Elsevier

The Lancet

Volume 370, Issue 9593, 29 September–5 October 2007, Pages 1153-1163
The Lancet

Public Health
Achieving health equity: from root causes to fair outcomes

https://doi.org/10.1016/S0140-6736(07)61385-3Get rights and content

Summary

Health is a universal human aspiration and a basic human need. The development of society, rich or poor, can be judged by the quality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage due to ill-health. Health equity is central to this premise and to the work of the Commission on Social Determinants of Health. Strengthening health equity—globally and within countries—means going beyond contemporary concentration on the immediate causes of disease. More than any other global health endeavour, the Commission focuses on the “causes of the causes”—the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age. The time for action is now, not just because better health makes economic sense, but because it is right and just. The outcry against inequity has been intensifying for many years from country to country around the world. These cries are forming a global movement. The Commission on Social Determinants of Health places action to ensure fair health at the head and the heart of that movement.

Section snippets

Health inequality, inequity, and social determinants of health

Consider three children: one African, one south Asian, and one European. At birth each, representing the average for their country, has life expectancy of less than 50 years. The African and south Asian figures come from 1970, the European figure from 1901. Over the past century, life expectancy for the European child increased by about 30 years, and is still rising.1 Between 1970 and 2000, the south Asian child's life expectancy rose by 13 years, whereas for the child in sub-Saharan Africa,

Inequalities within countries and the social gradient

There is a second problem of inequalities in health: the dramatic differences within countries. These differences in health occur along several axes of social stratification including socioeconomic, political, ethnic, and cultural. One way of describing the magnitude of inequalities is the gap between top and bottom socioeconomic groups. In El Salvador, for example, if mothers have no education their babies have a one in ten chance of dying in the first year of life; if mothers have at least

Justice, inequality, and inequity

All societies have social hierarchies in which economic and social resources, including power and prestige, are distributed unequally. The unequal distribution of resources affects people's freedom to lead lives they have reason to value,14 which in turn has a powerful effect on health and its distribution in society. The Commission takes issue with the unequal distribution of social conditions when health suffers as a consequence

Not all health inequalities are unjust or inequitable. If good

Empowerment and freedom

At the heart of the concern with social determinants of health, and health inequity, is concern for people without the freedom to lead flourishing lives.14 To make a fundamental improvement in health equity, technical and medical solutions such as disease control and medical care are, without doubt, necessary. But they are insufficient. There will need to be empowerment of individuals, communities, and whole countries.

We see empowerment operating along three interconnected dimensions: material,

Social determinants of health and health equity

There is not a great deal of mystery as to why poor people in low-income countries suffer from high rates of illness, particularly infectious disease and malnutrition: little food, unclean water, low levels of sanitation and shelter, failure to deal with the environments that lead to high exposure to infectious agents, and lack of appropriate medical care. Similarly, we have a great deal of knowledge of the causes of non-communicable diseases that represent the major burden of disease for

Growing, living, and working

The tragedy of infant and child deaths in poor countries is that most are preventable. Child mortality shows a clear social gradient (figure 5).36 Child survival is crucial. But so is the quality of children's development. More than 200 million children worldwide are not reaching their development potential.37

The Commission's Early Child Development knowledge network stresses the need for a balanced approach to children's development, consisting of physical, cognitive and language, and social

Contextualising behaviour

Contemporary public-health interventions have often given primary emphasis to the role of individuals and their behaviours. The Commission recognises the important role of these factors, but sets them in the wider social context to illustrate that behaviour and its social patterning, as shown in Figure 6, Figure 7, is largely determined by social factors. Figure 6 shows how cirrhosis associated with heavy drinking is more common in lower socioeconomic groups. Countries with more restrictive

Health systems

Although inequities in health result from the social conditions that lead to illness, the high burden of illness particularly among socially disadvantaged populations, creates a pressing need to make health systems responsive to population needs. International, national, and local systems of disease control and health services provision are both a determinant of health inequities and a powerful mechanism for empowerment. Central within these systems is the role of primary health care, as

The shape of society

All societies are stratified along lines of ethnicity, race, gender, education, occupation, income, and class. Health inequities result from unequal distribution of power, prestige, and resources among groups in society. We see this very clearly in each of the case studies from India, Brazil, and Sweden. Although at very different stages of economic development, the differentiation of certain groups—be it by gender, caste, education, place, or income—is key to the way health inequity is

The social context

Economic and social policies affect the distribution of the social determinants of health, including resources for education, health, and financial security. It is clear therefore why the relation between the Ministries of Health and Finance is so crucial to a social determinants view of health. Indeed, recognition of the importance of social determinants of health means that government social policy, not just health policy, is fundamentally important for health equity.

Pro-health equity

Time for action

We are at a turning point. 60 years ago, in 1948, the establishment of WHO embodied a new global vision, emerging from the ashes of conflict, of universal health at the highest attainable level. 30 years later, in 1978, the community of nations came together again in Alma Ata to call for a new approach to health, founded on a holistic understanding of local primary health-care needs, across the social determinants, and of people-centred action.61 In 2008, the end of the Commission as a formal

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    This paper is an abridged version of the Interim Statement of the Commission on Social Determinants of Health

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