CLOSING THE HEALTH EQUITY GAP Policy options and opportunities for action

ISBN 978 92 4 150517 8

World Health Organization 20, avenue Appia CH-1211 Geneva 27 Switzerland http://www.who.int

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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Design & layout: L’IV Com, Villars-sous-Yens, Switzerland 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

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 WHO’s Information, Evidence and Policy cluster and with WHO regional advisors Tfollowing 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 Commission’s 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 Kingdom’s 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 Hernández, Clyde Hertzman, Lori Irwin, Heidi Johnston, Michael P Kelly, Tord Kjellstrom, Ronald Labonté, Susan Mercado, Antony Morgan, Carles Muntaner, Piroska Östlin, 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

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 H2005 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 Commission’s 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 child’s 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 country’s 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

150

100 Rate per 1000 live births Rate 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 80 Secondary or higher 70 60 50 40 30 20

Neonatal mortality rate (per 1000 live births) 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 1991–1996 1.80 1.60 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0 Relative Hazard (to university education) Relative 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 2001–2002 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 25.0 expect to live more than 80 years; in Minutes 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 Comoros Bangladesh Ecuador Bosnia- China and are seen worldwide. The poorest of Herzegovina the poor have high levels of illness and Source: World Health Survey, 2001–2002. 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 70 Maori It does not have to be this way and it 60 European heritage 50 is not right that it should be like this. 40 Where systematic differences in 30 health are judged to be avoidable

Percentage (%) Percentage 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 Mother’s Birth 2001–2203 Source: Final Report of the Commission on Social Determinants of Health (1). 12.0 11.0 10.2 10.0 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

Infant deaths per 1000 live births 2.0

0 India Ireland England Scotland Pakistan Caribean Sri Lanka and Wales East Africa West Africa West Bangladesh Rest of World of World Rest and not stated Eastern Europe Common wealth

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 Commission’s main WHO’s 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 need to address inequities in Commission both globally and actions outlined are based on 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 The social 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 and high-income countries offers options for raising more money society. 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 l The health system’s influence on several broad features. These health equity is not limited to its health systems: direct interactions (or lack of these) ººaim 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; ººthe degree to which national employers, public health ººintegrate 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 ººmeasure inequities in health the root causes of health system development can also and monitor actions to differences; contribute to social cohesion by address them; ººthe extent to which health empowering socially marginalized ººinclude 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 the presence or absence those working with socially ºº 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, ººpossess 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 ººthe 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.

l 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 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 Steps can 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. j

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

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 l 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. The Commission’s 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: Lönnroth 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. ººidentifying 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 ººcreating 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 ººdeveloping 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 ººincome; towards the most disadvantaged focus on expanding provision ººsex; groups may be the best and most to particular groups that are ººplace of residence; appropriate action, this is not excluded or marginalized or ººeducation;

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 Turkey 1998 Percent 40 Bangladesh 2004

20

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

Source: World health report, 2008

19 ººethnicity or race; actions to improve gender equity ººoccupation. (as described further in Section 2). 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 ººvital statistics, such as birth important step towards developing lives within urban areas). and death registrations; ººpopulation-based surveys, such as population censuses and demographic and health household surveys; What can be done? ººroutine 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 ººservice-generated activity data, such as hospital the design and evaluation of to better link and target policies 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 Commission’s report.

What can be done?

Health officials can encourage consultations with stakeholders ººinstitutionalizing access to social mobilization by taking on new policies and their decision-making through, for actions such as: implementation; example, clinic committees ººbringing professionals into ººpromoting 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 ººdrawing up service charters ººrecognizing, supporting and holding public hearings; that set out entitlements and funding mechanisms for direct ººpublic target-setting, with how they will be provided. participation by communities; independently verifiable ººimplementing 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 women’s 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 women’s 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 groups and organizations can early child development, of several ministries. The Ministry of Labour ºº help improve other areas of urban settings; has implemented a set of reforms to increase ºº 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; not necessarily, or even often, a globalization and increasing to reduce gender discrimination in access ºº matter of how much is invested economic interdependence, to work and pay; and to strengthen the but rather how resources are employment and working ability of workers to organize and negotiate ºº distributed and on whose conditions, fairly and collectively with their employers. account the costs show up. Some policy and attitudes towards The Ministry of Health and the Ministry ºº 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 ººinclusive policies, health sector and then later in engaging civil society. The Ministry of Health has also supported ºº 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 Children’s 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 child’s 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 child’s 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 6−18-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 child’s 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 0−60 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 children’s 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 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 a strength of cities; the rise to Consequently, infant and child of poverty and deprivation wealth of today’s 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 people’s 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 Box 6.) Providing technical support a 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. ººimproving access to clean − in addition to the formal and sufficient drinking-water government entities can result and sanitation; in more effective and more ººcreating healthy housing and equitable cities with the resources neighbourhoods; available. ººcontrolling air pollution; ººpromoting good nutrition and Devolving decision-making physical activity; and accountability to local ººpreventing urban violence level, making systems more and substance abuse; transparent, and involving ººpromoting 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 world’s 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 productivity. On a larger scale, liberalize. • 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 globalization’s 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 ººbuilding up their capacity for income scale. These policies also in terms of improvement in analysing potential impacts should be universal, funded people’s 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 ººwidening consultation since many of the world’s 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 ººenhancing 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 Organization’s 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 government’s 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$ 150−550 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 individual’s 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 Fixed term temporary Percent 15 Non-fixed term temporary No contract 10

5

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 women’s 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, women’s 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 women’s lack of women, a lack of recognition pressure to bear sons, the social power in sexual relationships. of women’s and men’s 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 women’s 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 10−20% 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 1−3% 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 government’s 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 women’s 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 women’s 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 women’s 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 people’s 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 people’s 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 Africa’s 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 India’s 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 India’s 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 women’s 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 women’s 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 ººallowing 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 ººinvolving 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. ººincorporating 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 ººexpanding 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, ººlegal 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 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 Commission’s 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 Organization’s 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 mechanisml 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 Box 12). 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 for action. 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 l 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.

Labonté 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, Östlin 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 References

1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008. Available at: http://www.who.int/social_determinants/thecommission/finalreport/en/index.html (accessed 16 April 2012).

2. Lönnroth K et al. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science and Medicine, 2009, 68:2240–2246.

3. World health report, 2008. Geneva, World Health Organization, 2008.

4. Manandhar DS et al. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomised controlled trail. The Lancet, 2004, 364:970−979.

5. Engle PF et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 2011, 378:1339−1353.

6. UN-HABITAT has documented more than 1700 initiatives from across the world aimed at improving the urban environment. Available at: http://www.unhabitat.org/content.asp?typeid=19&catid=34&cid=10256 (accessed 1 June 2012).

7. Divided we stand: why inequality keeps rising. Paris, Organisation for Economic Co-operation and Development, 2011 Available at: http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,00.html (accessed 16 April 2012).

8. Addison T, Arndt C, Tarp F. The triple crisis and the global aid architecture, Working Paper 2010/01. Helsinki, United Nations University/World Institute for Development Economics Research, 2010. Available at: http://www.wider.unu.edu/publications/ working-papers/2010/en_GB/wp2010-01/_files/82784791381278751/default/2010-01.pdf (accessed 16 April 2012).

9. Hawkes C et al. (eds). Trade, food, diet and health: perspectives and policy options. Oxford, Wiley Blackwell, 2010.

10. Declaration on fundamental principles and rights at work. Adopted by the International Labour Conference, Eighty-sixth Session, Geneva, 18 June 1998 (Annex revised 15 June 2010). Geneva, International Labour Organization, 1998. Available at: http:// www.ilo.org/declaration/thedeclaration/textdeclaration/lang--en/index.htm (accessed 16 April 2012).

11. Shaffer ER, Brenner JE. A trade agreement’s impact on access to generic drugs. Health Affairs, 2009, 28(5): w957−w968.

12. Smith RD, Correa C, Oh C. Trade, TRIPS, and pharmaceuticals. The Lancet, 2009, 373(9664):684−691.

13. Artazcoz L et al. Social inequalities in the impact of flexible employment on different domains of psychosocial health. Journal of Epidemiology and Community Health, 2005, 59(9):761−767.

14. The World Bank. The global burden of disease and risk factors. New York, NY, Oxford University Press, 2006. Available at: http:// www.dcp2.org/pubs/GBD (accessed 1 June 2012).

15. The global burden of disease: 2004 update. Geneva, World Health Organization, 2008. Available at: http://www.who.int/ healthinfo/global_burden_disease/2004_report_update/en/index.html (accessed 1 June 2012).

16. National and regional analyses are encouraged. For example, see the report Health inequities in the South-East Asia Region: selected country case studies. New Delhi, World Health Organization Regional Office for South-East Asia, 2009. Available at: http://203.90.70.117/PDS_DOCS/B4288.pdf (accessed 16 April 2012).

17. An integrated framework for trade-related technical assistance, including for human and institutional capacity building, to support least-developed countries in their trade and trade-related activities. Document WT/LDC/HL/1/Rev.1. Geneva, World Trade Organization, 1997. Available at: http://www.wto.org/english/tratop_e/devel_e/framework.htm (accessed 16 April 2012).

18. Drager N, McClintock E, Moffitt M. Negotiating health development: a guide for practitioners. Cambridge, MA, and Geneva, Conflict Management Group and the World Health Organization, 2000.

19. Adelaide statement on health in all policies: moving towards a shared governance for health and well-being. Report from the International Meeting on Health in All Policies, Adelaide 2010. Adelaide and Geneva, Government of South Australia and the World Health Organization, 2010. Available at: http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf (accessed 16 April 2012).

20. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization. 2007. Available at: http://www.who.int/healthsystems/strategy/everybodys_business.pdf (accessed 16 April 2012).

21. Morestin F et al. Method for synthesizing knowledge about public policies. Montreal, National Collaborating Centre for Healthy Public Policy/Institut national de santé publique du Québec, 2010. Available at: http://www.ncchpp.ca/172/publications. ccnpps?id_article=536 (accessed 16 April 2012).

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/L’IV Com Sàrl 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

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