonatal mortality rate (per 1000 live births)

80 Secondary or higher
70
60
50
40
30
20
10
0
Lesotho Bolivia Congo-Brazzaville Nepal Philippines Colombia
2004 2003 2005 2006 2003 2005
Source: Demographic and Health Surveys.

Figure C. Gradient by education level


All-Cause Mortality Relative Hazard by Education Level
Southeastern Netherlands 19911996
Relative Hazard (to university education)

1.80
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0
Source: Schrijvers et al. 1999. Schrijvers STM, Stronks K, van de Mheen HD, Mackenback J 1999.
Explaining differences in mortality: the role of behavioral and material factors. AJPH 89(4):535-540.

6 Closing the health equity gap: Policy options and opportunities for action
Figure D. Gradient by household asset categories The Commission on Social Determinants
Mean Time Taken to Reach Ambulatory Health Facility of Health has this to say about these
by Household Wealth 20012002 systematic, avoidable and unfair
50.0 Quintile 1 (poorest) differences which it calls health inequities:
45.0 Quintile 2
40.0 Quintile 3 Our children have dramatically different
35.0 Quintile 4 life chances depending on where they
30.0 Quintile 5 (least poor) were born. In Japan or Sweden they can
Minutes

25.0 expect to live more than 80 years; in


20.0 Brazil, 72 years; India, 63 years; and in
15.0 one of several African countries, fewer
10.0 than 50 years. And within countries, the
5.0 differences in life chances are dramatic
0 and are seen worldwide. The poorest of
Comoros Bangladesh Ecuador Bosnia- China
Herzegovina the poor have high levels of illness and
Source: World Health Survey, 20012002. premature mortality. But poor health is
not confined to those worst off. In countries
at all levels of income, health and illness
Figure E. Gradient by race or ethnic group follow a social gradient: the lower the
Modifiable Risk Prevalence and Preventive & Treatment Service Coverage, socioeconomic position, the worse the
New Zealand 1999, Maori & European Heritage health.
80
Maori
70 It does not have to be this way and it
60 European heritage
is not right that it should be like this.
Percentage (%)

50
40 Where systematic differences in
30 health are judged to be avoidable
20
10 by reasonable action they are, quite
0 simply, unfair. It is this that we label
Smoking Obese Obese Breast Cervical Transplants
males females cancer cancer for dialysis health inequity. Putting right these
screening screening patients
inequities the huge and remediable
Source: Bramley et al. 2005. Bramley D, Hebert P, Tuzzio L, Chassin M 2005, Disparities in Indigenous Health: A differences in health between and within
Cross-Country Comparison Between New Zealand and the United States, AJPH 95(5):844-850.
countries is a matter of social justice.
Reducing health inequities is an ethical
imperative. Social injustice is killing
Figure F. Gradient by country of origin people on a grand scale.
Infant Mortality Rate for England & Wales residents,
by Country of Mothers Birth 20012203 Source: Final Report of the Commission on Social Determinants
of Health (1).
12.0 11.0
10.2
10.0
Infant deaths per 1000 live births

8.8
8.0
6.1 6.1 5.9
6.0 5.0 5.0 4.7 4.7 4.6 4.4
4.0

2.0

0
Pakistan

West Africa

Caribean
Common wealth

India

East Africa

Bangladesh

England
and Wales
Rest of World
and not stated

Scotland

Sri Lanka

Eastern Europe

Ireland

Source: Bowles et al. 2007. Bowles C, Walters R and Jacobson B. 2007 Born Equal? Inequalities in Infant Mortality in
London. A Technical Report, London Health Observatory, London, UK.

7
The structure of this report
This report provides a brief and supporting action in other
overview of the best evidence sectors. Section 2 examines
regarding the principal social broader government policy
determinants of health and and is intended for use both
opportunities for action available in the policy areas concerned
to policy-makers. It draws on the and to support the health
work of nine knowledge networks sector in initiating dialogue on
set up by WHO to support the intersectoral action. For both the
Commission through the most health sector specifically and for
extensive collection, synthesis and the wider government, there are
examination to date of evidence- options for action in relation to
based actions to address the each of the Commissions main
WHOs World health report, social determinants of health recommendations.
2008 (which had the theme and to reduce health inequities.
Primary health care: now more The knowledge networks brought
than ever) proposed four together academics, health LINKS WITH EXISTING WORK
sets of reforms for revitalized practitioners, policy-makers and AND OTHER POLICIES
primary health care addressing senior decision-makers, and Box 2 shows how this report
representatives of civil society and links to the recommendations
1) universal coverage, 2)
nongovernmental organizations of the Commission on Social
service delivery, 3) leadership
(NGOs). Participants were Determinants of Health. A
and 4) public policy. To be included from low-, middle- and wide range of activities that
successful, each set of reforms high-income countries and from recognize the importance of
requires action on the social each WHO region. social determinants for health
determinants of health. This is under way both in countries
is particularly clear for public The material presented here and internationally. Examples
policy reforms where health is a sample of policy options are provided of successful action
is considered in all policies, or actions identified by the taken by countries, sometimes in
and for universal coverage knowledge networks and partnership with WHO, to address
reforms, where the commitment that are consistent with the these issues. The material in this
to equity is made explicit recommendations of the report is intended to support
by ensuring that all people Commission. In practice, these policy-makers in building
receive the same access to, options can contribute to policy on experience gained and
and quality of, all levels of dialogues on how to implement developing their own locally-
services. Leadership reforms the recommendations of the appropriate strategies. The policy
Commission both globally and actions outlined are based on
need to address inequities in
within individual country contexts, the best current evidence of
representation to ensure that
building on the ongoing work of what works, while noting that
the views of vulnerable or WHO and its partners. countries will need to adapt
excluded groups are heard them according to national
and their concerns addressed. The Commission has reported in circumstances and priorities.
Service delivery reforms need to detail on the available evidence
consider how universal health and has made three overarching Action on the social determinants
systems can best address the recommendations to policy- of health will benefit from linking,
expectations of those with the makers, as shown in Figure 1. For wherever possible, with other
greatest need, without falling ease of use by policy-makers, national policies and strategies
into the trap of the inverse care this report is structured by policy that already exist, have broad
law (i.e. those who are in the area. Section 1 focuses on the support, and are operational. The
greatest need are least likely to health sector and actions that last section of the report provides
receive care). it can take, both in its own guidance on how to build up a
domain and in promoting social determinants approach,

8 Closing the health equity gap: Policy options and opportunities for action
Figure 1. How this report links to the recommendations of the Commission on Social Determinants of Health

Overarching CSDH Link with this report


Recommendations

1 Improve daily living conditions, including


the circumstances in which people are
born, grow, live work and age.

Section 1. Section 2.
2 Tackle the inequitable distribution of
power, money and resources. What can the What can
health sector do? government do?

3 Measure and understand the problem


and assess the impact of action.

including connecting policies


or interventions that reduce
health inequities by changing More recently, the World health report 2010 (on Health systems
or shaping the conditions under financing: the path to universal coverage) maps out options for
which people live and work. countries to modify their health-financing systems so they can move
Thesocial determinants approach more quickly towards universal coverage, so that all people have
also fits with the current move to access to the health services they need prevention, promotion,
revitalize primary health care and treatment or rehabilitation without the risk of financial hardship
provide universal coverage. These associated with accessing services. Over the past century, a number
complementary efforts draw on of industrialized countries have achieved universal health coverage
common values based on equity in the sense that 100% of the population is covered by a form of
and social justice, and follow
financial risk protection that ensures they can access a range of
common strategies to pull together
needed services. Successful experience gained in low-, middle-
resources for health from across
society.
and high-income countries offers options for raising more money
for health, for extending financial risk protection to the poor and
All countries, rich and poor, face sick, and for delivering health services more efficiently and in an
challenges and no single mix of equitable manner. While the report focuses heavily on domestic
policy options will work well in financing policies appropriate to countries at all income levels, it
every setting. Any effective strategy also describes how the international community can better assist
for addressing the broader social low-income countries to develop domestic financing strategies,
determinants of health must be capacities and institutions by providing much more than simply
locally planned and developed. additional funding.

9
Section 1.
What can the
health sector do?

Section 1. The health sector

Health systems are themselves important social determinants of health: they can reduce
health inequities or make them worse. They do so not only through the way they
provide health care but also by shaping wider societal norms and values.

10 Closing the health equity gap: Policy options and opportunities for action
The health systems influence on several broad features. These

l
health equity is not limited to its health systems:
direct interactions (or lack of these) aim at universal coverage The way health systems
with service users. Around the and offer particular
organize, fund and deliver
world, health systems provide a benefits to children,
health care can exacerbate or
high-profile platform from which socially disadvantaged and
to shape social and economic marginalized groups, and make worse social stratification
norms and improve material others who are often not in four main ways, namely:
conditions. For example, as major adequately covered; the degree to which
national employers, public health integrate social determinants health systems actively
systems influence their employees approaches and work with and influence
lives, particularly those of women, consideration of health other sectors to address
through workforce structures equity into public health differential exposures and
and practices, and increased programmes; vulnerabilities which are
household income. Health measure inequities in health the root causes of health
system development can also and monitor actions to differences;
contribute to social cohesion by address them;
the extent to which health
empowering socially marginalized include organizational systems actively encourage
groups and enabling dialogue arrangements and practices and draw on social
between different groups within that involve population participation in decision-
society, even in states with fragile groups and civil society
making at all levels;
economies and political structures. organizations particularly
those working with socially the presence or absence
Contextual factors are extremely disadvantaged and
of access barriers (such
important in any health system, marginalized groups in as the costs of seeking
and what is appropriate will vary decision-making; care, lack of information
in different settings. However, possess leadership, processes and inaccessible services),
the positive impact of a health and mechanisms that and particularly those
system on equity is consistently encourage intersectoral which disproportionately
strongest where a primary health action across government affect women and other
care approach is applied as departments to promote disadvantaged groups;
the organizational strategy and population health and the extent to which loss
underlying philosophy. This that cooperate to meet the of income due to illness
approach itself enables the expectations of these other and high out-of-pocket
implementation of other features sectors as well. payments for health care
of the health system that are are allowed to push poor
important to promoting equity. This section of the report highlights people into poverty or
There is evidence that health evidence-based actions which
worsen their existing poverty.
systems which successfully can be taken in each of these five
address equity tend to share areas.

11
Working towards universal coverage
o Universal coverage is achieved when effective services are available for all, when they are
accessible without financial barriers, and when users are protected from the financial consequences of
using health services.

o At all levels of national income, steps can be taken towards universal coverage that will improve
health outcomes and health equity.

oEven in systems of universal coverage, women and socially marginalized groups may be denied
appropriate health care unless the system actively sets out to address social and cultural barriers.

12 Closing the health equity gap: Policy options and opportunities for action
j
Most societies support the view Universal coverage is achieved pooled progressive funding,
that everyone should be able to when 1) services are available for usually by means of tax funding
get the health care they need, everyone regardless of income or mandatory health insurance.
when they need it. Despite level, ethnicity, social status or Mechanisms to administer
this, the poorest groups often residency, 2) financial barriers universal coverage generally
forego health care because it to the uptake of services are require less administrative capacity
is unaffordable, unavailable or removed, and 3) families are and are more sustainable than
they face barriers to taking it up. given protection against the approaches that target specific
Expanding coverage to all people financial consequences of their subgroups of the population.
is therefore a key condition for use of health care. Access to
improving health equity. health care is improved through

What can be done?


The timescale and the policy Stepscan be taken towards Moving towards universal
measures necessary to move universal coverage by all countries coverage often requires specific
towards universal coverage will in order to extend services to measures that will benefit socially
vary between settings and over people who are currently not marginalized groups. Such
time. Even the intermediate steps covered, to include additional measures include better targeting of
can yield substantial beneficial services that are not covered, and investments in underserved areas,
impacts in terms of financial to reduce cost-sharing and fees in reduction of transport costs, better
protection and access gains. an equitable manner (see Table 2). coordination between services

Table 2. Intermediate steps to universal coverage

INITIAL STEPS TOWARDS UNIVERSAL COVERAGE IN LOW-INCOME COUNTRIES COULD INCLUDE SOME
OR ALL OF THE FOLLOWING ACTIONS:
Advocate for and mobilize increased public funding for health care.
Reduce out-of-pocket payments, wherever possible, by removing public sector user fees.
Improve the availability of comprehensive services by investing in primary and secondary services in currently underserved areas and by
improving coordination between levels of care.
Re-allocate government resources between geographical areas, taking account of population health needs and all available funding sources.
Address technical efficiency, especially in relation to pharmaceuticals.
Test and evaluate strategies to extend access and ensure the quality of non-state providers of health services that cater to low-income
populations, providing that inequity and stigmatization are not reinforced
IN MIDDLE-INCOME SETTINGS, FURTHER ACTIONS CAN BE TAKEN TO MOVE TOWARDS UNIVERSAL
COVERAGE, SUCH AS:
Expand prepayment funding through a combination of tax funding and mandatory health insurance (ensuring that insurance contributions are
related to income and that the tax deductibility of insurance contributions is limited for higher-income groups).
Widen the package of health-care entitlements of poorer groups over time.
Reduce fragmentation and segmentation within the health-care system by pooling funds and harmonizing contribution levels and benefit
packages between population groups.
Explore the use of risk-equalization mechanisms, where appropriate, to ensure equitable resource allocation between financing schemes.
Strengthen purchasing strategies, such as contracting arrangements, to leverage performance improvements and cost containment, particularly
in relation to private health-care providers.
Regulate private insurance to prevent distortions in the overall system that undermine equity, and ensure that it acts primarily as top-up
insurance for higher-income groups.

13
and, most importantly, improved
responsiveness of health services
when dealing with the poor and
marginalized.

The acceptability of public


services, particularly for women
and marginalized groups, is
also an important issue that
needs to be taken into account.
Acceptability is determined by
the social and cultural distance
between health systems and their
users, and depends on factors
l
such as differences between lay
and professional health beliefs
and the influence of organizational
arrangements for health care on
patients responses to services.
Acceptability affects more than
user attitudes to a service. It also
influences the opportunities for
effective diagnosis and treatment,
patient adherence to advice and
treatment, and self-reported
health status. Interventions that
support the implementation of
universal coverage include those
that encourage a client-centred
approach to service delivery,
enabling patients and society in
general to participate in decision-
making about health and health
care, and tackling health workers
low morale and poor attitudes to
patients. Moreover, health systems
can be made more women-friendly
by upgrading the skills of health
professionals so that they apply
gender perspectives in their work.

14 Closing the health equity gap: Policy options and opportunities for action
Public health programmes
o Sustainable improvements in control of communicable and noncommunicable diseases will not be
achieved in many settings without tackling the social determinants of health.

o Individual programmes can address social determinants in their management and incentive
structures as well as by collecting information on condition-specific distribution of health in
populations.

o There is potential for public health programmes to collaborate in tackling social determinants that
are common to many diseases.

15
Evidence from the growing care or other health services and
Box 2. Social determinants and body of research on the social addresses the social determinants
tuberculosis determinants of health has of health.
significant implications for
There is a strong socioeconomic gradient public health programmes. Programmes on both tobacco
for TB, both across and within countries. TheCommissions findings and injury have successfully
Poor and vulnerable social groups are more indicate that the balance of demonstrated that health-sector-
at risk from TB due to factors that include resources needs to be adjusted based programmes can address
malnutrition, crowding, HIV/AIDS, smoking, so that investment is made not upstream determinants of
alcohol abuse, indoor air pollution, and poor only directly in disease prevention health and can work effectively
access to health services. and control but also indirectly with other sectors. Many of
in reducing the causes of ill- the interventions can also be
The current global TB control strategy health at the source. Without this usefully applied in disease control
(the Stop TB Strategy) mainly focuses adjustment, it will be impossible programmes. For instance, in the
on reducing the incidence of TB through in many settings to achieve case of tuberculosis (TB) there is
cutting transmission of the disease by sustainable improvements in evidence that, in some contexts,
curing patients with infectious TB. However, reducing communicable and approaches to controlling the
recent evidence suggests that while the noncommunicable diseases, disease through early detection
strategy effectively reduces death rates and and many international targets and cure are unlikely to succeed
prevalence, the impact on incidence is less will not be achieved. Such fully on their own (see Box 2).
than expected. For example, both Morocco adjustments also represent a In other words, unless a social
and Viet Nam have successfully implemented move towards adopting a systems determinants approach is
the control strategy yet, in those countries, approach in the management, integrated into public health
incidence has remained stable or has been organization and delivery of programmes, there is a risk that
reduced less than expected. public health programmes, that increases in inequity will be greater
places the principles of primary than the benefits from treatment
From such findings, it seems likely that health care at its core, is not and cure of disease.
further progress in TB control in many limited to the provision of health
settings will require additional preventive
measures, in particular targeting the
proximate TB risk factors, such as crowding
and malnutrition, and their social and
economic determinants, including poverty
and poor living conditions. What can be done?
Source: Lnnroth et al., 2009 (2).

Specific action points for individual to collect information on the


public health programmes pursuing social gradient or distribution
a social determinants approach of health in populations is likely
include: to be an important first step
in many country programmes
Changing programme towards gaining insight into
incentives to acknowledge the role of social determinants.
cross-cutting issues as a short- Evidence is patchy and in most
term measure will enhance cases absent which tends to
the capacity of programmes to limit the ability to implement a
address the social determinants social determinants approach.
of health. Such cross-cutting
issues tend to be lost when Allowing for and encouraging
management is focused on a range of intervention
short-term outcomes or a results- packages that are relevant
based framework. In the longer to different social patterns of
term, reforming education and disease, such as situations of
management within public health mass deprivation where, except
systems can develop this further. for the most wealthy, almost no
one has access to services, or a
Developing or improving social exclusion pattern where
information systems in order specific marginalized groups do

16 Closing the health equity gap: Policy options and opportunities for action
not have access, whether due to such as tobacco, indoor air
poverty or to other demographic pollution and unsafe sex);
characteristics. identifying and prioritizing the Various approaches to action
collection of information that
on social determinants have
Enormous untapped potential is relevant to common social
been tried. Experience indicates
exists for closer collaboration and determinants, disaggregated
joint action between programmes. by different population that success depends on
Starting points for collaboration characteristics so that the integrating the action into the
might include: evolution of social patterns can core agenda of each health
creating an institutional be monitored and reported. programme. Focal points or
mechanism for identifying centres of specific expertise are
social determinants that International programmes can useful supporting mechanisms,
are common to different support the actions of national but independent social
conditions, particularly where public health programmes by determinants units will often
they are present in the same acknowledging the importance struggle to have their agenda
population groups (e.g. HIV of the social determinants of taken up by programmes.
and TB); health. National policy-makers
developing intervention can strengthen this recognition
packages targeting the by incorporating action on social
circumstances and needs determinants into the results
of population groups that frameworks of donor programmes.
are vulnerable to a range of
conditions (e.g. coordination
can reduce the prevalence of a
variety of infections and better Dedicated disease control
tackle common risk factors programmes have a special
appeal to the public because
such programmes deal directly
with real people rather than
with systems. This presents a
communications challenge:
how can one utilize the power
of disease-specific or condition-
specific programmes for
resource mobilization while also
addressing upstream social
factors that increase vulnerability
to the disease and lead to
its inequitable distribution?
One response is to develop
strategies with more than one
time horizon. In the short and
medium term, available tools
and services for disease control
can be applied to compensate
for inequities. At the same
time, programmes can start
to take action with a longer-
term perspective to tackle the
upstream determinants of the
disease.

17
Measuring inequities in health
o Social gradients include all sections of the population, from the wealthiest to the poorest. To be
comprehensive, measurements need to cover the entire population.

o Disaggregating data in health and other sectors by income, education, ethnicity, sex, occupation
and place of residence is an important prerequisite for understanding the social pattern of diseases or
conditions within a population.

o The effects of new policies or other interventions need to be carefully monitored because the
evidence base on interventions to tackle the social determinants of health is evolving and needs to be
strengthened.

o Setting specific targets to decrease systematic and unfair differences in health at national, state or
local level raises awareness and provides a vision for collective action.

18 Closing the health equity gap: Policy options and opportunities for action
Good data and measurement necessarily the case. As Figure 2 on the processes that lead
provide the basis for political shows, very different patterns of to exclusion. When almost
action and accountability on the access to health services exist. The everyone does not have access
determinants of health and the example here is for births attended to a service (the three lower
improvement of health equity. A by a trained health worker, shown lines), more wide-ranging
number of high-level considerations by household wealth quintile. strategies are usually required.
about how to measure and what However, similar systematic patterns In many settings the pattern will
is to be measured are relevant to of access can be observed by other fall somewhere between the two
policy-makers. Ministries of health characteristics that measure the extremes and a combination
can provide evidence to health social position of individuals or of strategies will be needed,
practitioners, communication groups (such as place of residence, with specific policies taking into
strategies oriented to different ethnic group, educational level account each national context.
audiences, and support their or sex - see Box 1). Such patterns
own advocacy function within can be seen across many different To support the development of
government by adhering to certain services, as well as for health actions in the areas outlined in
principles. outcomes such as mortality due to this report, health and other data
specific causes. (e.g. on environment, housing,
An approach which takes into labour, education) will need to be
account the whole of the gradient These observations show the disaggregated by socioeconomic
in health equity in a society and importance of measuring the status and by other social stratifiers
not only the most disadvantaged pattern of inequality accurately that measure social position. The
groups is an important starting as an input to policy formation. appropriate stratifiers to measure
point. This is so because health When only the poorest do not will depend on the local context
and illness follow a social gradient. have access to a service (the but as a minimum they are likely
While in some circumstances three upper lines on Figure to include:
targeting policy or interventions 1), policies probably need to income;
towards the most disadvantaged focus on expanding provision sex;
groups may be the best and most to particular groups that are place of residence;
appropriate action, this is not excluded or marginalized or education;

Figure 2. Different patterns of access to health services-Percentage of births attended by trained personnel by
household wealth

100

Nicaragua 2001
80

Colombia 2005 Niger 1998


60
Chad 2004
Percent

Turkey 1998

40
Bangladesh 2004

20

0
Quintile 1 (Poorest)
(poorest) Quintile 2 Quintile 3 Quintile 4 Quintile 5 (Wealthiest)

Source: World health report, 2008

19
ethnicity or race; actions to improve gender equity
occupation. (as described further in Section2).
A key strategy for most Improvements in measurement, There remain challenges to
countries is to increase monitoring and evaluation would measuring both absolute and
improve understanding of the relative measures of health
coverage of socioeconomic
impact of policies and of more inequalities and inequities and
and other social stratifiers
specific health interventions how to interpret information (e.g.
that describe individuals on health equity. In particular, the categorization of urban
within national data sources, disaggregating health data by versus rural given the increasing
including: sex and analysing them is an complexity and variation of who
vital statistics, such as birth important step towards developing lives within urban areas).
and death registrations;
population-based surveys,
such as population censuses
and demographic and
health household surveys; What can be done?
routine disease-specific
statistics collected through
health surveillance systems Where good data exist, and environment and to link
(e.g. TB or cancer registers); measurement and analysis these data together. This is
can serve as powerful inputs in needed in all countries in order
service-generated activity the design and evaluation of to better link and target policies
data, such as hospital
interventions (see Box 3). to reduce health inequities
statistics or financial
through addressing the social
transactions. An effective policy is one which determinants of health. Provincial,
achieves both absolute and district or municipal policy-makers
Box 3. Tracking health relative improvements in the and programme managers can
inequalities at the local level in health of the poorest groups or also better analyse local data
the United Kingdom across the social gradient. The in order to develop, implement
choice of whether to use absolute and evaluate solutions with the
The government of the United Kingdom or relative measures can affect the appropriate sectors and levels of
and Northern Ireland has a commitment to assessment of whether a health government involved.
reducing health inequalities. Specific targets inequity exists and how big it is.
have been set to decrease inequalities in Sometimes a difference on the The effects of policies and
infant mortality and life expectancy at birth relative scale may not appear to programmes on inequities need
by 10% by 2010. A health inequalities be a difference on the absolute to be measured, monitored and
intervention tool has been introduced scale. It is critical that researchers evaluated. Not only will this
to assist local government and health and policy-makers are clear about provide an evidence base on
commissioners to measure differences in life which type of measure is being the effectiveness of interventions
expectancy. The tool compiles good-quality used and, where possible, that (which may be lacking in many
data on key indicators at the local level and they use both relative and absolute areas or countries), but it can
puts these into an easy-to-use format that measures of health inequities also help reinforce the case for
shows the pattern of inequality in each local (i.e. both rate ratios and rate action. Demonstrating success
area. The tool also allows local areas to model differences comparing two or more is likely to be a key element in
the likely effects of specific interventions and contrasting groups) to ensure that building broader political support
to estimate which will have the highest impact inequities are identified. for action. The health sector can
on narrowing the equity gap. facilitate action and can support
One step towards intersectoral its own advocacy role by investing
Further details on the tool are available action is to negotiate access to resources in the analysis of actions
from the London Health Observatory website data from other sectors such both within and outside the health
at www.lho.org.uk. as education, justice, housing sector.

20 Closing the health equity gap: Policy options and opportunities for action
Facilitating mobilization of people and groups
o Social mobilization is essential for increasing overall performance and accountability of health
systems.

o Participatory processes to mobilize individuals, households, communities, and informal and formal
organizations are indispensable for addressing the social determinants of health.

o Health systems can support social mobilization by recognizing its importance and by taking steps to
facilitate action.

o Accountability can be improved by specifically involving disadvantaged and marginalized groups in


priority-setting, planning and resource allocation processes.

21
Social mobilization strategies Strategies to improve health
Box 4. Participatory approaches encompass a range of activities system accountability are
to reducing neonatal mortality in aimed at increasing social likely to be most effective and
Nepal awareness of health and health representative when directed
systems, strengthening health towards health policy and
A pilot community-based programme literacy, and enhancing social management decisions, and
in Makwanpur district, Nepal, used capacities to take health actions. when disadvantaged and
participatory methods to reduce neonatal marginalized groups participate
mortality. During the project, groups of Social mobilization has been in decision-making in a
women were supported by a facilitator shown to improve the performance meaningful way.
through an action-learning cycle where and accountability of health
groups work regularly and collectively on systems, as well as health It is important to note that poverty
complicated problems, take action, and learn outcomes for communities and lack of power may exclude
as individuals and as a team in which especially in relation to health disadvantaged and marginalized
they identified perinatal problems that promotion and public health groups (e.g. women, the elderly,
occurred locally and formulated strategies to activities. Participatory processes unemployed persons) from social
address them. The intervention was shown that engage individuals, action. Therefore, it is necessary to
to be associated with significant reductions households, communities, social develop institutional mechanisms
in maternal mortality and improvements networks, formal organizations and appropriate governance
in birth outcomes, as well as higher use of and more informal groups of procedures that directly address
antenatal care, institutional delivery and people actively in planning and the inclusion of such groups
trained birth attendance. The participatory resource allocation can deliver and build trust. Additionally,
intervention led to a 30% reduction in benefits in addressing the social participation alone is insufficient
neonatal mortality and a larger reduction in determinants of health (see Box if strategies do not also build
maternal mortality, and an evaluation found 4). Social mobilization is also the capacity of individuals and
it to be highly cost-effective. instrumental in furthering the community organizations in
redistribution of power, money and decision-making and advocacy.
Source: Manandhar et al., 2004 (4).
resources towards more equitable
health opportunities, as stated in
the Commissions report.

What can be done?


Health officials can encourage consultations with stakeholders institutionalizing access to
social mobilization by taking on new policies and their decision-making through, for
actions such as: implementation; example, clinic committees
bringing professionals into promoting existing and new that help to forge closer
roles that support social accountability mechanisms working relations between the
mobilization, and supporting by widely advertising their community and health clinics;
and rewarding these roles; existence in the media and drawing up service charters
recognizing, supporting and holding public hearings; that set out entitlements and
funding mechanisms for direct public target-setting, with how they will be provided.
participation by communities; independently verifiable
implementing mandatory monitoring and evaluation;

22 Closing the health equity gap: Policy options and opportunities for action
Intersectoral action
o The health sector can play a central role in initiating intersectoral action, even though it does not
directly control many of the interventions that tackle social determinants of health.

o Action to support intersectoral action includes tailoring advocacy messages to particular sectors,
establishing organizational arrangements that promote ongoing cooperation across sectors, and
institutionalizing health equity goals.

o Cooperation across sectors also means that the health sector contributes to the strategic priorities
of other sectors, emphasizing joint benefits.

23
Ministries of health generally do equity. However, those with the upstream determinants of health
not implement interventions that capacity to intervene on many can be a highly effective way
address the structural determinants important social determinants to address unfair or inequitable
of health disparities. Nevertheless, often do not know what to do or health consequences. Section 2
ministers of health and health what the consequences are of not of this report outlines some of the
managers can play a central intervening. key areas where such action might
role in initiating and monitoring take place.
intersectoral action that has an Expending resources, effort and
impact on health and health political capital in tackling the

What can be done?


At government level the health a clear mandate and should The health sector can also play
sector can promote action on be clearly linked to activities an important role in supporting
the social determinants of health which show measurable the delivery of key intersectoral
through the following interventions: results, thereby helping to build actions on the social determinants
confidence as well as providing of health. For instance, in
Make the case for intersectoral a good basis for evaluation. early child development (ECD)
action on health. Use sound services, the health sector is
epidemiological and other Establish organizational usually the first point of contact
evidence and, where possible, arrangements that promote with public services for most
make the case for how ongoing dialogue and children. Thus the health sector
intersectoral action can address cooperation across sectors, can transform this entry point
economic and budgetary such as sharing accountability to help ECD interventions
concerns. mechanisms and budgets reach a high proportion of the
between sectors. population. Similarly, while the
Take the strategic needs of health sector does not have all
other sectors into account. Work towards institutionalizing of the policy levers to improve
Frame objectives in ways that health equity as a central goal urban environments directly, it
are commonly understood of government policy. This may be able to facilitate dialogue
and share responsibilities. could involve Cabinet-level among stakeholders at local
Emphasizing joint benefits and ownership and coordination of level, leading to empowerment of
opportunities for improving action on health equity, binding communities through engagement
public policy in general can targets for other ministries, and participation. The specific
support cross-government or requirements to conduct requirements in these areas are
coalitions. a health impact assessment discussed further in Section 2.
(including potential effects on
Set explicit goals and equity) of new policies.
objectives. These should give

24 Closing the health equity gap: Policy options and opportunities for action
Section 2.
What can
government do?

Section 2. Cross-government actions


A key message for policy-makers from the Commission is that actions in all areas of
government policy affect health. Policies in areas as diverse as trade policy and the
urban environment have important implications for health.

25
Actions taken across government at every income level there are
Box 5. Working across can therefore improve population multiple demands on public
government to achieve universal health, particularly for the most policy and financial resources. In
social protection in Chile vulnerable groups. However, many sectors, tackling the social
these are not the only advantages determinants of health can benefit
In recent years, Chile has implemented a to accrue from action on social all those involved. In others, by
range of social protection strategies and determinants of health. In many taking a comprehensive social
directed attention towards coordinating areas, there is a significant generic view of costs and benefits when
government action on the social benefit for public policy and for the allocating and regulating the flow
determinants of health. Policies and sectors where the action is being of resources, national governments
programmes include: taken. For instance, improving and planners complemented by
delivery of ECD services will not non-state actors and a cooperative
Chile Crece Contigo (Chile Grows with You) only reduce stunting and infant private sector can deliver more
which addresses early child development mortality but can also raise effective policy. For an example,
through improved training of health educational outcomes and reduce see Box 5.
professionals on the development needs of crime rates. Instituting policies
children coupled with increasing the access
which improve womens rights This section outlines policy
of communities to health facilities and social
and social status can greatly implications and evidence-based
services;
reduce girls and womens actions in several key areas. These
Chile Solidario (Chile Solidarity), an
vulnerability to disease and has are grouped into three themes
initiative for the poorest families, which
also been strongly correlated according to the different levels
provides a range of support, including
with economic growth. Engaging at which government action may
cash transfers, day care, and psychosocial
effectively and appropriately affect population health, namely:
services.
with civil society has consistently
improved the quality of health Priority areas for coordination of
Improving social protection and reducing
in communities, and the same intersectoral actions, such as
health inequities have been on the agenda
of several ministries. The Ministry of Labour
groups and organizations can early child development,
has implemented a set of reforms to increase
help improve other areas of urban settings;
government policy.
the security of workers in the informal sector
Specific government policy areas
and encourage formalization of their work;
In financial terms, tackling the with significant implications for
to provide increased access to child care,
social determinants of health is health, such as
especially for the poorest communities;
to reduce gender discrimination in access
not necessarily, or even often, a globalization and increasing
matter of how much is invested economic interdependence,
to work and pay; and to strengthen the
ability of workers to organize and negotiate
but rather how resources are employment and working
distributed and on whose conditions,
fairly and collectively with their employers.
The Ministry of Health and the Ministry
account the costs show up. Some policy and attitudes towards
sectors may have short-term gains women and girls;
of Labour have increasingly cooperated
from ignoring the effect of their
on intersectoral activities, including
actions on population health but Changing how government acts,
programmes such as the National Plan for
the long-term costs will eventually such as
the Eradication of Silicosis.
show up elsewhere first in the inclusive policies,
The Ministry of Health has also supported
health sector and then later in engaging civil society.
social, political and economic
the creation of a social cabinet which will
sectors. While each of these areas
serve as a coordination mechanism between
is critically important, even
the ministries of health, planning, finance
We must not underestimate the together they do not represent a
and labour, along with agencies such as
challenge that governments comprehensive list of all areas
the National Service of Day Care Facilities,
and government sectors face in of government policy which may
the National Childrens Agency, and the
balancing competing priorities impact on health. For example,
National Service for Women. This social
and negotiating across groups a focus on urban settings is
cabinet tries to ensure that government
with different sets of values not intended to downplay the
policies across sectors promote, or at least
and agendas. In every country importance of rural policies
do not undermine, efforts to address social
determinants of health and to coordinate
better implementation of policies with
national, regional and local authorities.

26 Closing the health equity gap: Policy options and opportunities for action
on the health of those who live determinants of health. Rather, of available evidence in order to
in rural areas. Likewise, the the knowledge networks set up to identify options for action. The
absence of specific suggestions support the Commission focused following chapters aim to present
on education, climate change attention on those areas where material which is new and relevant
or food does not imply that there was a perceived need for to policy-makers worldwide.
these are not important social further research and for synthesis

27
Early child development
o The early childhood period is the most important developmental phase of life. Experiences during
this time determine health, education and economic prospects throughout life.

o Social and emotional development are key dimensions of early life and impact on physical and
educational outcomes.

o ECD interventions (including parenting and caregiver support, child care, nutrition, education, and
social protection) yield benefits throughout life that are worth many times the original investment.

o Hallmarks of successful government action on ECD include:


strong interministerial coordination on ECD;
integration of ECD into the formal agenda of each sector;
use of existing platforms such as health services for delivery of ECD programmes;
identification and scaling-up of existing models in local settings.

28 Closing the health equity gap: Policy options and opportunities for action
Experiences in early life are crucial the childs optimal development.
determinants of health and of
social outcomes throughout life. Social and emotional Children benefit when national
Many challenges in adult society development is a key dimension governments adopt family-
including mental health conditions, of early life and influences
friendly social protection
obesity, stunting, heart disease, physical and educational
policies that guarantee
criminality, gender inequity, and outcomes. The more stimulation
poor literacy and numeracy all the early environment offers adequate income for all,
have their roots in childhood. While in terms of positive social maternity benefits, affordable
considerable attention is directed to interaction, the more secure child care, financial support for
supporting children, recent research the child feels and the better the poorest, and allow parents
has highlighted the following two he or she thrives in all aspects and caregivers to devote time
crucial points which are often not of life including physical, and attention to young children
integrated in current policy: cognitive, emotional and social (for some examples, see Table
development. Child survival 3). Globally, societies that
The first three years of life and child health agendas are invest in children and families
provide a critical development therefore indivisible from ECD in the early years rich or poor
opportunity because a childs programmes. have the most literate and
early environment has a vital numerate populations. These
impact on the way the brain Consequently, to reach their societies also have the best
develops. It is at this stage that a potential, young children need health status and lowest levels
developing child is most sensitive to live in caring, responsive
of health inequities.
to the influences of the external environments that protect them
environment. Brain development from neglect, from preferential
is adversely affected, leading to treatment based on gender
cognitive, social and behavioural norms, and from inappropriate
delays when children spend their disapproval and punishment.
early years in non-stimulating While parents and families have
and emotionally and physically the principal role and responsibility
unsupportive environments. Thus for ECD, an important policy
intervention only at preschool implication is the need to provide
age may be too late to ensure a favourable legislative context.

What can be done?


Success in promoting ECD does ECD services include parenting services that are centred on the
not depend upon wealth. Because and caregiver support, child child. National governments can
ECD programmes rely primarily care, nutrition, primary health lead the way in this regard. An
on the skills of caregivers, the cost care, education and social interministerial policy framework
varies with the wage structure of protection. While delivery of for ECD that clearly articulates
a society. Increasing preschool these will be highly dependent on the roles and responsibilities of
enrollment to 25% or 50% in low- the local context, the case studies each sector, and how they will
and middle-income countries will in this section illustrate that collaborate, is an effective way to
result in a 618-fold increase successful programmes can be facilitate such coordination.
in benefits to costs (5). In fact, implemented at all income levels.
economists now assert that Hallmarks of successful Integration of ECD into the
investment in early childhood is government action on ECD formal agenda of each sector,
the most productive investment include: with appropriate performance
a country can make, with measures and metrics to drive
benefits throughout life that are Strong interministerial performance.
worth many times the original coordination on early child
investment. development, which is essential Use of existing platforms for
for successful delivery of delivery of ECD programmes,

29
which is known to be the Identification and scaling-up at national level. Schemes
most effective route for of existing models from local which have strong roots in local
implementation. For example, settings, which are likely to be communities are likely to be
the health system has a pivotal more effective than the creation more successful. Local flexibility
role to play since it is usually of new models. In doing this, is therefore more important than
the childs first point of contact it is important to retain local ensuring consistency across
with public services and can accountability and involvement, programmes.
serve as a gateway to other early even once a programme has
childhood services. been rolled out or scaled up

Table 3. Examples of ECD interventions

WHAT WAS DONE TO PROMOTE DEVELOPMENT? WHAT WERE THE RESULTS?


The Reach Out and Read (ROR) programme in the USA uses doctors Children enrolled in ROR showed significant improvement in preschool
and nurses who encourage parents to read aloud to their young language scores, which is a good predictor of subsequent literacy.
children, and offer age-appropriate advice and encouragement. This is
supported by the provision of books and reading-friendly health-care
environments
When counselling caregivers on care for early child development, WHO Simple ECD interventions can be integrated into existing health-care
and UNICEF used an interactive strategy to incorporate messages services with a positive impact on parenting behaviours and on the
regarding development, feeding and caregiving practices into child selection of toys to stimulate psychosocial development.
health visits in Turkey. This illustrates the feasibility of integrating
simple ECD interventions into existing services.
The PROGRESA programme in Mexico offers cash transfers to families Children born during the two-year intervention period who were part of
provided that children aged 060 months are immunized and attend the programme experienced 25% less illness in the first six months of
well-baby, or preventive care, visits. During these visits the childrens life than the children who did not receive the intervention. In general,
nutritional status is monitored, they are given nutritional supplements, children in the PROGRESA programme were 75% less likely to be
and parents and caregivers are offered health education. anaemic, and grew one centimeter more on average.

30 Closing the health equity gap: Policy options and opportunities for action
Urban settings
o Where people live is an important social determinant of their health. Increasing urbanization
throughout the world has major global health implications.

o The challenges posed by the urban environment, including air quality, standards of accommodation
and sanitation, can adversely affect many of the social determinants of health.

o Actions can be taken at all income levels to improve urban settings. These actions will improve
health, and can also create major returns for the economy.

o Multisectoral interventions promoting good governance in urban settings are the key to making
improvements and ensuring multiple benefits.

31
Urbanization can be a positive
a
water and sanitation, air quality,
force for improvement in living cramped conditions, housing and
The challenges of urban standards and health outcomes. shelter quality, land use, planning
settings are not limited to Technical and social development and transport.
low-income countries. Pockets is driven by the economic
strength of cities; the rise to Consequently, infant and child
of poverty and deprivation
wealth of todays high-income mortality rates among groups of
exist within cities worldwide.
countries was intrinsically linked the urban poor often approach
For instance, in extremely with the growth of cities. However, or exceed rural averages in
wealthy cities, there are in many areas of the world, a low-income countries. This fact
concentrations of obesity (poor combination of rapid growth of renders traditional stratifiers of
urban planning has been urban populations and neglect of place of residence i.e. urban
linked to falling exercise levels), longstanding problems found in and rural less meaningful.
infectious disease (globally, all cities, such as environmental In addition to their direct impacts
HIV incidence is 1.7 times pollution, poses major challenges on health, these factors also
higher in urban than in rural to societies. exacerbate other health risks.
areas) and violence (homicide The absence of social support
rates are higher in cities in Urban settings are therefore networks, lack of empowerment
many high-income countries a social determinant of and increased social exclusion
in comparison to low-income health. Despite all of the can directly and indirectly affect
countries). positive opportunities offered health. Women, the elderly, and
by cities, poor management the disabled are particularly
and governance, inadequate affected by these vulnerabilities.
infrastructure, and policy failures The stresses of poverty contribute
will magnify the effects of poverty, to poor mental health, with studies
inequity and unhealthy conditions. in developing countries showing
For instance, a problem of that up to one half of urban adults
inadequate housing for a scattered living in slums suffer from some
population in a rural area, if form of depression or other mental
reproduced on a large scale in health problem.
In their overall approach to a densely populated city, would
slums, governments are faced result in a crowded slum settlement Reducing the burden of disease,
with three main options: to where infectious diseases spread disability and death for the 3.3
remove them, upgrade them or much more easily. billion people living in urban areas
leave them as they are. requires special attention to be
A complex web of interlinking given to the particular problems of
Substantial evidence indicates determinants related to the quality those settings and to the socially
that upgrading is the most of the physical environment patterned distribution of broader
effective way to improve influences health in urban determinants of health.
conditions in most instances. settings. The main factors include
In addition to being generally
cheaper than whole scale
removal, upgrading avoids
dislocations of population
groups that impact on peoples
livelihoods and social networks.
Regularizing tenure is often an
important part of upgrading
because it allows official (public
or private) utilities to extend
infrastructure and services to
previously excluded groups.

32 Closing the health equity gap: Policy options and opportunities for action
What can be done? Box 6. Civil society and urban
improvements in Dhaka
Investments in healthy cities Box6.) Providing technical support
produce major returns for for improved housing structures or The city corporation in Dhaka, Bangladesh,
economies. The Commission on extensions can gradually improve could not provide waste removal services to
Macroeconomics and Health housing standards. large sections of the city. Neighbourhoods
documented this and it has been were left with accumulations of waste in the
reaffirmed in recent studies. For Improving urban settings is not streets. The city engaged in a cooperative
example, in developing regions only about what is done but effort with neighbourhood organizations
a US$ 1 investment in improving also how it is done. Typically, to set up waste removal services covering
water supplies can lead to cities are subject to the power of active composting, collection, proper disposal
economic benefits ranging from higher government bodies who and recycling. The city constructed transfer
US$ 5 to US$ 28. determine, to a considerable stations for secondary collections in order
extent, the resources available to centralize the local communities waste
Improving the urban living and actions that can be taken. collection drop-offs. This cooperative effort
environment is an essential step to has led to a substantial increase in the
improving the health of the urban Good governance which number of areas of the city covered by waste
population. Important areas for is locally based and involves removal services and has done so at minimal
action include: the community at all levels extra cost to the Dhaka city corporation.
improving access to clean in addition to the formal
and sufficient drinking-water government entities can result
and sanitation; in more effective and more
creating healthy housing and equitable cities with the resources
neighbourhoods; available.
controlling air pollution;
promoting good nutrition and Devolving decision-making
physical activity; and accountability to local
preventing urban violence level, making systems more
and substance abuse; transparent, and involving
promoting social cohesion civil society in policy design
within urban communities and implementation are likely
by providing opportunities to to improve health in cities. To
build social capital. be successful, the community
itself needs to drive the agenda,
There are numerous examples whether in a slum area or a
of successful interventions in more affluent neighbourhood.
these areas (6). Interventions Governments at all levels can
to support the improvement of encourage and facilitate such
the urban environment will vary community involvement.
by city context. For example,
public information campaigns Fostering opportunities for
on improving stove design, exchange of information,
home ventilation, food storage, experience and networking
or appropriate solid waste between cities and communities
management in households, can is a powerful strategy for
lead to improvements in each promoting mutual learning and
of these areas (See example in implementation of best practices.

33
Globalization and increasing economic
interdependence
o Globalization represents many complex processes and can have both positive and negative effects
on health.

o Careful sequencing of trade liberalization policies together with strengthened economic, labour
and social protection policies can mitigate some of the potential negative effects of increased global
market integration on health and health systems.

o Actions that could reverse increasing inequities in health include:


expanding capacity for health impact assessment of trade policy and foreign investments,
particularly incorporating impact on equity across all population groups;
improving the collection of statistics on the impact of globalization on national health systems
(how the benefits and risks are shared and distributed across countries and within countries, and
evidence on what actions reduce inequities) in order to better inform policy options;
increased global and national policy coherence addressing related challenges such as migration
of health professionals from poorer to richer countries, reduced food security associated with
climate change, and global convergence towards diets high in saturated fat, sugar and refined
foods.

34 Closing the health equity gap: Policy options and opportunities for action
The worlds growing economic opportunities within a society.
interdependence is characterized Box 7 gives examples of some Box 7. International trade
by trade liberalization and international trade agreements agreements that can influence
financial deregulation, as well as that may influence health policies, health policy
by greater movement of goods, while Box 8 addresses the need
services, capital, technology and for governments to ensure that International trade and trade rules that
to some extent labour across health is not prejudiced by such maximize health benefits and minimize
national borders. agreements. health risks, especially for poor and
vulnerable populations, should be
For some people, globalization Despite this complexity, the health pursued. Multilateral trade agreements
has brought health benefits that impacts of economic policy have the potential to influence health
include more rapid diffusion choices are seldom considered and health policies in positive or negative
of new technologies, stronger systematically, whether within ways, reflecting specific policies, timing,
demand and support for rights- countries or at the international negotiation points and implementation.
based approaches to development, level, and the distribution of these Examples of such trade agreements include:
and increased funding for global impacts within a country even The Agreement on the Application of
health initiatives. Globalization has less so. Part of this oversight is Sanitary and Phytosanitary Measures
also increased risks and negative due to differences in bargaining (SPS) contains rules for countries wishing
impacts on health such as power and resources during the to restrict trade to ensure food safety and
the protection of human life from plant- or
more rapid transmission of old process of trade negotiations. For
animal-carried diseases.
and new forms of communicable many countries, this also reflects The Agreement on Technical Barriers to
diseases, increased migration of the limited involvement of health Trade (TBT) allows countries to restrict trade
health professionals from poorer and other social ministries in such for legitimate objectives (e.g. protection of
to richer countries, and greater processes. human health or safety, protection of animal
exposure to hazards such as unsafe or plant life or health, protection of the
drinking water, pollution, and In many countries, rapid outflows environment).
dangerous working conditions. of investment funds have sparked The General Agreement on Trade in
These processes underline the national financial crises with the Services (GATS) allows countries to choose
need for coherent international and domino effects of increasing which service sectors (e.g. health services)
national policies that mitigate the poverty, unemployment and lost to open up and which modes of service to
actual and potential harmful effects liberalize.
productivity. On a larger scale,
The Agreement on Trade-Related
of globalization on health in both inadequate regulation of the
Aspects of Intellectual Property Rights
the less industrialized and more global financial system led to (TRIPS) establishes minimum standards
industrialized countries alike (7). a worldwide economic crisis in for many forms of intellectual property
2008 that dramatically revealed regulation and includes patent protection for
An important dimension of the extent of global economic pharmaceutical products.
globalization is the restructuring interdependence, the uneven
of national economies and distribution of globalizations
societies as these become risks and rewards, and the
integrated into the global consequences for health.
marketplace. For example,
trade policy can be a powerful Early warning signs point to a
mechanism for improving triple crisis reflecting financial,
standards of living. However, trade food and climate instabilities (8),
policy can also adversely affect which will worsen existing patterns
the viability of national health of inequity and deprivation. This
systems if reductions in tariffs situation shows the need for
significantly reduce governments shared responsibility for improved
capacities for generating revenues international governance and
for essential programmes, such greater national policy coherence
as health and education, unless that is pro-health.
approaches to replace revenues
lost from tariffs or increase the Other aspects of globalization also
efficiency of revenue collection have health impacts. A growing
are also put in place. Trade policy interdependence between
can also have more far-reaching domestic and health foreign
effects on health by changing policy is apparent worldwide.
the distribution of economic For example increasing

35
urbanization, rising incomes and to diets high in saturated fat, should be taken to address the
different employment patterns sugar and refined foods (nutrition role of trade and investment
have interacted with increasing transition) and to the prevalence treaties in relation to tobacco
liberalization of trade, foreign of overweight and obesity at levels or obesogenic foods, such as at
direct investment in food, and approaching those in high-income international high-level meetings
advertising and global branding countries, with rising incidence and in declarations that address
of food. In many low- and middle- of cardiovascular disease and noncommunicable diseases.
income countries, this has led diabetes (9). Every opportunity

What can be done?


Overall, social and economic flight and debt servicing. to essential medicines) can help
policy should emphasize rights, avoid negative impacts on the
regulation and redistribution to Expand capacity for health social determinants of health
counterbalance the influence of equity impact assessment of and avoid widening inequities in
the global marketplace on the both domestic and foreign health. At the same time, policies
distribution of opportunities for policy, including trade and to increase social protection will
people to lead healthy lives. Cross- foreign investment policy, mitigate negative impacts and
government actions and initiatives actively involving civil society improve social cohesion.
focused on social determinants organizations. Governments can
of health are essential to such an better ensure that national health Labour market and social policies
approach. For instance: and social priorities are not can buffer the negative impacts
negatively affected by economic of globalization, particularly for
Measure success not only in policy choices by: workers at the low end of the
terms of economic growth but building up their capacity for income scale. These policies
also in terms of improvement in analysing potential impacts should be universal, funded
peoples lives and how benefits of trade policy and foreign through progressive taxation
are shared within a country. investment; and not tied to employment,
Collect, analyse and widely share widening consultation since many of the worlds
disaggregated data to measure processes to include public and poorest workers are in the
social progress consistent with private health-care providers, informal economy or lack
national priorities. At the same consumers, and civil society access to employment-based
time, continue to reorient aid organizations; social insurance schemes.
architecture away from a charity enhancing the capacity of Governments need to ensure
or donor interest model and health ministries to document safe working conditions and
towards health and development and express pro-health views adherence to the International
goals that are consistent with in discussions on economic Labour Organizations core
multilateral agreements, such policy. labour standards (10) of
as the Millennium Development free association, collective
Goals. Governments can track Appropriate sequencing of bargaining, the elimination of
how the beneficial effects of trade policy commitments (e.g. economic discrimination by
development assistance may be through full use of trade treaty gender, and the elimination of
offset or undermined by other flexibilities governing intellectual forced labour.
financial flows such as capital property rights to protect access

36 Closing the health equity gap: Policy options and opportunities for action
Box 8. Making space for public health policies within bilateral and multilateral trade and investment
treaties, and ongoing monitoring of the impact on health, should be a requirement, not an option
Looking back: TRIPS and medicines for AIDS
In April 2001, the South African government legislated to allow parallel importation of medicines to treat HIV/AIDS, asserting that this was legal under TRIPS.
Pharmaceutical companies challenged the decision in court, but later pressured by local and global civil society protests and growing political support for
the South African governments position withdrew their case. The decision by the South African government was followed by a sharp upsurge at the United
Nations of international statements on treatment as a human right and articulations of state obligations on the availability of antiretroviral (ARV) drugs. The
same year saw the World Trade Organization issue its Declaration on TRIPS and Public Health. These commitments were matched by considerable policy and
price shifts. ARV treatment costs in many low-income countries fell from US$ 15 000 to US$ 150550 per year.

In other cases, however, countries have had limited ability to make use of the flexibilities provided by TRIPS and TRIPS-plus provisions in
bilateral and regional trade agreements. For instance, the Central American Free Trade Agreement (CAFTA) has been widely viewed as limiting
access to essential medicines by delaying or precluding the production of generic medicines. The ongoing monitoring and evaluation of the impact
of trade and investment policies will add to the growing evidence base on health impacts.
Sources: Shaffer & Brenner, 2009 (11); Smith, Correa & Oh, 2009 (12).

Looking forward: nutrition transition and childhood obesity


Governments should ensure that trade and investment liberalization does not take precedence over domestic policies that protect population health.
For instance, national regulations that limit advertising of foods high in fat, salt or sugar targeted to children, or taxes on such foods and their
advertisements, could contribute to slowing the incidence of childhood overweight and obesity.

37
Employment and working conditions
o Employment or economic policies which increase work insecurity can be harmful to employees.

o Unemployment or employment that is temporary, informal or precarious can lead to increased risk
of poor health and reduced life expectancy, whereas employment policies which provide permanent or
stable fixed-term jobs result in important associated benefits for health and well-being.

o Working conditions affect health and health equity in countries at all stages of economic
development.

o Measures to improve workplace conditions include:


worker representative organizations are supported;
worker representatives are required to be trained in occupational health;
workers are informed of work-associated risks and can act on them.

38 Closing the health equity gap: Policy options and opportunities for action
Employment can provide many Evidence shows that: policies which achieve a similar
benefits to an individual, including level of overall employment but in
financial security, social status, Mortality is significantly higher informal or temporary settings. For
personal development, social among temporary workers than example, policies that liberalize
relations, self-esteem, and among workers with permanent and deregulate financial markets
protection from physical and jobs in the pursuit of greater foreign
psychosocial hazards. Each of investment may be harmful to
these factors is also an important Workers who experience job workers where there are no social
determinant of the individuals insecurity report significant protection policies in place.
health and often of the health adverse effects on their physical
of others in the same household. and mental health (see Figure 3). Working conditions. These are
Employment and workplace conditions related to the tasks
policies therefore have an Workers in the informal economy performed by workers, the
important bearing on health and have less favourable health way the work is organized, the
well-being. indicators than those in the physical and chemical work
formal economy. environment, ergonomics, the
Employment conditions. While it psychosocial work environment,
has long been established that There is therefore a health and the technology being used.
unemployment leads to poor premium on permanent and Working conditions affect health
health, employment itself does not stable employment compared and health equity in countries
guarantee an absence of adverse to temporary and insecure at all stages of economic
effects on health. jobs. This premium can be very development.
large, as illustrated in Figure 2.
The conditions of employment are Evaluating employment policies Work-related fatalities through
crucial in determining the impact solely in terms of their impact on hazardous exposures continue to
on employee health. For example, the total employment rate misses be an extremely serious problem,
informal employment is not many important costs and benefits with around 2 million deaths per
covered by statutory regulations of employment. Policies which year related to work. In high-
protecting working conditions, achieve an increase in permanent income countries the direct risk of
wages, occupational health and employment are likely to be much injury or death at work is usually
safety, or injury assistance. more beneficial for people than less (although still present) than

Figure 3. Prevalence of poor mental health among manual works in Spain by type of contract

35

30

25

20 Permanent
Percent

Fixed term temporary


15 Non-fixed term temporary
No contract
10

0
Men Women

Source: Artazcoz et al., 2005

39
in lower-income countries, but that expose individuals to a range determinant of death and injury
working conditions also have of hazards tend to cluster in lower- among workers. This oversight has
other important effects on health. paid occupations. particularly negative effects among
For example, stress at work is workers with no contract, with a
associated with a 50% excess risk Lack of training on, and of temporary contract, or in manual
of cardiovascular disease. Across equipment for protecting against, occupations.
all countries the adverse conditions workplace risks is an important

What can be done?


Acknowledging health effects migrants and other vulnerable Occupational health and safety
when comparing different workers. These groups are (OHS) policy and programmes
national employment policies disproportionately represented can be applied to all workers
would allow for a more in precarious and informal formal and informal and the
accurate evaluation of options employment. coverage of these programmes
in both economic and social can be expanded to include
terms. Full-time and secure Legislation to require work-related stressors and
employment carries with it enterprises to have worker inappropriate behaviours such as
significant benefits, as outlined representatives trained in harassment, as well as exposure
in this section. Employers desire occupational health and to material hazards.
for flexibility to adjust to demand responsible for prevention in the
should be balanced with workplace is a low-cost measure Increases in enforcement
appropriate social protection that can improve workplace budgets and/or capabilities
policies that protect workers and safety. In countries with low would enable better
their families. rates of occupational injury and enforcement of regulations.
ill-health, workers organizations Failure of existing regulations to
Develop active labour market have often played a fundamental protect vulnerable workers can
policies (such as interventions to role in reducing health risks. often be traced to failures in
facilitate access to employment Extending the scope for collective enforcement. In most contexts,
among women, young people action and protection, such as there is considerable scope for
and older persons). by supporting the formation of more rigorous enforcement
workers organizations in the of standards; this could be
Promote regulation to avoid informal sector, would enable enabled by better funding of the
employment discrimination improvements. enforcement agencies.
against foreign-born,

40 Closing the health equity gap: Policy options and opportunities for action
Policy and attitudes towards women
o Gender inequity is one of the most influential social determinants of health. Women and girls in
many settings face discrimination, increased exposure to disease, and public services which do not
adequately meet their needs. This situation damages the physical and mental health of vast numbers
of girls and women worldwide.

o Gender inequity can be reduced through effective political leadership, well designed policies and
programmes, and institutional incentives and structures that influence social norms and household
behaviours.

oImproving girls and womens educational and economic opportunities will not only improve health
outcomes but will also lead to other benefits such as raised productivity.

oSocial norms which harm women are not fixed and can be challenged and changed over time. For
instance, social marketing and public awareness campaigns and legal changes have contributed to
changing attitudes on domestic violence.

o A relatively low-cost action is to equalize the balance of men and women in government
departments and political and research institutions, as well as in other decision-making bodies from
local to international levels.

41
The way in which they are perceived 2. It is often poorly recognized causes of the burden of disease
and treated by society damages the that women and men in women.
health of vast numbers of women experience differential
and girls worldwide. Women have exposures and vulnerabilities 3. There are biases in the way
less land, wealth and property in to a range of health problems. public services, and particularly
almost all societies, yet they often The Global Burden of Disease health systems, treat
have greater burdens of work than estimates that combine women. Furthermore, women
men do. Girls in some contexts morbidity and mortality data compensate for inadequate
are fed less, educated less and are for 2001 (14) indicate that, for health systems through unpaid
more physically restricted than boys, 68 of the 126 heath conditions health-care work within families
and women are typically employed and health risk factors, at least but receive little support,
and segregated in lower-paid, 20% differ between women and recognition or remuneration (see
less secure, and more informal men. While some differences also Section 1).
occupations than men. These may be explained by biological
factors lead to inequitable health factors, such as those related 4. Gender imbalances affect the
outcomes through four interrelated to reproduction, most relative content and process of health
routes: differences are shaped by research through gender
a complex interaction of imbalance in government-
1. There are discriminatory values, both biological and social sponsored committees, research
norms and behaviours that factors. For instance, womens funding, study populations and
affect health within households increased vulnerability to HIV advisory bodies. This leads
and communities. Examples infection is not only due to to slow recognition of health
include practices relating to female biology but can also be problems that particularly affect
selective abortions due to the attributed to womens lack of women, a lack of recognition
pressure to bear sons, the social power in sexual relationships. of womens and mens
acceptability of sexual abuse The Global Burden of Disease differential health needs, and
or physical violence towards 2004 update (15) shows that poor attention to the interaction
women, and the consequences HIV/AIDS, neuropsychiatric between gender and other
of widowhood. conditions and sense organ social factors, such as class,
disorders remain the three main occupation, race and ethnicity.

What can be done?


There are several routes through Improving female education increasing female literacy is
which government can make a can deliver major improvements likely to have considerable co-
difference: in womens health, reduction benefits for other areas of policy:
in infant mortality rates and it is estimated that each year of
Effective implementation of laws increased economic growth. schooling lost means a 1020%
to support women can help Globally, 64% of illiterate adults reduction in girls future incomes.
change norms and establish are women and it is known that Equalizing education across boys
rights. Structural factors of society people with low levels of literacy and girls could lead, on average,
which disadvantage women and are 1.5 to 3 times more likely to a 13% increase in economic
contribute to health inequities can to experience poor health. The growth.
often be addressed. Examples children of women who have
of specific action that could be never received an education are Campaigns involving public
taken include strengthening laws 50% more likely to suffer from information, social marketing
on domestic violence, ensuring a malnutrition or to die before and education have proved
legal right to equal pay for equal the age of five; and of the 76 successful in changing attitudes
work, or conducting an audit of million children who were out on issues such as domestic
existing laws to identify existing of primary school in 2006, 53% violence. Alongside changes
cases of discriminatory legislation. were girls. As with many other in laws, such campaigns can
actions to improve gender equity, challenge the norms and social

42 Closing the health equity gap: Policy options and opportunities for action
attitudes which underpin the Government can lead the
unequal and harmful ways way in mainstreaming the Box 9. The Soul City intervention
women are treated. An example equal treatment of women in in South Africa
is provided in Box 9. organizations. Government
can establish and enforce high As from 1999, the Soul City intervention
Including the value of unpaid standards for equality within state operated at multiple, mutually-reinforcing
work in national accounts would organizations that it manages levels (individual, community and
formally identify its contribution directly, as well as by applying sociopolitical) to address domestic violence
to the economy. Public policy pressure on contractors, private by increasing knowledge about it and
often ignores the very substantial sector partners and NGOs with shifting perceptions of social norms on
contribution of unpaid work to the links to the state. For example, the issue. An evaluation showed that the
economy, thus directing attention equalizing the balance of men Soul City intervention successfully reached
away from this important area and women in government- 86%, 25% and 65% of audiences through
of economic activity. A high- run research committees, and television, booklets and radio respectively.
level approach to address this funding, publication and advisory There was a shift in knowledge relating
would ensure that it is reflected in bodies would be a simple, zero- to domestic violence, including 41% of
public policy discussions. More cost way to make a difference. respondents hearing about the helpline.
specifically, social insurance and Attitude shifts were also associated with
protection systems could formally Channelling funding to the intervention, with a 10% increase in
recognize and protect unpaid grassroots organizations may respondents agreeing that domestic violence
workers. be a particularly cost-effective is not a private matter.
way of raising the profile of
Setting up a central unit to gender issues. In common
support gender equality can with other social determinants,
lead these changes and support from civil society is likely
act as an important signal to be a strong driver of change.
of the governments intent.

Seven approaches that can make a difference


1 Address the structural dimensions of gender inequity.
2 Challenge gender stereotypes and adopt multilevel strategies to change the norms and
practices that directly harm womens health.
3 Reduce the health risks of being a woman or a man by tackling the exposures and
vulnerabilities that differ due to gender norms, roles or relationships.
4 Improve health systems awareness and handling of the problems of women, as both
producers and consumers of health care, by improving womens access to health care,
and making health systems more accountable to women.
5 Take action to improve the evidence base for policies by changing gender imbalances in
both the content and the processes of health research.
6 Take action to make organizations at all levels function more effectively in
mainstreaming gender equality and equity and empowering women for health by
creating supportive structures, incentives and accountability mechanisms.
7 Support womens organizations which are critical to ensuring that women have the
capacity to act and have meaningful influence on policy decisions that impact their lives.

43
Inclusive policies
o Participation in economic, social, political and cultural relationships are important to peoples lives.
Policies which focus on particular excluded groups miss many of the problems of exclusion and may
stigmatize the intended beneficiaries of the policies.

o An alternative approach is for policy to address exclusionary processes, rather than the excluded
groups, thereby directing attention to the root causes of social problems.

o Universalist policies are the most successful in reaching disadvantaged and marginalized groups as
such policies avoid the problems of social stigma that are inherent in targeting.

o Where policies do follow a targeted approach, measures can be taken to facilitate their uptake
(e.g. simplifying eligibility criteria and means tests).

44 Closing the health equity gap: Policy options and opportunities for action
Current policies to address cases but across the population to Perhaps most importantly, such an
disadvantage and marginalization different degrees. approach is of practical value to
often focus on particular groups policy-makers because it directs
that are defined as being excluded An alternative framework for attention towards the root causes
from mainstream society. However, policy development is therefore of social exclusion rather than
such an approach has significant to consider the exclusionary having a limited focus on the
limitations as a framework for processes which cause problems differential outcomes of specific
policy development. Identifying rather than to focus on particular groups.
certain groups as suffering from groups that are excluded.
disadvantage is unhelpful where Such an approach recognizes a In addition to showing the
large proportions of the population continuum of possible outcomes importance of a broader
are living in poverty. Furthermore, and that many different groups conceptualization of social
participation in economic, social, and individuals can be affected exclusion, recent evidence
political, and cultural relationships in different ways by the same highlights a number of important
are important to peoples lives. exclusionary processes. This does new points for policy-makers to
Processes which exclude access, not deny the existence of extreme consider when developing policy
participation and relationships in states but it helps avoid the approaches to reduce social
these areas adversely affect health stigmatization inherent in labelling exclusion.
and well-being not just in extreme particular groups as excluded.

What can be done?


Box 10. The experience of the
Programa Bolsa Familia in Brazil
TARGETED POLICIES will improve the delivery of
Contemporary policies aimed at targeted policies. Investing The Programa Bolsa Familia (PBF) is
reversing exclusionary processes resources in promoting access a large-scale national conditional cash
are often selective, targeting and understanding eligibility for transfer programme focusing on low-
groups living in poverty and means-tested services will improve income families with dependent children.
involving some kind of test based their uptake. Established in Brazil in 2003, PBF was
on minimum assets, requirement introduced in the context of universal
or threshold. Targeted cash Conditional transfers are national health and education services. The
transfers or policies providing an increasingly popular form programme includes: school registration
access to essential services such of targeted policy whereby a of children, completion of immunization
as health care and education benefit is made contingent on programmes, attendance at clinics for
have also improved incomes or particular behaviours, often in monitoring the growth and development of
service coverage in some contexts. addition to being targeted at children, and attendance at prenatal clinics.
However, such policies also risk certain groups (see Box 10).
increasing the stigmatization of Conditional transfer programmes Positive results have been obtained as a
those in receipt of the resources can have significant positive result of PBF: 11 million families received
and services. There are also impacts in alleviating poverty a stipend, increasing income on average by
practical drawbacks. Considerable and improving living standards 21%, and around 87% reported that family
resources tend to be spent on and health outcomes, but two life has been better or much better since
complex administrative systems important limitations should be receipt of the stipend. There are also some
for policing and monitoring the noted. First, evidence on the need areas for improvement within PBF: while
means test, and there is a high for conditional requirements to an estimated 90% of the 15 million families
incidence of fraud. Furthermore, motivate behaviour change is registered for PBF met the eligibility
differential access to information, often inconclusive. For example, criteria, only 79% of them are in receipt
complex eligibility rules and stigma evaluations of South Africas of a stipend, and uptake among eligible
all restrict the reach of selective support grant and of child benefit families is lowest among those on the lowest
policies, disadvantaging those in in the United Kingdom suggest that incomes. Local research has also suggested
most need. Other things being mothers will spend additional cash that the services that must be used in order
equal, simplifying eligibility on promoting the health and well- to meet some of the conditions (particularly
criteria and access mechanisms being of their children without any schools) are often of poor quality.

45
conditional requirements. Second, methods, in view of the uncertainty uptake of, and improved access
insufficient attention is often surrounding the specific value to, public services. For example,
given to the quality of the services added by setting conditions and the introduction of comprehensive
that are available. For instance, the limited nature of the evidence systems of social protection in
when conditionality refers to base on effectiveness in some Brazil, South Africa and Venezuela
participation in the labour market, areas and contexts. has in each case been associated
the quality and sustainability with improved access to services.
of employment has often been UNIVERSAL APPROACHES In Brazil, the conditional cash
neglected or ignored. The tackling of exclusionary transfers programme is clearly
processes through universal linked to its universal health-care
Implementation of conditional approaches is typically found and national education systems.
transfer programmes will usually in high-income industrialized Better health and educational
benefit from attention to the countries, but a number of low- outcomes also result as additional
quality and availability of services and middle- income countries benefits of such comprehensive
required to meet conditionality are pursuing similar policies. programmes. In addition to these
requirements. It is also advisable While there are clearly challenges practical and quantifiable gains,
to ensure careful monitoring in funding such systems, these universal approaches have the
of conditional programmes, as are by far the most successful important added advantage of
well as to compare with other systems for encouraging increased promoting social cohesion.

46 Closing the health equity gap: Policy options and opportunities for action
Engaging civil society
o Appropriate engagement of target communities in decision-making and policy implementation
increases the likelihood that government policies and actions will be appropriate, acceptable and
effective.

o Actions to address the social determinants of health are generally more effective where such
engagement with civil society has taken place, with adequate resources.

o National governments can take a number of specific actions to support and derive the most benefit
from the contribution of civil society, including:
systematically involving civil society in policy development, implementation and monitoring;
providing dedicated resources as part of programme budgets to support ongoing community
engagement and empowerment;
reforming professional education to give greater status to lay and indigenous knowledge;
encouraging public debate on health matters and supporting the media in holding the system to
account.

47
Civil society includes community hamper opportunities for health in
Box 11. Protection of women groups, formal civil society disadvantaged groups); monitoring
from domestic violence in India organizations (CSOs) such as the performance of health systems
labour organizations, indigenous in line with priorities; providing
Indias Protection of Women from Domestic peoples groups, and other mechanisms for engaging with
Violence Act was passed in 2005. An early large-scale social movements marginal groups; supporting the
draft in 2002 of Indias Domestic Violence such as the anti-apartheid development of social capacities
Bill had many loopholes, including lack of movement in South Africa. These for engaging with bureaucracies
recourse for a woman who might be thrown actors can play an important and authorities; and engaging with
out onto the streets by a violent husband if role in contributing to the formal local and national political
she dared to challenge his use of the law. improvement of health equity, leaders to strengthen political
As a result of strong lobbying by womens particularly if correctly supported support for social action and
groups and effective re-drafting by feminist and engaged by governments, participatory processes.
lawyers, the draft was changed. as has been shown in many
different contexts. For example, Additionally, community
The improved Act uses a broad definition womens organizations have been organizations may be best
of violence to include beating, slapping, at the forefront in generating placed to support the delivery of
punching, forced sex, insults or name-calling new and compelling evidence of health programmes. With their
and allows abused women to complain gender inequality and inequities extensive community networks, civil
directly to judges instead of to the police in health, in experimenting society groups can organize and
who usually side with men and rarely act on with innovative programmes, implement some projects more
complaints. Moreover, the Act covers not only in mobilizing political support effectively (and more efficiently)
wives and live-in partners but also sisters, effectively, and in demanding than would be possible through
mothers, mothers-in-law or any other accountability from governments direct government control.
female relation living with a violent man. and the intergovernmental system Moreover, considerable evidence
This is one of the most far-reaching pieces (see Box 11). suggests that power devolved
of legislation on domestic violence to date to communities is more likely to
worldwide. CSOs can also be powerful lead to an equitable distribution
drivers for broader government of resources. Monitoring and
action on the social determinants assessment of implementation
of health in several ways, ensures a growing and objective
including by: facilitating social evidence base that incorporates
processes and community-led innovations that are often
action (including exposing and pioneered by civil society.
redressing power imbalances that

What can be done?


Systematically involving civil allowing CSOs to deliver policies, such groups are also
society in policy development, services in addition to or in likely to lack resources and have
implementation and monitoring partnership with state-run a limited base from which to
can significantly improve policies enterprises; operate. It is therefore important
and the effectiveness of their involving CSOs in research, to ensure dedicated financing to
delivery. Methods to achieve this monitoring and programme support civil society efforts.
include, but are not limited to: evaluation.
incorporating formal Reforming professional education
consultation mechanisms Providing dedicated resources to give greater status to lay
into the policy development as part of programme budgets and indigenous knowledge
process; will ensure support for ongoing can support better and more
expanding the involvement community engagement and equitable provision of health
of civil society in governance empowerment. While there is care. In many countries the
arrangements; strong evidence that civil society knowledge of lay people,
legal protection for CSOs; can support and improve health particularly indigenous peoples,

48 Closing the health equity gap: Policy options and opportunities for action
is often devalued and ignored, preventing innovations and programmes and the media
with the consequence that health potentially discriminating against have joined forces to stimulate
policies and services are designed particular groups. and sustain sound national and
without taking into account international public debates
important cultural, economic and Encouraging public debate (e.g. on infant feeding, essential
social contexts. Civil society can on health and allowing the drugs, tobacco use, or access
play a role in better documenting media to hold the health system to HIV treatment). The actions
this knowledge and assessing its accountable supports better required to support this will vary
application in improving health health policy. The media have greatly between countries but an
across many sectors. Overlooking an important role in this area. important theme is to work towards
lay knowledge can severely inhibit Powerful synergies have emerged increased transparency in health
the effectiveness of public services, when civil society, public health information and governance.

49
An example programme of action
BUILDING UP HOME- that cover a range of social social objectives. The dividing
GROWN POLICIES TO determinants are possible, and line between the health sector
REDUCE HEALTH INEQUITIES that these can be linked together and other sectors can vary in
BY ADDRESSING THE SOCIAL on the basis of the objectives and each country depending on the
DETERMINANTS OF HEALTH enabling mechanisms of each mandate of the health sector.
country in order to build up home- The majority of actions outlined
Table 4 summarizes a hypothetical grown policies to reduce health here require only limited additional
programme of action to reduce inequities. investment of public funds. They
health inequities. It is offered not do, however, require leadership
as a specific recommendation As highlighted throughout this and concerted action to mobilize
of what should be done, as this report, every sector can play private-sector funds and broader
will vary by country. Rather, it is a role in improving health civil society engagement.
a demonstration that extensive, equity and, in many instances,
specific, evidence-based actions doing so will support other

Table 4. Programme of action to reduce health inequities involving many sectors

COMMISSION*
RECOMMENDATION HEALTH SECTOR OTHER SECTORS
1. Improve daily living Primary health care Early child development
conditions, including approach adopted as ECD programme delivered through primary health clinics that
the circumstances organizational strategy offer parents advice on child care
in which people are New Cabinet-level committee on early years set up
born, grow, live, work
Public health programmes
and age.
HIV and TB programmes set up Urban Settings
joint programme board, identify Additional investment in improved water supply and access
shared objectives on social Public information campaign on safe indoor fuel alongside
determinants and build these into investment in new affordable and safe fuel sources
local delivery structures Legislation to regularize tenure of slum-dwellers
Devolving of control of slum upgrading programme (including
Facilitating intersectoral resources) to community NGOs
action
Cabinet committee on health Employment
inequities and or social National employment policies place premium on permanent
determinants convened and employment
specific objectives agreed with Legislation to require occupational health worker representation
each sector and across government in all workplaces

Social empowerment
Mechanism created for community
consultation on health spending

50 Closing the health equity gap: Policy options and opportunities for action
2. Tackle the Universal health care Globalization: focus on trade and investment
inequitable Advocate for and mobilize Expand capacity and requirements for health impact assessment
distribution of power, increased public funding for of trade policy and foreign investments that incorporate impact
money and resources health services on equity and health
the structural drivers
Test and evaluate strategies to Improved statistics on trade in health services in order to better
of those conditions
extend access to more people understand and communicate key trends
globally, nationally
and locally. and ensure quality of non- Improved capacities of health officials to engage in trade and
state providers investment negotiations and articulate the health consequences
Expand prepayment of services of domestic social and economic policies
through pooling of funds, such
as through a combination Gender
of sources, taxes or health Action programme to increase female education and new laws on
insurance schemes equal pay
Staff in public training Social marketing campaign on addressing domestic violence
programmes altered to reflect Policy of gender equity integrated throughout government
diversity and sensitivity to departments
gender issues
Universal policies
Leading intersectoral action Gradual phasing-out of means-testing to reach specific
Dedicated unit within Ministry population groups, when these are evaluated as inefficient
of Health to deal with trade and Move towards assessing all social and economic policies for
investment issues health impact (health in all policies)

Civil society
Mandatory consultation period for all new policy announcements
and earmarked funds to support = engagement
Shift from awareness on the right to health to concrete
mechanisms for different parties to ensure access to health
services
3. Measure and Measurement
understand the All government data routinely broken down by socioeconomic status, sex, age and ethnicity
problem and assess Support for disaggregated analysis of existing data from different sources, including national
the impact of action. household surveys (16)
Dedicated unit created within the Ministry of Health to promote and support all ministries in
using health impact assessments that integrate equity analysis, including gender equity and sex-
disaggregated data
Support for monitoring and evaluation of innovative interventions implemented in partnership with
civil society, in health and other sectors, that address social determinants of health
Funds earmarked to pay for analysis of impact of all new policies on social determinants of health
*Commission on Social Determinants of Health

51
l
Questions and next steps
The following questions may provide a tool for evaluating major WHERE ARE THE KEY POINTS
be helpful in facilitating policy new government policies and OF OPPOSITION IN THE
dialogue and debate in countries programmes and for incorporating SYSTEM?
about the appropriate next steps the consideration of equity and There will inevitably be opposition
in developing policy options and social determinants, ensuring that to any new policies in some
opportunities to reduce health important effects are not missed. quarters. Economic concerns,
inequities: vested interests, opposition from
professional groups or other
WHAT ARE SPECIAL ideologies may present barriers to
WHO ARE THE OTHER CONSIDERATIONS implementation of a programme
IMPORTANT ACTORS IN THIS FOR COUNTRIES WITH of action. These elements can
AREA? MINIMAL RESOURCES AND usually be overcome through
This document has focused almost CHALLENGING CONTEXTS? a combination of dialogue,
exclusively on the opportunities The options for policies and negotiation, advocacy and control.
for action at government level, actions are based on experiences A WHO book on mediation and
but success regarding improving in low-, middle- and high-income conflicts may be a useful tool for
health equity and addressing the countries. Nevertheless, the policy-makers (18).
social determinants of health will options for the least economically
require action at multiple levels, developed countries are likely to
including by communities, local depend particularly heavily on WHAT ARE THE EXISTING
governments, and regional, external donor support, given the POLICIES IN THIS AREA?
national and global authorities. likely context of weaker human HAVE THEY BEING
The Commissions report (1) resources and higher economic EVALUATED AND CAN THEY
provides recommendations for vulnerability in comparison to other BE SCALED UP?
action at each of these levels countries. Aligning country-specific The material in this document is
and this detailed set of potential frameworks for action with health intended to support policy-makers
actions may provide helpful systems strengthening is one means in building on existing policies.
inputs to policy and action. For to increase consistency in donor In many contexts it will be easier
instance, consultations involving investments and coordination. to build on and scale up existing
participation of communities and Another is to adapt models policies than to develop new ones.
affected population sub-groups from other relevant frameworks. One important step is to share and
also help identify starting points For example, the World Trade review implementation frameworks
for specific interventions to reduce Organizations Integrated developed in different sectors;
health inequities. framework of action for the least another is to support innovative
developed countries (17) begins to research, as well as ongoing
address issues of market access, monitoring and evaluation that
WHAT ARE THE OTHER special and differential treatment contributes to a growing national
IMPORTANT SOCIAL provisions, and participation in and global evidence base in this
DETERMINANTS? the multilateral trading system, area.
While each of the areas discussed among other areas. Moreover,
in this document is critically combining international frameworks
important, they do not represent with tools that can be used within WHAT ARE THE MAIN
a comprehensive list of topics individual countries to support SYSTEMS FOR CROSS-
or government policies which the development of home-grown GOVERNMENT WORKING
may impact on health and its policies and strategies, such AND DO THEY NEED TO BE
distribution within a country. In as those addressing a range STRENGTHENED?
each area, there will be important of social determinants (e.g. As noted in Section 1 and
matters of context to consider in employment, gender, trade) can elsewhere in this document, the
setting policy. The use of health offer a mechanism to address coordination of intersectoral action
impact assessments as inputs to social determinants of health in a can benefit from institutionalizing
policy dialogue and programme coordinated and country-specific tools and instruments (see Box12).
design would be one way to way. An international conference on

52 Closing the health equity gap: Policy options and opportunities for action
health in all policies in 2010 2. Make explicit the intervention Box 12. Tools and instruments
reached consensus (19) that logic (logic model) i.e. the
that have shown to be useful
policies that support health for sequence of effects expected to
cross-government policy and link the policy under study to
at different stages of the policy
action work best when: there is a the targeted problem. cycle:
clear mandate that makes joined-
interministerial and interdepartmental
up government an imperative; 3. Conduct a literature review and
committees
systematic processes take account synthesize data on the effects of
community consultations and citizens
of interactions across sectors; this policy in contexts in which it
juries
mediation occurs across interests; has already been implemented
cross-sector action teams
accountability, transparency (effectiveness, unintended
partnership platforms
and participatory processes are effects, effects related to equity)
integrated budgets and accounting
present; engagement occurs and on the issues related to its
cross-cutting information and evaluation
with stakeholders outside of implementation (cost, feasibility,
systems
government; and practical cross- acceptability).
impact assessments
sector initiatives build partnerships
joined-up workforce development
and trust by considering the 4. Enrich and contextualize the
legislative frameworks
benefits for other sectors. data drawn from the literature
through deliberative processes Source: Adelaide statement on health in all policies, 2010 (19).
that bring together actors
WHAT ARE THE and stakeholders who are
IMPLICATIONS FOR THE concerned with the health
WORKFORCE? problem or its determinants,
The readiness of the workforce is and are working within the
one of the key elements of action context where the policy was
in order to make programmes implemented.
operational that aim to reduce
health inequities and address
social determinants of health, and HOW CAN THIS
is also one of the key building KNOWLEDGE BE
blocks identified by WHO in efforts TRANSLATED INTO AN
to strengthen health systems (20). ACTIONABLE AGENDA?
An audit of skills and capacity, Building on a commitment that
not only in the Ministry of Health all people should have equal
but elsewhere, can help prepare opportunities to improve or
foraction. maintain their health, evidence
from within the country can be
combined with global evidence on
WHAT NEW EVIDENCE IS potential policy and programme
THERE FROM WITHIN THE options. Objective information on
COUNTRY? different options for action and
The aim is to encourage national consultation with a wide range
policy-makers and technical experts of stakeholders, can build up an
to understand and incorporate action agenda whether aiming
evidence from their own country. for fundamental changes or simply
This is a powerful way to guide fine tuning existing strategies. This
the development of new policy report provides many examples of
options or support the evaluation policy options and opportunities
of implemented policies. A recent for action, within the health sector
framework (21) for analysing public and in other sectors. Monitoring,
policies outlines four steps on how evaluation and reporting on
to do so: how policies and actions are
implemented, and their impact
1. Compile an inventory of public on health equity, will also provide
policies that could address the further evidence on what works to
targeted health problem, and improve health equity.
choose the policy on which the
knowledge synthesis will focus.

53
The Knowledge Network reports
Available at: www.who.int/social_determinants/themes/en

Benach J, Muntaner C, Santana V. Employment conditions and health inequalities. (Final report of the
Employment Conditions Knowledge Network of the Commission on Social Determinants of Health). Geneva,
World Health Organization, 2007.

Blas E, Sivasankara Kurup A (eds.) with inputs and contributions from the members of the Knowledge
Network. Equity, social determinants and public health programmes. (Final report of the Priority Public Health
Conditions Knowledge Network of the Commission on Social Determinants of Health). Geneva, World Health
Organization, 2010.

Bonnefoy J et al. Constructing the evidence base on the social determinants of health: a guide. (Report of
the Measurement and Evidence Knowledge Network of the Commission on Social Determinants of Health).
Geneva, World Health Organization, 2007.

Gilson L et al. Challenging inequity through health systems. (Final report of the Health Systems Knowledge
Network of the Commission on Social Determinants of Health). Geneva, World Health Organization, 2007.

Irwin LG, Siddiqi A, Hertzman C. Early child development: a powerful equalizer. (Final report of the Early Child
Development Knowledge Network of the Commission on Social Determinants of Health. Geneva, World Health
Organization, 2007.

Kelly MP et al. The social determinants of health: developing an evidence base for political action. (Final report
of the Measurement and Evidence Knowledge Network of the Commission on Social Determinants of Health).
Geneva, World Health Organization, 2007.

Kjellstrom T et al. Our cities, our health, our future: acting on social determinants for health equity in urban
settings. (Final Report of the Urban Settings Knowledge Network of the Commission on Social Determinants of
Health). Geneva, World Health Organization, 2007.

Labont R et al. Towards health-equitable globalization: rights, regulation and redistribution. (Final Report of
the Globalization Knowledge Network of the Commission on Social Determinants of Health). Geneva, World
Health Organization, 2008.

Popay J et al. Understanding and tackling social exclusion. (Final Report of the Social Exclusion Knowledge
Network of the Commission on Social Determinants of Health). Geneva, World Health Organization, 2008.

Sen G, stlin P, George A. Unequal, unfair, ineffective and inefficient . Gender inequity in health: why it exists
and how we can change it. (Final Report of the Women and Gender Equity Knowledge Network to the WHO
Commission on Social Determinants of Health). Bangalore and Stockholm, Indian Institute of Management and
Karolinska Institutet, 2007.

Siddiqi A, Irwin LG, Hertzman C. Total environment assessment model for early child development: evidence
report. (Report of the Early Child Development Knowledge Network of the Commission on Social Determinants
of Health). Geneva, World Health Organization, 2007.

Commission on Social Determinants of Health Knowledge Networks, Lee JH, Sadana R, eds. Improving equity
in health by addressing social determinants. Geneva, World Health Organization, 2011 (http://whqlibdoc.who.
int/publications/2011/9789241503037_eng.pdf , accessed 1 June 2012).

54 Closing the health equity gap: Policy options and opportunities for action
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55
Photo credits

Cover Shoeb Faruquee/awarded photograph in WHO photo contest Images of Health and Disability 2007 www.who.int/classifications/icf
p 4 Irene R. Lengui/LIV Com Srl
p 10 WHO/Christopher Black
p 12 WHO Bulletin/Pharmaccess
p 14 Fabienne Pompey/IRIN
p 15 UNICEF/NYHQ2006-0779/Noorani
p 18 Siegfried Modola/IRIN
p 21 WHO/Onasia/Vinai Dithajohn
p 23 UNAIDS
p 25 UN Photo/Eskinder Debebe
p 28 WHO/ Harold Ruiz
p 31 IARC/Roland Dray
p 34 Daniel Hayduk/IRIN
p 38 Shoeb Faruquee/ awarded photograph in WHO photo contest Images of Health and Disability 2007 www.who.int/classifications/icf
p 41 UNICEF/ HQ05-2388/Anita Khemka
p 44 WHO /Pierre Virot
p 47 UN Photo/Rossana Fraga
P 49 UN Photo/Luiz Roberto Lima

56 Closing the health equity gap: Policy options and opportunities for action
CLOSING THE HEALTH EQUITY GAP
Policy options and opportunities for action
ISBN 978 92 4 150517 8
World Health Organization
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