Www.bournemouth.ac.uk Inequities In Health: A Global Perspective Dr Ann Hemingway Oct 2009

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Inequities In Health: A Global Perspective

Dr Ann Hemingway

Oct 2009

www.bournemouth.ac.uk 2

Definitions

Inequalities in health are: “Differences in the prevalence or incidence of health problems between individual people of higher and lower socio-economic status”.

Inequities in health are these differences but articulated as being preventable, unjust and wrong.

Kunst A. & Mackenbach J. (1994) Measuring Socio-economic Inequalities in Health WHO monographWHO CSDH (2008) Commission on the social determinants of health final report WHO: Europe


Explanations for inequities in health

• The artefact explanation• The social selection/illness

explanation• The behavioural explanation• The materialist/structuralist

explanation


Epidemiological Transition

• Some countries experiencing double burden of disease

• Also demographic transition

Non-communicable Non-communicable diseasesdiseases

Communicable Communicable diseasesdiseases


Why Reduce Health Inequities?

• Public health programs that reduce inequities in health can be cost effective

• Conditions that lead to marked health disparities are detrimental to all members of a society

• Inequities in health are undesirable to the extent that they are unfair or unjust

• Disparities in health are avoidable to the extent that they stem from policy options such as welfare benefits, health care funding, regulation of business and labour and tax policies

Woodward A. & Kawachi I. 2000 Why reduce health inequalities J. Epid Comm Health 54 p 923-929


The Social Determinants of Health: The Evidence (WHO 2003)

64

66

68

70

72

74

76

78

80

82

Prof Skilledmanual

Unskilledmanual

Men

Women

1. The social gradient


2. Stress

Social and psychological circumstances can cause long term stress and early death.

Insecurity

Low Self Esteem

Social Isolation

Lack of control

Lack of supportive friendships

Continuing anxiety

Poor mental health

Feeling a failure


3. Early Life

A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime

Poor circumstances during pregnancy

Deficiencies in nutrition

Maternal stress/risk of smoking + misuse of drugs/alcohol

Insufficient exercise and inadequatePrenatal care


4. Poverty and Social Exclusion

Life is short where its quality is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives. The stress of poverty and social exclusion are particularly harmful during pregnancy, to babies, children and older people.Increases risks of divorce/separation

Increases the risk of becoming disabled

Increases the risk of becoming chronically ill

Increases the risks of developing an addiction


5. Stress in the workplace

0

0.5

1

1.5

2

2.5

High Low

People who have more control over their work have better health.

Risk of suffering with CHD related to degree of control at work –high degree of control = 1 (Marmot et al 1997)


6. Unemployment

Job security increases health,

well-being and job satisfaction. Higher rates of unemployment

cause more illness and premature death.


7. Social Support

Friendship, good social relations and strong supportive networks improve health at home, at work and in the community. Those who get less social and emotional support are more likely to experience depression and a greater risk of pregnancy complications. In addition poor close relationships can lead to worse mental and physical health.


8. Addiction

Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting.


9. Food

Because global market forces control food supplies, healthy food is a political issue. A good diet and adequate food supply are central to promoting health and well being.


10. Transport

Healthy sustainable transport means less driving and more walking and cycling, backed up by better public transport. Healthy transport also encourages social interaction in the street and greater social cohesion.


Housing

• No matter which country in the world you live in your housing affects your health and well being either directly through damp, cold, heat or infestation. But also indirectly by affecting your status and the stability of your home environment.


Life Expectancy And Mortality Rates, By Country Development Category

(2000)

Development Category

Population 1999

Millions

PC Income

US $

Life expectancy at

birth

Infant Mortality

Under 5 mortality

Least-developed countries

643 296 51 100 159

Other Low-Income countries

1,777 538 59 80 120

Lower-Middle-Income countries

2,094 1,200 70 35 39

Upper-Middle Income Countries

573 4,900 71 26 35

High-Income Countries

891 25,730 78 6 6

Source: WHO (2001)

www.bournemouth.ac.uk 18Source WHO (2005) World health statistics 2005 Geneva p 9

Global Distributional InequityUnder Five Mortality Rate, WHO 2003


Health Challenges: Maternal Mortality

• 210 m women become pregnant annually

• 20 m experience pregnancy-related illness

• 500,000 die from complications of pregnancy or childbirth.

• Lifetime risk of dying in pregnancy in Africa is 1 in 12 versus 1 in 4,000 in Europe


Health Challenges: HIV/AIDS TB Malaria

• 3 million people died of AIDS in 2005. More than 12 million children were orphaned.

• TB is the leading infectious cause of death globally, and is a major and growing public health challenge. Interaction with HIV.

• Malaria causes 1 million deaths p.a. 40% of the world at risk of malaria. Primary cause of mortality in under 5s


Health Challenges: Mental Illness

• 13% of Disease Burden caused by neuropsychiatric disorders

• <1% of health budgets in developing countries

Source: WHO 2009


Chronic diseases: Cardiovascular disease and global health

• Cardiovascular disease thought to be a quintessential `western disease` is fast becoming a threat in developing countries.

• It now causes four times as many deaths in mothers in developing countries than do childbirth and HIV/AIDS combined

• The INTERHEART study found that 90% of heart disease is avoidable

World Heart Federation (2006) http://www.worldheart.org


0

10

20

30

40

I II IIInm IIIm IV V

socioeconomic group

%

men womensource: ONS, 2000

Rates of limiting long-standing illness among adults, Britain, 2000


CHD and inequalities

• There is a strong correlation between CHD risk and deprivation, the poorest members of society in the UK now suffer a risk three times the rates of those who are better off.

• One in three children in the UK grow up in relative poverty, a higher proportion that any other European member state.


Coronary Heart Disease the UK`s biggest single killer

Despite reductions in death rates CHD is the biggest single cause of premature death in the UK. One in four British men and one in five British women die from CHD. The UK has one of the highest rates of CHD in the European Union (NHF 2004).

National Heart Forum (2004) Young@heart campaign policy document NHF


• Poverty

• Gender

• Water and sanitation

•War and refugees

•Equity and human rights

Other influences on the Determinants of Health


Final recommendations from the WHO Commission on the Social Determinants of Health Sept 2008

• Improve daily living conditions• Tackle the inequitable distribution of

power, money and resources• Measure and understand the problem

and assess the impact of action


Health System Issues

• Access to services• Governance and structures• Policy processes• Public/private mix and roles• Professional staffing• Type of health care offered

• Urban vs. rural vs. peri-urban• Chronic versus acute care• Cure vs. care balance• Home based versus institutional• Referral systems• Care paths and integration of care

• Financing


Selected Countries: Levels And Sources Of Health Finance

TaxSocial

securityOut of pocket

Other incl. insurance

Ethiopia 5 5.9 58.2 0.2 32.7 8.9Uganda 18 7.3 30.4 0.0 36.5 33.1India 27 4.8 23.8 1.0 72.9 2.3Thailand 76 3.3 41.9 19.7 28.7 9.7Cuba 211 7.3 86.8 0.0 9.9 3.3Argentina 305 8.9 21.0 27.6 28.6 22.8UK 2,428 8.0 85.7 0.0 11.0 3.3France 2,981 10.1 2.5 73.8 10.0 13.7USA 5,711 15.2 31.9 12.7 13.5 41.9

Total expenditure per capita (2003) at official

exchange rate $

Total expenditure on health as

percentage of GDP (2003)

Private (%)Government (%)

Source: WHO (2006) World Health Report. Working Together for Health. (annex tables 2 and 3, pp. 178-189 ) WHO, Geneva


2000’s

• Changing wider context • Re-emergence of a focus on the wider

determinants of health• WHO and Tobacco• Commission on Social Determinants of Health

• Policy-making processes:• Focus on Evidence-based policy-making• NGOs and advocacy

• WHO 2000 Report on health system performance


Globalisation

• Ill-health does not need a visa

• Rising influence of commercial interests such as pharmaceutical/media/food multinationals

• Worth of top 5 companies is 2 x total GDP of sub-Saharan Africa


Globalisation

• International regulation challenges

• Effects of conflict on health

• Changing user expectations about community and individual rights

• Shrinking of professional world

• Increasing international migration of human resources


International trade – unlocking the potential for human development

“Until the lions have their historians” declares an African proverb “tales of hunting will always glorify the hunter”.

The same is true of global trade, for enthusiasts rapid

expansion over the last two decades has been an unmitigated blessing. Under the right conditions it has potential to reduce poverty, narrow inequality and overcome economic injustice. For many of the worlds poorest people these conditions have yet to be created.

(UN Human Development Report (2005), Aid trade and security in an unequal world, UNDP)


Contextual Issues

• Global economic and political shifts• Crises – natural and artificial and Aid• Urbanisation• Environmental degradation and global warming• Technology in health care including genetic medicine and

telemedicine• Changing health needs:

• Ageing populations• Non Communicable Diseases growing• Major Communicable Diseases including existing (AIDS

etc) and emerging ones such as avian ‘flu• ‘Neglected’ diseases


Aid in the 21st century

“The people of this country are distant from the troubled areas of the earth and it is hard for them to comprehend the plight and consequent reactions of the long suffering peoples and the effect of those reactions on their governments in connection with our efforts to promote peace in the world. The truth of the matter is that …….. requirements are so much greater than her present ability to pay that she must have substantial additional help or face economic, social and political deterioration of a very grave character”.

George C Marshall


• With these words US Secretary of State George Marshall outlined his plan for European reconstruction in 1947, over the next three years the US transferred $13 billion in aid to Europe, equivalent to more than 1% of US GDP.

• This was done partly for reasons of moral conviction but also by the recognition that US prosperity and security depended on European recovery.


• At the end of the 1960`s the Commission on International Development argued for donors to contribute 0.7 of GDP by 1975. Many countries have committed to delivering this but none have done it. An average % of 0.22 was achieved in 1997.

• For Sub-Saharan Africa per capita aid fell from $24 in 1990 to $12 in 1999, in 2003 it was just below the 1990 level.


• New donors are appearing though including the former soviet union countries with the Czech Republic being the most generous at 0.1% GDP.

• The russian government is also working with the UN to create and aid agency called RUSAID.

• However overall aid commitments remain unmet and the aid that is offered is often unstable, inconsistent, and often transitory.



Tackling Health Inequalities: Status Report On The Program For Action

2005 (UK, DOH)

• A continuing widening of inequalities as measured by infant mortality and life expectancy at birth in line with the trend

• Reductions in childhood poverty and improvements in housing have occurred. Some signs of narrowing of the gap in relation to heart disease mortality and to a lesser extent cancer


UK Life Expectancy

• The latest data (2005) indicate that since the baseline (1997) the relative gap in life expectancy between England as a whole and the fifth of local authorities with the worst life expectancy has increased for men and women. For males the gap increased by nearly 2%, for females by 5%


UN Millennium Development Goals (MDG)

• Eradicate extreme poverty and hunger

• Achieve universal primary education

• Promote gender equality and empower women

• Reduce child mortality • Improve maternal health • Combat HIV/AIDS, malaria and

other diseases• Ensure environmental

sustainability • Develop a global partnership

for development


2000’s

• Changing wider context • Re-emergence of wider determinants of health as policy

issues• Policy-making processes• WHO 2000 Report on health system performance• Millennium Development Goals• Recognition of growing Human Resource crisis


Countries With A Critical Shortage Of Health Service Providers (Doctors, Nurses And

Midwives)

Source: WHO (2006) World Health Report 2006. Fig 1.5

www.bournemouth.ac.uk 45Source WHO (2005) World health statistics 2005 Geneva p 9

Global Distributional InequityUnder Five Mortality Rate, 2003

Global Distributional InequityUnder Five Mortality Rate, 2003


Growing Human Resource Crisis

• Global shortage e.g.:• 334,000 additional midwives needed in next 10

years• Global inequities• Losses due to complex reasons• Ability of richer countries to plunder poorer

health systems• Quality and morale of existing staff affected –

vicious circle


Interestingly……..

The final report of the WHO CSDH over arching recommendations focus on

• Improving daily living conditions• The inequitable distribution of power,

money and resources, and:• Measuring and understanding the problem

and the impact of action Health care is mentioned (particularly

primary health care) but not as the main answer to the problems of inequities in health

www.bournemouth.ac.uk

Dr Ann Hemingway

[email protected] 962796

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Www.bournemouth.ac.uk Inequities In Health: A Global Perspective Dr Ann Hemingway Oct 2009