Promoting health and reducing health inequities


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Promoting health and reducing health inequities by addressing the social determinants of health

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WHO Strategic Objective 7: “To address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human-rights-based approaches”

It is only through a proactive and inclusive policy development and advocacy process that we can convince other parts of government and society that health is not a hopeless public expenditure, but is a resource for better economies, better quality of life and, ultimately, the way
towards more just and more equitable societies.
Zsuzsanna Jakab, WHO Regional Director for Europe

© WHO
WHO/Europe’s efforts to address the social determinants of health can be grouped into the following six areas of work:
>> T echnical assistance services to
countries, including capacity building and learning exchange
>> E vidence, data collection and analysis
>> G ender and health
>> P romoting the health of vulnerable
groups
>> S trengthening local-level governance –
Healthy Cities
>> S trengthening governance at
subnational level – Regions for Health Network

Introduction
Poor health cannot be explained simply by germs and genes. It is much more complex, involving both the circumstances in which people live (access to health care, schools and education, and conditions of work, leisure, homes, communities, towns or cities) and their individual and cultural characteristics (such as social status; gender, age and ethnicity norms; values and discrimination). All of these factors influence an individual’s chances of leading a flourishing, healthy life.
Chances for good health are not equally distributed in our societies and this causes health inequities. The recent Interim Report on Social Determinants of Health and the Health Divide confirmed that significant inequities in health and the role played by their social determinants are present across and within countries in the WHO European Region.
Addressing these health inequities requires dealing with their root causes: the unequal distribution of power, income, goods and services in our societies. Robust evidence collected at the global, European, national and subnational levels has led to an increasing call for action on social determinants. The report by the WHO Commission on Social Determinants of Health (CSDH) in 2008 and the related 2009 World Health Assembly resolution point to the urgent need to increase the commitment by Member States to address these root causes of health inequities. The call to action goes beyond health ministries, reaching out across borders and sectors to all the players and stakeholders that can contribute to a fairer and healthier Europe. The wide range of stakeholders includes ministries and other governmental entities, academic/research institutions, NGOs and civil society organizations.
The issue of health inequities is a top priority of the WHO Regional Director for Europe, Zsuzsanna Jakab. Tackling health inequities will be a key and integral part of WHO’s new strategy for better health in Europe, Health 2020, which is currently being developed in collaboration with Member States.

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Health divide in the WHO European Region

890 million people
Up to 20 Years
difference in life expectancy amongst men in the WHO European region

53 Member States
Up to 12 Years
difference in life expectancy amongst women in the European region

Life expectancy at birth, in years, male

Life expectancy at birth, in years, female

Albania Andorra Armenia
Austria Azerbaijan
Belarus Belgium Bosnia and Herzegovina Bulgaria
Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland
Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan TFYR Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan European Region
EU EU members before May 2004 EU members since 2004 or 2007
CIS CARK Eur-A Eur-B+Cª

Albania Andorra Armenia
Austria Azerbaijan
Belarus Belgium Bosnia and Herzegovina Bulgaria
Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland
Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan TFYR Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan European Region
EU EU members before May 2004 EU members since 2004 or 2007
CIS CARK Eur-A Eur-B+Cª

0

20

40

60

80

0

20

40

60

80

100

*World health statistics (2010), ** European Health for All database [online database]. (2010)

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Executive Summary
To tackle health inequities, WHO/Europe promotes an intersectoral and whole-of-government approach, which calls for action at different levels of policy-making. The wide range of activities and technical assistance provided by the Regional Office can be synthesized under the following major areas of work.
Technical assistance, including capacity building and learning exchange. WHO/Europe works with Member States to build and sustain their institutional and human resource capacities to address health inequities through a number of activities, including the review of public health policies and strategies, training and the facilitation of networks. Collecting and capitalizing on a wide range of experiences across sectors and across Europe, WHO provides expert guidance and support to policy-makers in the formulation of sustainable equity-centred policies, governance mechanisms and interventions. WHO/Europe also supports countries in sharing the lessons learnt from specific interventions at national and subnational levels.
Evidence, data collection and analysis. It is essential to have a reliable and clear picture of how health and opportunities for health are distributed in a given population, and what factors (indicators) contribute to or reduce opportunities to be healthy. This requires disaggregated data that must be analysed through a health equity lens. In addition, the WHO Office for Investment for Health and Development conducts indepth analyses on socially determined health inequities, and reviews evidence of successful interventions to support decision-makers and those implementing policies and services.
Gender and Health: promoting gender responsive policies. Addressing gender inequalities is recognized as a condition for achieving health equity. WHO/Europe promotes the use of sex-disaggregated data and the integration of gender analysis and actions in all policies. It also actively mainstreams gender throughout its technical assistance and policy advice to countries. This is the approach supported by WHO and Member States through the World Health Assembly Resolution 60.25.
Promoting the health of vulnerable groups. There is mounting evidence that some processes and conditions systematically prohibit or restrict population groups from gaining economic, social, political and cultural inclusion; and these factors are strongly associated with inequities in health status and access to health services. WHO contributes to the promotion of awareness, political commitment and action to address the conditions that make people vulnerable to ill health and in particular to address the needs and expectations of vulnerable groups, including the Roma, migrants and ethnic minorities.
Strengthening local-level governance – Healthy Cities. The WHO Regional Office for Europe recognizes the key role of local governments in creating conditions that support health and well-being. It therefore has longstanding, well-established cooperation links with hundreds of cities across the WHO European Region. The WHO Healthy Cities project seeks to put health high on the agenda of decision-makers in cities and to mobilize action for health and health equity in all local policies. Its approach is based on explicit political commitment, strong leadership and institutional change, intersectoral partnerships, innovative action addressing all aspects of health and living conditions (including issues relating to vulnerable groups, lifestyles and urban planning) and extensive networking between cities across the European Region and beyond. More than 1500 cities and towns throughout 30 countries are currently involved in the WHO Healthy Cities movement in the European Region.
Strengthening subnational governance – Regions for Health Network. Action on social determinants of health is required at all levels. WHO/Europe is currently re-launching its Regions for Health Network, which aims to accelerate action on social determinants of health at regional level, including through the sharing of experiences and joint interventions.
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Technical assistance

WHO/Europe works with Member States to support the design, implementation and review of policies, programmes and governance capacity to improve health and health equity. This ranges from applying an equity lens during the formulation of national health plans and strategies to building the capacity of policy-makers across the whole of government in the area of health equity. WHO/Europe works with a wide array of partners at the country, regional and local levels – for example, with regions on implementing strategies that address vulnerability and with national institutes of public health on indicators and data analysis to better understand the impact of policies on health inequities at all levels.

What the WHO Regional Office for Europe is doing

© Fotolia

Challenges
Effectively addressing social determinants requires multistakeholder and multisectoral action across government and society. This includes strengthening capacity to govern for better health across sectors and implementing multistakeholder policies, services and systems. These need to engage citizens, service providers, civil society, the media, planners, policymakers and politicians. Recent reviews of progress in advancing Health equity in All Policies and multistakeholder approaches to health improvement highlight the increased need for ongoing training and development in these areas. A key focus is to increase know-how and problem-solving skills, strengthen evidence-informed practice and support ongoing learning and development in analysis and adaptation of multisectoral approaches to health equity.

WHO/Europe works with Member States to build and sustain their institutional and human resource capacities to address the social determinants of health and tackle health inequities through a number of activities and services. These include the review of public health policies and strategies, human resource training and the facilitation of networks. WHO/Europe provides expert guidance and support to policy-makers in the formulation of sustainable equity-centred policies and interventions.
One of WHO/Europe’s main efforts is to build up and support a critical mass of human resources in Member States. This critical mass must be appropriately allocated within health systems and within the specific country policy context. The various professionals must have adequate skills and know-how and be accountable for the achievement of health equity targets. This is a key area in which WHO/Europe aims to bring about substantial change in countries, through the combined efforts of its Centre for Excellence (the European Office for Investment for Health and Development currently based in Venice) and its technical units in Copenhagen.

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WHO/Europe has been rapidly scaling up its work in this area. Requests from Member States have increased over the past two years following the report by the Commission on Social Determinants of Health and the World Health Assembly Resolution on this issue.
WHO/Europe is working with Member States across the Region to build and sustain capacity through
o reviewing and strengthening national strategies, development policies and governance systems to better address social determinants of health and the specific health inequity challenges in a country or region;
o ongoing training and development of policy-makers, public health institutions, NGOs and government authorities in using and adapting evidence, promising practices and instruments that support systematic action to reduce socially determined health inequities; this includes case-study-based workshops for policy-makers and problem-based learning between countries facing common challenges, such as implementing cross- sectoral approaches in reducing health inequities;

o drawing on the expertise of and engaging WHO collaborating centres in country work in ways that foster greater capacity within national institutes of public health, ministries and other partners within countries;
o fostering networks between actors across the Region through the development of high-level, regional and local forums. This includes work through the European Commission Expert Group on Social Determinants and Health Inequalities, the Regions for Health Network and the Healthy Cities movement. It also includes the provision of technical assistance to regional policy dialogues.
Strengthening governance for social determinants of health and health equity
Investments and decisions made outside the health sector (directly and indirectly) influence the patterns and magnitude of health inequities within European societies. In order to address the complexity of drivers that shape health and the determinants of health inequities, collective action across government, between government and society and across countries is required. This was most recently recognized in the Adelaide Statement on Health in All Policies, 2010, and previously in the Final Report of the WHO Global Commission on Social Determinants of Health (2008) and related WHA Resolution 62.14. (2009). These documents all highlight the need to further strengthen governance of health equity through cross-sectoral policies and mechanisms at local, national and supranational levels.

The social determinants of health (SDH) governance appraisal is a service offered by WHO, mainly through its Centre of Excellence in Venice. The service enables Member States to undertake a strategic review of their governance capacity to better address SDH and reduce health inequities. The service uses an organizational development approach to engage a wide range of stakeholders across health and development communities with the aim of identifying critical actions and opportunities for better governance of health equity.

© WHO/ Djordje Novakovic

The main steps in the governance appraisal include the following: a) A desk review of major health and development
policies, services and investments. This leads to a report summarizing the current and potential future impact of policies to address the specific health inequity challenges of the requesting Member State.

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© gettyimages

b) In-country interviews with a cross-section of stakeholders to gather primary data on the effectiveness of the current approach to governing for health equity.
c) In-country workshops and roundtable discussions to generate and test priorities and options for action.
d) A country-specific analysis report outlining the major findings of steps a-c above. The report covers key priorities for action in the short and medium terms, current evidence, promising practices and examples from Europe and internationally on proposed action areas and related governance support instruments.
e) An in-country consultation (usually web based) on the findings of the analysis report.
f) An in-country roundtable to present and debate findings with decision-makers and other stakeholders key to successful implementation. This step also includes reaching agreement on priorities and subsequent steps and identifying the nature and type of support needed for implementation and review.

Additional services and tools
• Capacity building in methods and approaches for improved accountability for health equity.
• Policy dialogues and roundtable forums to debate and advance critical thinking and commitment to increase investment in health and health equity.
• Policy and governance support tools, for example policy briefings and evidence reviews on economic incentives for addressing SDH and health equity.
• Promising practice and synthesis reports on how countries are tackling SDH and health equity, for example, ‘Setting a Political Agenda to Tackle Health Inequality in Norway’ http://www.euro.who.int/en/ what-we-publish/abstracts/setting-the-politicalagenda-to-tackle-health-inequity-in-norway

Equity-focused health impact assessment and related policy learning mechanisms
Technical assistance to countries includes also a crossgovernment assessment of how policies in other sectors affect health equity and the social determinants of health. Training can be given in how to measure the effects of policies and how to evaluate the impact of interventions to address social determinants and health inequities. In some instances, assistance may include an analysis of stakeholders and institutions within a country. This allows countries to better understand the structural and organizational environment needed to accelerate action on social determinants of health and health inequity.

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Practical examples of

WHO/Europe’s work

© WHO

Increasing investment in social determinants of health and health equity – integrating health into regional development plans and investment frameworks

Slovakia

Decentralized systems of governance and planning pose new challenges and opportunities for ensuring that health is considered in subnational policies and strategies. In Slovakia, regional governments now have increased autonomy in relation to social and economic decisions and investments, many of which affect health and health equity and their determinants. At the same time, health remains essentially a centrally managed and organized function.
Cross-sectoral and interdisciplinary planning teams were established, using regional planning cycles and mechanisms, to include health equity considerations in priorities and investment plans. Goals related to the health of the most vulnerable groups (e.g. elderly persons, the Roma, rural communities, homeless or migrant populations, and the unemployed) were integrated into regional cross-sectoral priorities and actions, backed up by resources and financial investments. A range of mechanisms was used to ensure cross-sectoral consideration of health in regional development plans. These mechanisms included:

– an assessment of health (e.g. an equity-focused health impact assessment) in regional equity plans;
– seminars for presenting and discussing data on the local health situation and evidence on the links between health, social and economic conditions and the policies of other sectors;
– joint identification of what policy sectors were already doing that benefitted health and health equity;
– bringing to the table what the health sector could do to further support joint action;
– press conferences and media interviews on health and development, to stimulate local interest and draw political attention to the issue; and
– intercountry twinning and learning exchange to support implementation.
The work resulted in a health chapter being adopted by regional parliament. This was included in the regional development plan with actions on the social determinants of health inequities formally linked to the regional investment framework.

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Tajikistan
Tajikistan is among the 18 high-burden countries prioritized for implementation of WHO’s updated Stop TB Strategy. In 2009, WHO convened a workshop in Tajikistan to review global findings related to the impact of social determinants (e.g. labour migration) on the design and delivery of public health programmes, specifically for tuberculosis (TB). This built on existing work within the country between the Ministry of Health and the International Organization for Migration: to understand how social determinants impact TB treatment and to improve programme coverage and outcomes, a survey among labour migrants had been conducted on their knowledge, attitudes and practices regarding tuberculosis and treatment. The new National programme for population protection against Tuberculosis The Republic of Tajikistan, 2010-2015 (NTP) makes specific mention of the need to decrease TB vulnerability through action on social determinants. The programme aims to ensure and improve equal access to TB services for the entire population, particularly for at-risk groups and poor communities.

Scaling up our work
The fact that an increasing number of Member States are requesting technical assistance from WHO/Europe in the area of social determinants can be seen as an indicator of success in itself. Hence the need to strengthen and expand the services outlined in this brochure is paramount.
The following 23 countries have approached WHO/ Europe for support and collaboration since 2009: Albania, Armenia, Czech Republic, Estonia, Finland, France, Italy, Kyrgyzstan, Latvia, Lithuania, Malta, Republic of Moldova, Montenegro, Norway, Poland, Portugal, Serbia, Slovakia, Slovenia, Spain, Tajikistan, the former Yugoslav Republic of Macedonia, the United Kingdom.
Several countries throughout the Region have now included an equity focus in their disease-specific plans, national health policies and systems and in many cases this has been achieved with the technical support of the WHO Office for Investment for Health and Development.
In addition to responding to an increasing number of requests for assistance from Member States, progress has been made in advancing the commitment of governments and partners, such as the European Commission, to accelerate action on social determinants.

>>What additional progress can be achieved with more resources?
A unique European-wide training and know-how programme
The WHO European Office for Investment for Health and Development is currently seeking partnerships and investments to expand its support to Member States. Greater skills and human resource capacity is urgently required if the European Region is to meet the challenges in addressing persistent and in some cases increasing health inequities. Additional support and resources would enable the establishment of a unique centre for training and know-how development and transfer.
The centre would bring policy-makers, politicians and practitioners together to solve common problems, explore and test practical options for action on health inequities, share and adapt promising practices and exchange learning experiences on implementing policies and governance solutions to improve health equity. It would also make a significant contribution to building and supporting a critical capacity of human resources in the Region capable of responding to the growing challenge of health inequity in Europe. The programme is designed to increase the health equity performance of both public health policies and development plans at national and local levels.

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Building an appropriate knowledge base: Evidence, data collection and analysis

It is essential to have a reliable and clear picture of how health is distributed in a given population, and what factors (indicators) contribute to or reduce opportunities to be healthy. This requires disaggregated data and analysis through a health equity lens. In addition to documenting areas for action, WHO/Europe is also focusing on gathering evidence of successful policy action for addressing health inequities at local, regional, national and interregional levels.

Challenges
The global financial crisis and resulting budget restrictions implemented in many countries have led in some cases to reductions in social policy and health budgets. In this climate, making the argument for consistent investments in health and for addressing inequities is particularly important and challenging. At the same time, less funding is available to produce the documentation and evidence required to support the argument for continued and increased action on health inequities.
What the WHO Regional Office for Europe is doing
While much is known about the impact of social determinants on health, information is still lacking on the scale of inequities within many countries of the WHO European Region. A clear picture of what interventions work in addressing health inequities is also still in the process of development.

WHO/Europe is working to fill these knowledge gaps. Part of this work includes tailoring know-how to the specificity of different country contexts.
The European Review on Social Determinants of Health and the Health Divide
The Regional Office for Europe recently commissioned the ongoing European Review on Social Determinants of Health and the Health Divide. In its final report, the Review will provide analysis of health inequities across and within all 53 Member States and identify effective policy interventions for the European Region. The Review is being conducted by a consortium of academic institutions chaired by Professor Sir Michael Marmot of University College London. The Review is one of the major studies underlying the new health policy Health 2020.

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Promoting health and reducing health inequities