Elsevier

The Lancet

Volume 380, Issue 9846, 15–21 September 2012, Pages 1011-1029
The Lancet

Review
WHO European review of social determinants of health and the health divide

https://doi.org/10.1016/S0140-6736(12)61228-8Get rights and content

Summary

The European region has seen remarkable heath gains in those populations that have experienced progressive improvements in the conditions in which people are born, grow, live, and work. However, inequities, both between and within countries, persist. The review reported here, of inequities in health between and within countries across the 53 Member States of the WHO European region, was commissioned to support the development of the new health policy framework for Europe: Health 2020. Much more is understood now about the extent, and social causes, of these inequities, particularly since the publication in 2008 of the report of the Commission on Social Determinants of Health. The European review builds on the global evidence and recommends policies to ensure that progress can be made in reducing health inequities and the health divide across all countries, including those with low incomes. Action is needed—on the social determinants of health, across the life course, and in wider social and economic spheres—to achieve greater health equity and protect future generations.

Introduction

This report presents the recommendations of the Review of Social Determinants of Health and the Health Divide, which addressed inequities in health between and within countries across the 53 Member States of the European region. The review was commissioned to support the development of the new health policy framework for Europe: Health 2020. There are good reasons for the specific European focus of this review. Health inequities across the region are known to be high, and the region's great diversity creates opportunities to offer policy analysis and recommendations specific to low-income, middle-income, and high-income countries. The results of the review are clear: with the right choice of policies, progress can be made across all countries, including those with low incomes.

The European region includes countries with some of the best levels of health and narrowest health inequities in the world. Evidence suggests that this welcome picture is related to a long and sustained period of improvement in the lives people are able to lead. Socially cohesive societies, which are increasingly affluent, with developed welfare states and high-quality education and health services, have created the conditions for people to have the freedom to lead lives they have reason to value. Remarkable heath gains have been the result.

However, not all countries have shared fully in this social, economic, and health development. Although social and economic circumstances have improved in all countries, differences remain and health has suffered (figure 1). Furthermore, even more affluent countries in the region have increasingly seen inequities in people's life conditions and declining social mobility and social cohesion. As a likely result of these changes, health inequities are not diminishing and are increasing in many countries (figure 2). Since 2008, the economic crisis, which was more serious than most predicted, has exacerbated this trend and exposed stark social and economic inequities within and between countries.

Human rights approaches support giving priority to improving health and reducing inequities. Achieving these goals requires definitive action on the social determinants of health as a major policy challenge. These inequities in health are widespread, persistent, unnecessary, and unjust, and tackling them should be a high priority at all levels of governance in the region. Necessary action is needed across the life course and in wider social and economic spheres, to protect present and future generations.

The Review of Social Determinants of Health and the Health Divide provides guidance on what is possible and what works, to be considered within the specific circumstances and settings of individual countries. Its recommendations are practical and focused. One response open to all is to ensure universal coverage of health care. Another is to focus on types of behaviour (smoking, diet, and alcohol) that are the immediate cause of part of these health inequities but are also socially determined. The review endorses both these responses. But the recommendations of the review extend further—to the causes of the causes: the conditions in which people are born, grow, live, work and age and inequities in power, money, and resources that give rise to these conditions.

Section snippets

Action needed across society

Systematic differences in health between social groups, that are avoidable by reasonable means, are unfair. Hence the term “health inequities” is used throughout this review to describe these avoidable inequalities.

The analysis shows that action is needed across the whole of government, on the social determinants of health, to achieve advances in health equity. Health ministers clearly have a role in ensuring universal access to high-quality health services, but they also have a leadership role

Areas for action—emphasising priorities

Countries should have two clear aims: improving average health and reducing health inequities by striving to bring the health of everyone up to levels achieved by the most advantaged. Improving the levels and equitable distribution of the social determinants should achieve both aims. Similarly, to reduce health gaps between countries, efforts should be made to raise the level of the least healthy countries to that of the healthiest countries. To achieve this goal, two types of strategy are

New approaches

This review draws on the findings and recommendations of the Commission on Social Determinants of Health: health inequities arise from the conditions in which people are born, grow, live, work, and age and inequities in power, money, and resources that give rise to these conditions of daily life. The explicit purpose of the review was to assemble new evidence and to develop new ideas for promoting health equity (panel 1) that could be applied to the diversity of countries that make up the

Do something, do more, do better

The key message “do something, do more, do better” emerged from the work of the task groups, set up to review what actions would work in the various countries in the European region. In other words, if countries have very little in place in terms of policies on social determinants of health, some action matters. Where there are some existing policies this review shows how these policies can be improved to deal with large and persistent health inequities. In the richest countries of Europe,

Social determinants, human rights, and freedoms

What is perceived as a tension between action on social determinants and individual freedoms has given rise to a vibrant debate. This review calls for social action—but individual freedoms and responsibilities are a feature of the approach taken by the review, drawing on Amartya Sen's insights on freedoms to enable people to lead a life they have reason to value.3 The wider influences of society on the social determinants of individual health are of fundamental importance in enabling people to

Action in a challenging economic climate

The review argues the moral case for action. In many areas, the moral and the economic case for action come together. Investment in early child development and education could meet the demands both of efficiency and justice. As a companion study for Health 2020 notes, prevention is a “good buy”.3 Furthermore, action on social determinants of health leads to other benefits to society, which might in turn have more immediate economic benefits. For example, a more socially cohesive, educated

Perpetuation of inequities across generations

The review makes recommendations on inequities across generations (panel 2). Children's early development, life chances, and ultimately health inequities are strongly influenced by the social and economic background of their parents and grandparents; location, culture, and tradition; education and employment; income and wealth; lifestyle and behaviour; and genetic disposition. Furthermore, morbidities such as obesity and hypertension, as well as behaviours that put health at risk, such as

Conclusions

Persistent and widespread inequities in health occur across the European region. These inequities, both between and within countries, arise from inequities in the distribution of power, money, and resources. As such they are unnecessary and unjust and tackling them should be a high priority at all levels of governance in the region.

Action is needed on the social determinants of health across the life course, in wider social and economic spheres, and to protect future generations.

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