SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIESi
Embargoed to 10pm, Thursday 28 August 08
The following key messages have been distilled from the WHO report Closing
the gap in a generation: Health equity through action on the social determinants of
health. New Zealand and Pacific examples have been given in some places.
KEY MESSAGE 1: Health inequities are avoidable differences in the
opportunity to be healthy and in the risk of illness and premature death.
They continue to persist in higher and lower income countries across the
Pacific.
Examples include:
1. An infant in NZ can expect to live eight years longer than one in Tonga, Niue or
the Cook Islands.1
2. A mother in Samoa can expect four times the risk that her baby will die before
they reach age five compared with Australia or New Zealand; whereas a
mother in Tuvalu can expect more than eight times the risk.2
3. Maori and Pacific people are surveyed to be 1.5 to 2 times more likely to have a
mood or anxiety disorder compared with the total population, but are much
less likely than the general population to have been diagnosed or treated for
such a mental health disorder.3
4. A woman in the lowest third of income households is 15 percent more likely to
die of breast cancer in New Zealand than a woman in the wealthiest third. 4
5. A Maori man in New Zealand is nearly three times more likely to die of heart
disease than a Europeanii man.5
6. A Pacific woman in New Zealand is 80 percent more likely to die from a
condition that is preventable or treatable than a European woman. 6
IMPLICATIONS FOR ACTION

Ministries of Health should explicitly consider investing in the reduction of health
inequities as one of the main strategies for improving health system outcomes.

Ministries of Health should explicitly consider investing in action with other sectors
to address the social determinants of health as one of the main options by which
to reduce health inequities.

Health systems have a responsibility in ensuring that their own policies and
interventions do not unintentionally widen socioeconomic and health inequities.
Definition re inequities: The terms inequities or socially determined health inequities used in this
briefing refer only to inequities that are unfair and unjust and not to all inequalities (eg. differences
resulting from factors that are unavoidable such as age, biology etc). For further explanation please see
Key Terms from Dahlgren G, Whitehead M (2007). European strategies for tackling social inequities in
health: Levelling up Part 2. Copenhagen, WHO Regional Office for Europe (Studies on social and
economic determinants of population health, No. 3).
ii
“European” in this context is non-Maori, Non-Pacific and non-Asian.
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KEY MESSAGE 2: Health inequities have important economic implications and
lead to significant losses to welfare and to the attainment of growth and
development targets of a country, irrespective of the prevailing economic
conditions.
The economic cost associated with avoidable differences in health opportunity is
substantial and there is growing evidence that the costs of health inequities are
significant.7
Evidence is available of the economic consequences of ill-health, and of the estimated
economic gains of improved health – both at the level of the national economy and at
the individual and household level.
Published studies of the economic and development
socioeconomic inequities in health estimate that:
costs
associated
with
1. Calculations of the annual inequity-related losses to health account for 15
percent of the costs of social security systems, and for 20 percent of the costs
of health care systems in middle and high-income countries.
2. Inequities-related losses to health as a ‘capital good’ in the European Union, in
absolute terms, are estimated at €141 billion.
3. One of the most powerful investments a country can make to its future
prosperity is in securing the health and development of all children equally in
their early years of life. This produces significant returns over the life course,
many times the size of the original investment 8. As such, governments should
adopt a strategy of investing in early child development. 9
4. Addressing the social determinants of smoking through an equity-oriented
approach to tobacco-control has been estimated to yield significant gains in
healthy life-years, reduce health care costs and generate important economic
benefits for society. 10
5. Ill-health is both a consequence and a cause of poverty, while health is a
pathway out of poverty. More advantage should be taken of the health
contribution to the attainment of poverty-reduction strategies and action plans.
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IMPLICATIONS FOR ACTION

Health and economic policy-makers should explicitly consider investing in
health and conditions that create equal opportunity to be healthy, as one of the
options by which to achieve their economic and development goals

Ministries of Health have a key stewardship role to play in scaling up actions
that tackle health inequities, integrating them into government development
agendas and into their own health care and public health policies and services.
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KEY MESSAGE 3. There is evidence of promising policies and programmes
that are effective in reducing health inequities and tackling the social
determinants of health. 12
Examples include:
1. New intersectoral models of governing health, which show positive results
including impacts on the social determinants of health and health behaviors as well
as ‘wins’ for other sectors including agriculture, labor, tourism and trade. 13
2. Evidence shows how for the same level of economic development, better health
status depends on the extent to which additional economic resources generated
benefited low-income groups and were invested in public systems for health and
education.14
3. Civil society involvement in policy development has been shown as important to
improving the design, implementation and outcome of health inequities strategies
and to win broader public support for action. 15
4. Internationally a mixture of universal and targeted policies and interventions are
being implemented to reduce the gradient in opportunity to be healthy and in
exposure to health risks, between different social groups. 16 17
5. Innovations in the design and delivery of public health programmes including
accident prevention, TB, smoking and HIV, which address the health and
socioeconomic circumstances of the target group, show improved programme
impact on self-reported health status, compliance with treatment protocols and
reductions in rates of reinfection and risk behaviour. 18
IMPLICATIONS FOR ACTION

Health inequities are amenable to change through a combination of universal and
targeted policy interventions.

Systematic actions to reduce health inequities are possible irrespective of the
development conditions and economic circumstances of a country.

Ministries of Health should explicitly consider taking action on the social
determinants of health as one approach for improving the efficacy of their public
health policies and programmes to influence lifestyles.
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KEY MESSAGE 4: There is significant evidence and a range of tools and
support available from WHO to enable countries to put in place and monitor
policies and actions that tackle the social determinants of health and
reduction of health inequities.
The WHO is working with Ministries of Health and their partners across government to
provide services, know-how, tools and guidance to reduce socially determined health
inequities. These include:
1. Technical support and guidance in the area of performance management of health
inequities – including methodologies and approaches to measuring, monitoring and
analysing inequities in health and their reduction.
2. Support to policy development and implementation, including generation and
testing policy options for reducing socially determined health inequities.
3. Tools and capacity building to assess the impact of policies and investments on the
level and distribution of health including health impact assessment and equity
focused health impact assessment.
4. Technical support, evidence and methodologies to inform the design and delivery
of equity-orientated public health and health programmes and services.
5. Evidence, know-how and tools for building cross-sectoral and whole-ofgovernment approaches to tackle social determinants of health and reduce health
inequities, including public health advocacy for agenda setting and alliance
building, economic argument for increasing incentives for investing in health and
social determinants of health.
New Zealand is well placed as many of these tools and evidence are in here.
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KEY MESSAGE 5: The final report of the Global Commission on Social
Determinants of Health (CSDH), established by WHO in 2005 and chaired by
Sir Professor Michael Marmot will be released on 28 August 2008.
The Report summarises the global picture of health inequities and provides evidence
on the role of social factors and pathways leading to increasing health gaps between
population groups. Evidence highlights the existence, in countries at all levels of
income, of a social gradient determining health: the lower the socioeconomic position,
the worse the health.
The report recommendations are based on three principles for action, which are
relevant for New Zealand and the Pacific:
1. Develop policies that positively influence the conditions of daily life – the
circumstances in which people are born, grow, live, work and age.
2. Direct attention at reducing differences in opportunity to be healthy that stem
from differences in access to education, employment, social participation and
access to services.
3. Measure the problem, evaluate action, expand the knowledge base, develop a
workforce that is trained in, and raise public awareness about, the social
determinants of health.
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References
World Health Organisation 2005 The world health report 2005 - make every mother and child count
http://www.who.int/whr/2005/en/index.html accessed 28 August 2008
2 World Health Organisation 2005 The world health report 2005 - make every mother and child count
http://www.who.int/whr/2005/en/index.html accessed 28 August 2008
3 Ministry of Health 2008 A portrait of health – key results of the 2006/07 NZ Health Survey Wellington:
Ministry of Health
4 Blakely T et al 2007 Tracking disparity: Trends in ethnic and socioeconomic inequalities in mortality,
1981 -2004 Wellington: Ministry of Health
5 Blakely T et al 2007 Tracking disparity: Trends in ethnic and socioeconomic inequalities in mortality,
1981 -2004 Wellington: Ministry of Health
6 Blakely T et al 2007 Tracking disparity: Trends in ethnic and socioeconomic inequalities in mortality,
1981 -2004 Wellington: Ministry of Health
7 Adapted from: Suhrcke M et al. The contribution of health to the economy in the European Union.
Public Health, 2006.
8 Adapted from: Siddiqi, A., Irwin, L.G. & Hertzman, C. (2007). The Total Environment Assessment Model
of Early Child Development. Evidence Report for the Commission on Social Determinants of Health, World
Health Organization
9 Adapted from: Irwin, L.G, Siddiqi, A. & Hertzman, C. (2007). Early Child Development: A Powerful
Equalizer. Final Report for the World Health Organization’s Commission on Social Determinants of Health
(http://www.who.int/social_determinants/resources/ecd_kn_final_report_072007.pdf accessed on 31
July 2008).
10 Adapted from: Suhrcke M et al. The contribution of health to the economy in the European Union.
Public Health, 2006.
11 Adapted from: PRSPs: Their Significance for Health: second synthesis report. Geneva, World Health
Organization, 2004. http://www.who.int/hdp/en/prsp.pdf accessed 31 July 2008
12 Adapted from: Dahlgren G, Whitehead M (2007). European strategies for tackling social inequities in
health: Levelling up Part 2. Copenhagen, WHO Regional Office for Europe (Studies on social and
economic determinants of population health, No. 3).
13 Evidence can be found at: Buzeti T, Maucec Zatonmik J (2008. Investment for health and development
in Slovenia, Programme Mura. Centre for Health and development Murska Sobota
Evidence can be found at: Scottish Government Strategy (2008). Vision for Success for Scotland –
inequalities outcomes.
14 Adapted from: PRSPs: Their Significance for Health: second synthesis report. Geneva, World Health
Organization, 2004. http://www.who.int/hdp/en/prsp.pdf accessed 31 July 2008
15 Evidence can be found at L Bauld and K Judge (2005). Health Improvement Planning in Scotland, an
analysis of joined health improvement plans and regeneration outcome agreements. NHS Scotland Publ.
Brinkerhoff D, McEuen M (1999) New NGO partners for health sector reform in Central Asia: family
group practice associations in Kazakhstan and Kyrgyzstan. Special Initiatives Report 19:1--29 . Cited By
Lowenson 2003). http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2004/03/01/000265513_20040301114
512/additional/310436360_20050276093820.pdf accessed 31 July 2008.
16 Brinkerhoff D, McEuen M (1999) New NGO partners for health sector reform in Central Asia: family
group practice associations in Kazakhstan and Kyrgyzstan. Special Initiatives Report 19:1--29 . Cited By
Lowenson 2003). http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2004/03/01/000265513_20040301114
512/additional/310436360_20050276093820.pdf accessed 31 July 2008.
17 Adapted from: Department of Health. Review of the Health Inequalities Infant Mortality PSA Target.
London 2007
18 HM Government PSA Delivery Agreement 15: Address the disadvantage that individuals experience
because of their gender, race, disability, age, sexual orientation, religion or belief http://www.hmtreasury.gov.uk/media/C/E/pbr_csr07_psa15.pdf . accessed 31 July 2008.
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