Ref. WHO/EIP/EQH/01/2006

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Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The conditions in which people live and work can help to create or destroy their health – lack of income, inappropriate housing, unsafe workplaces, and lack of access to health systems are some of the social determinants of health leading to inequalities within and between countries. “Interventions aimed at reducing disease and saving lives In both rich and poor countries, realities of people’s daily lives and the societies people’s health largely depends in which they live. Such an approach requires succeed only when they take the social determinants of on the social conditions in which incorporating into all policies. they live and work – the social The Commission on Social Determinants of health adequately into account.” determinants of health. Health (CSDH) recognizes health is a social goal and a responsibility across the whole The link between people’s health and their of society. There is increasing evidence that Dr LEE Jong-wook, Director-General, surroundings can no longer be ignored. Health better coordination and leadership to address inequities continue to grow across social classes, the social dimensions of health across all World Health Organization, occupations, and ethnic groups within countries, governmental policy-making is possible, and even where more resources are made available results in improved health and access to health The Lancet, 19 March 2005 and in spite of applying “the best” evidence- care. By acting on the social causes of ill- based interventions. Faced with this challenge, health, governments are poised to meet their health policy-makers are seeking ways to shift development goals, reduce health disparities, from disease-focused solutions to people- promote population health, and create and focused solutions, taking into account the sustain economically-viable societies. “At the core of the Commission’s Leading action on - to help build a sustainable global movement Create new alliances for action on health equity and social Action and knowledge agendas are being work is the belief that a society health inequities determinants, linking governments, developed with the simultaneous involvement international organizations, research of leading scientists, practitioners, civil society institutions, civil society and communities. organizations, government offi cials and global that has organized its social The Commission on Social Determinants initiatives, creating new networks of advocates of Health (CSDH) created by the World The Commission’s approach to tackle the social determinants of health. Health Organization draws the attention conditions so that its population allows it to: of governments, civil society, international Set the foundation for a new health agenda organizations, and donors to pragmatic ways has better health is a better Re-dress major gaps in evidence The innovative global, regional and national of creating better social conditions for health, CSDH collects state-of-the-art information on networks being created by the CSDH enable especially for the world’s most vulnerable society. Health is a measure of major social determinants of health on a global it to create the foundations for a new and people. WHO Director-General Dr LEE Jong- scale which will improve the performance of sustainable global agenda, which promotes a wook launched the Commission in March 2005. the degree to which the society health policy, its targeting and monitoring. comprehensive approach to health and health equity. It will operate until May 2008.

Promote learning by doing delivers a good life to its citizens.” The goals of the Commission are: Countries advancing action on social - to support health policy change in countries determinants are contributing their learning Sir Prof. Michael Marmot by assembling and promoting effective, to the evidence-gathering work of the evidence-based models and practices that Commission, while learning from the experts Chair, Commission on address the social determinants of health; and evidence assembled by the Commission. - to support countries in placing health equity Social Determinants of Health as a shared goal to which many government departments and sectors of society contribute; A key to achieving development targets Country example: Chile

CSDH works with countries to develop more In partnering with countries from both the CSDH is supporting Chile to analyse - target families in extreme poverty, making effi cient health policies that lead to health developing and developed world, CSDH health equity gaps in infant mortality and them priority subjects of public policy; equity. Its main focus is on: creates a learning platform through which . Chile is forging ahead with - traverse government departments and use - improving the performance of health policy by countries, already advanced or beginning to act the social determinants of health agenda selective interventions to tackle inequities; tackling the social determinants of health in all on social determinants of health, share their and launched the Health Reform and Chile - include all sectors of policy-making that policies affecting health outcomes experiences and build support mechanisms. Solidario (Chile in Solidarity Programme) infl uence health. across government; Examples from countries as diverse as Brazil to address health inequalities and improve - increasing the capacity to design, implement Chile, and Sweden show how improving one health opportunities for the most vulnerable Families covered under Chile Solidario are and monitor interventions and address the area of development can snowball into other communities. provided with a counsellor who facilitates social gradient of health; and areas and promote the well-being of society. access to a variety of social services including - placing equity at the centre of all government The Ministry of Planning and Cooperation programmes that offer occupational skills, planning, policy and decision-making. was tasked to coordinate different social support for the disabled, and facilities for health sectors, with equity as the goal. Through the and child development. Incentives have been Ministry’s Solidarity and Social Investment created for employers who hire unemployed Fund, the innovative Programa Puente (Bridge heads of households covered by the Solidario Programme) was established to: programme. Between 2002 and 2005, the number of families covered increased from 56 000 to 225 000.

Reaching beyond Civil society participation national borders redefi ned

Regional-based strategies to address the social In formulating its regional strategies, An innovative approach has been developed The active participation of civil society determinants of health provide opportunities CSDH emphasizes: to work with civil society representatives organizations in the work of the Commission for exchange and collaboration among from across the globe to gather knowledge aims to: countries, both within the same region and - The dissemination and use of from different levels of society outside - provide a global platform for the civil across regions, while ensuring the sustainability existing knowledge in the region, formal structures. Instead of merely “rubber- society voice; of the CSDH process beyond its tenure. including the compilation of country- stamping” decisions made by others, civil - strengthen capacities among participating civil specifi c information on studies, policies and society organizations working with CSDH society organizations; The Commission is playing a key role in interventions on social determinants of health. have developed their own strategies through - advance civil society agendas in relation to promoting cooperation and support between - Advocacy through regional forums national and regional consultative processes. social determinants; countries through regional and international to all the countries in the region to Thus, their knowledge and concerns contribute - broaden the political uptake of the bodies. Through its work with civil society incorporate social determinants of health collaboratively to the process. Commission’s messages; organizations, it is already witnessing a dynamic into public policies, with an emphasis on - provide social monitoring of system failures process in which organizations from different intersectoral action in the health policies of This approach seeks to respect civil society’s and inequities; moreover, participating social regions are beginning to identify common governments. critical autonomy and regional specifi cities, groups can lead the action to correct such areas of interest and are developing ways - Strengthening institutions and while empowering civil society partners and failures. to synchronize their actions on the social regional networks monitoring health reinforcing their capacity for action on social determinants of health. inequities, promoting interventions, and determinants of health and health equity. assisting countries to address the social determinants of health and health inequities. - Strengthening and promoting the participation of civil society organizations in regional work.

Knowledge for action Working through nine specifi c themes, The nine specifi c themes are: Health systems: The way health systems the objectives include: are designed, operate and fi nanced acts Early child development: as a powerful determinant of health. The Countries are often aware of the social causes Collecting best practices on a global Well-established evidence illustrates that effectiveness of different models of health of ill health, but few are successful in sustaining scale: the focus is on “what works” and opportunities provided to young children systems in improving health equity outcomes the implementation of actions to reduce providing policy-makers with interventions/ are crucial in shaping their lifelong health and will be reviewed. In an effort to gather and inequities in health. Knowledge of how to act actions that can be used to improve health and development status. Evidence of successful mainstream knowledge and action on how to is still fragmented and not always useful for reduce inequities. models, and challenges to implementing overcome social barriers to health, the focus different stakeholders. early child development (pre-natal - 8 years) is on innovative approaches that incorporate Using an innovative process for programmes, will be collected from countries, effective action on social determinants of The CSDH aims to evaluate on a knowledge collection: not only through international agencies, nongovernmental health. The recommendations from this work global scale: research institutions but also from governments, organizations and civil society. Criteria will be will be particularly relevant for resource-poor - the situation and evidence base in relation communities, civil society organizations and developed for successful implementation in countries. to health inequities and social determinants, international institutions. a range of country contexts with particular including evidence of interventions, and focus on low-income countries, and an easily- Urban settings: The focus is on - policies and programmes tackling social Providing an interface between accessible database of successful programme urbanization, particularly broad policy determinants that have proven effective in know-how and policy-making models will be created. interventions related to “healthy urbanization”. helping to reduce health inequities. processes: through its approach to The Network will closely examine slum knowledge collection, changing the way all Globalization: The scope is to examine upgrading as an entry point for other possible types of knowledge are valued and used by how the dynamics and processes of interventions. The upstream determinants key stakeholders to improve health and health globalization affect health outcomes. Trade of healthy urbanization will also be analysed equity. liberalization, integration of production of including stimulation of job creation, land tenure goods, consumption and lifestyle patterns, and and land use policy, transportation, sustainable household-level income are among the aspects urban development, social protection, under study. The uneven distribution of gains settlement policies and strategies, community and losses resulting from globalization, and its empowerment, vulnerability reduction and impact on inequities will be analysed to inform better security, among others. policies aimed at mitigating the actual and potentially harmful effects of globalization on health. Women and gender equity: The aim is Employment conditions: Fresh insight Measurement and evidence: to defi ne mechanisms and actions to reduce will be sought on approaches to address The aim of this cross-cutting theme is gender-based inequities in health by examining: employment conditions at the level of to develop methodologies and tools for (1) factors affecting social stratifi cation and how comprehensive policy, rather than interventions measuring the causes, pathways and health to improve women’s status relative to men; in specifi c workplaces. Evidence of the outcomes of policy interventions to tackle (2) differential exposures to health-damaging effectiveness on health equity of existing the social determinants of health and health factors; (3) differential vulnerabilities leading policies and programmes which address inequities. The focus is on approaches to to inequitable health outcomes; (4) differential employment conditions in different countries document processes of change and to economic and social consequences of illness and different vulnerable and high-risk groups attribute improvements in health outcomes and reproductive health needs; and, (5) factors will be gathered. Models and measures to to programmes and policies. The group will which promote issues related to women in improve the understanding of links between produce guidelines for designing evaluations, health systems and health research. In addition, employment conditions and social determinants including recommendations on appropriate women and gender equity will feature in each will be developed for different country quantitative and qualitative evidence, selection of the other themes. contexts and for different vulnerable groups of indicators and variables, and development of (such as migrants and workers in the informal measurement tools. These will also serve as a Social exclusion: The relational processes economy). Ways to translate this knowledge resource for the other specifi c themes and for that exclude particular groups of people into public and occupational health policy the evaluation of CSDH as a whole. from full engagement in community life may recommendations to improve the health of operate at the macro-level (access to affordable workers and their families will be elucidated. education, equal employment opportunity legislation, cultural and gender norms) and/or at Priority conditions: micro-levels (income, occupational status, social In the design and implementation of networks around race, gender, and religion). The specifi c priority public health programmes, linkages between social exclusion and concepts there are often factors which increase or such as social capital, social networks and perpetuate barriers to access to health care social integration will be examined. The nature for disadvantaged groups and exacerbate and operation of such processes and their inequities in health status. Evidence of these association with population health status and factors will be examined in country settings health inequalities will be analysed in various that vary by level of income and socioeconomic country contexts selected to refl ect the impact development. of differing structural (political, economic and social) constraints.

Country example: Brazil Country example: Sweden

In March 2006, Brazil launched a national To interface with the national Commission, In the late 1990s, Sweden launched an late 1999, following an intersectoral steering Commission to participate offi cially in the an intersectoral committee has also been innovative public health strategy and national mechanism, a national strategy for equity in CSDH process and to address the needs of a established, bringing together the social equity targets across government sectors. Based health was proposed to the government. This large portion of the Brazilian population still ministries (education, labour, health, women’s on a comprehensive review of health indicators culminated in a health system that promotes suffering from social conditions that produce affairs, etc.), agriculture and development across the social gradient, the government fair health opportunities for all social strata. inequities in health. The national Commission ministries, and other government bodies such established eleven targets for improving health The new health strategy and targets refl ect a has initiated a process to monitor these as the national secretariat of municipal health outcomes. commitment, at the highest political levels, to an inequities and is emphasizing the expansion of councils. These councils are connected with the equity-orientated and intersectoral approach existing knowledge. It aims to make a systematic provision of primary health care and directly The new national agenda for improving which delivers real improvements in health. study of the leading determinants of national manage social and health action at the district health was established through an extensive health inequities, and the interventions that level. Thus, the Brazil Commission and its consultation and consensus-building process have been, and are being, used to address linked bodies aim to achieve intersectoral involving different political constituents, civil them. It will then facilitate the incorporation action, social participation and the inclusion society, technical and scientifi c stakeholders. In of this knowledge into the development and of areas responsible for managing and implementation of public policies. The national implementing public policy from local to commissioners are drawn from many spheres national levels of governance. including academic, political, media and business, “Pressure from below has been useful in ensuring that and social leaders. health concerns are incorporated. For instance, one of the targets which refers to “Better health in working life” is the result of active pressure and support from employees and

trade unions.” Swedish Commissioner Denny Vagerö. ° Commissioners – leading (1984). An academic since leaving politics, Dr William H. Foege is Emeritus Presidential Kiyoshi Kurokawa is President of the Bégin has taught Women’s Studies at Ottawa Distinguished Professor of International Health, Science Council of Japan and the Pacifi c Science voices on health inequities and Carleton Universities, Canada. Emory University (USA), and a Gates Fellow. Association. He is also Adjunct Professor, An epidemiologist, Dr Foege worked in the Research Center for Advanced Science and Michael Marmot – Giovanni Berlinguer is a member of the successful campaign to eradicate smallpox in Technology of the University of Tokyo, Adjunct Commission Chair is Director of the European Parliament where he serves in two the 1970s. He was appointed Director of the Professor of the Institute of Medical Sciences International Centre for Health and Society, and Commissions: “Environment and Health” and United States Centers for Disease Control and of Tokai University, and Professor Emeritus Professor of and Public Health, “Culture, Education and Information”. Dr Prevention in 1977. In 1984, he co-founded the of the University of Tokyo. Dr Kurokawa has University College London, United Kingdom. Berlinguer was responsible for Italy’s fi rst Task Force for Child Survival, a working group served in many ministerial committees in Japan Professor Marmot has been at the forefront of National Health Plan approved by Parliament for WHO, UNICEF, The World Bank, UNDP, and and is currently Member of the Science and research into health inequalities for the past 20 (1968). He is a member of the International the Rockefeller Foundation. From 1999–2001, Technology Policy Committee of the Cabinet years, as principal investigator of the Whitehall Bioethics Committee of UNESCO (2001– Dr Foege served as Senior Medical Adviser for Offi ce. studies of British civil servants, investigating 2007) and rapporteur on the project “Universal the Bill and Melinda Gates Foundation. explanations for the striking inverse social Declaration on Bioethics”. Ricardo Lagos Escobar is the former gradient in morbidity and mortality. Yan Guo is Professor of Public Health President of Chile. An economist and lawyer by Mirai Chatterjee is Coordinator of Social and Vice President of the Beijing University qualifi cation, he worked as an economist for the Frances Baum is Head of Department Security for India’s Self-Employed Women’s Health Science Centre, China. She is also United Nations from 1976–1984. In the 1990s and Professor of Public Health at Flinders Association (SEWA) - a trade union of Vice Chairman of the Chinese Rural Health Lagos served in Chile under President Aylwin University and Foundation Director of the over 200 000 self-employed women. She is Association and Vice Director of the China and his successor, President Eduardo Frei, as South Australian Community Health Research responsible for SEWA’s Health Care, Child Academy of Health Policy. Professor Guo is Education Minister and from 1994–1999, he Unit. Professor Baum is one of Australia’s Care and Insurance programmes. She has been an active advocate in promoting health policy, was Minister of Public Works. leading researchers on the social and economic a member of national task forces on social primary health care, rural health services determinants of health. security, health and poverty reduction. Most management, maternal and child health care, Stephen Lewis was Canadian Ambassador recently, she was appointed to the National and health education and promotion in China. to the United Nations from 1984–1988. In Monique Bégin is a sociologist and the fi rst Advisory Council and the National Commission this capacity, he chaired the Committee that woman from Québec elected to the House of for the Unorganised Sector. drafted the Five-Year UN Programme on Commons, Canada. She was twice appointed African Economic Recovery. From 1995–1999, Minister of National Health and Welfare and Mr Lewis was Deputy Executive Director of remains best known for the Canada Health Act UNICEF in New York, USA. He is currently UN Special Envoy for HIV/AIDS in Africa, appointed by UN Secretary-General Kofi Annan in 2001. Alireza Marandi is Professor of Pediatrics Charity Kaluki Ngilu is the Minister of Amartya Sen is Lamont University Professor Gail Wilensky is a Senior Fellow at Project at Shaheed Beheshti University, Islamic Republic Health of Kenya. Since 1989, she has been and Professor of Economics and Philosophy at Health Opportunities for People Everywhere, of Iran. Dr Marandi is former Minister of a leader of the Maenbeleo ya Wanawake Harvard University, USA. Dr Sen has served as an international health education foundation. Health and Medical Education. He is Chairman organization, the national women’s movement. President of the Econometric Society, the Indian From 1990–1992, she was Administrator of the Iranian Society of Neonatologists, the Before entering politics, Mrs Ngilu was Economic Association, the American Economic of the United States Health Care Financing Board of Directors of the Islamic Republic Managing-Director of a food-manufacturing Association and the International Economic Administration, overseeing the Medicare and of Iran Breastfeeding Promotion Society, and company in Nairobi, Kenya. Association. In 1998, Dr Sen was awarded the Medicaid programmes and from 1997–2001, the National Committee for the Reduction of Nobel Prize in Economics. she chaired the Medicare Payment Advisory Perinatal Mortality and Morbidity. Hoda Rashad is Director and Research Commission. From 2001–2003, she co-chaired Professor of the Social Research Center of Anna Tibaijuka is Executive Director the President’s Task Force to Improve Health Pascoal Mocumbi was Prime Minister of the American University in Cairo, Egypt. She is of the United Nations Human Settlements Care Delivery for Our Nation’s Veterans, which the Republic of Mozambique from 1994–2004. member of the Senate (El Shoura Council), one Programme (UN-HABITAT). Mrs Tibaijuka has covered health care for both veterans and Prior to that, he headed the Ministry of Foreign of the two parliamentary bodies in Egypt and spearheaded UN-HABITAT’s main objective of military retirees . Affairs for eight years and the Ministry of she serves on the National Council for Women. improving the lives of slum dwellers in line with Health for six years. He has been the High She is currently a Vice-Chairman of the Dutch the Millennium Development Goals. She is also Representative of the European and Developing Development Assistance Research Council. In the founding Chairperson of the independent Countries Clinical Trials Partnership (EDCTP) the past, Dr Rashad has served as a member of Tanzanian National Women’s Council, and of since March 2004. Dr Mocumbi also has an the Scientifi c and Technical Advisory Group of the Barbro Johansson Girls Education Trust active role in global health initiatives, serving on the UNDP/UNFPA/WHO/World Bank Special dedicated to promoting high standards of the board of the International Women’s Health Programme of Research, Development and education for girls in Africa. Coalition and the Medicines for Malaria Venture. Research Training in Human Reproduction. Denny Vågerö is Professor of Medical Ndioro Ndiaye is Deputy Director-General David Satcher is Interim President of Sociology and Director of the Centre for of the International Organization for Migration. Morehouse School of Medicine, National Health Equity Studies, Sweden. He is a member In 1988, she was appointed by the President of Centre for Primary Care, USA. Dr Satcher of the Royal Swedish Academy of Sciences, and the Republic of Senegal to the post of Minister served simultaneously as United States Surgeon of its Standing Committee on Health. Dr Vågerö for Social Development. From 1990 to 1995, General and Assistant Secretary for Health has been a key fi gure in European health Professor Ndiaye was Minister for Women’s, from February 1998 to January 2001. From inequalities research and is presently Vice- Children’s and Family Affairs. 1993–1998, he served as Director of the President of the European Society of Health United States Centers for Disease Control and and Medical Sociology. He was involved in the Prevention and Administrator of the Agency for Swedish Government´s Commission on Work, Toxic Substances and Disease Registry. Environment, and Health. For information: Commission on Social Determinants of Health Room 3162 World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland http://www.who.int/social_determinants Email: [email protected]

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