Elsevier

The Lancet

Volume 372, Issue 9650, 8–14 November 2008, Pages 1661-1669
The Lancet

Public Health
Closing the gap in a generation: health equity through action on the social determinants of health

https://doi.org/10.1016/S0140-6736(08)61690-6Get rights and content

Summary

The Commission on Social Determinants of Health, created to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it, is a global collaboration of policy makers, researchers, and civil society, led by commissioners with a unique blend of political, academic, and advocacy experience. The focus of attention is on countries at all levels of income and development. The commission launched its final report on August 28, 2008. This paper summarises the key findings and recommendations; the full list is in the final report.

Introduction

Life chances differ greatly depending on where people are born and raised. A person who has been born and lives in Japan or Sweden can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in several African countries, less than 50 years. Within countries, the differences in life chances are also great. The poorest people have high levels of illness and premature mortality—but poor health is not confined to those who are worst off. At all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

If systematic differences in health for different groups of people are avoidable by reasonable action, their existence is, quite simply, unfair. We call this imbalance health inequity. Social injustice is killing people on a grand scale, and the reduction of health inequities, between and within countries, is an ethical imperative.

Section snippets

Social determinants of health and health equity

The commission took a holistic view of social determinants of health.1 The poor health of poor people, the social gradient in health within countries, and the substantial health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people's lives—their access to health care and education, their conditions of work and leisure, their homes,

A new approach to development

Health and health equity might not be the aim of all social and economic policies, but they will be a fundamental result. For example, economic growth is, without question, important, particularly for poor countries, because it gives the opportunity to provide resources to invest in improvement of the lives of their populations. But growth by itself, without appropriate social policies to ensure reasonable fairness in the way its benefits are distributed, brings little benefit to health equity.

Closing the health gap in a generation

The Commission on Social Determinants of Health calls for the closing of the health gap in a generation: this is an aspiration not a prediction. Great improvements in health, worldwide and within countries, have been made in the past 30 years. We are optimistic that the knowledge exists to continue to make a huge difference to people's life chances and hence to provide improved health equity. We are also realistic and know that action must start now.

The commission's analysis leads to three

Equity from the start

Investment during the early years of life has some of the greatest potential to reduce health inequities within a generation. Child survival, rightly, has been a focus of worldwide interest. The Commission on Social Determinants of Health has gone further and emphasised the importance of early child development, including not only physical and cognitive or linguistic development but also, crucially, social and emotional development. Early child development affects subsequent life chances

Health equity in all policies, systems, and programmes

Every feature of government and the economy has the potential to affect health and health equity. Coherent action across government—including finance, education, housing, employment, transport, and health—at all levels, is essential for improving health equity.30 Traffic injury, a major public-health issue, is an example of where action must come from outside the health sector. Legislation for the mandatory wearing of helmets by cyclists reduced bicyle-related head and other injuries in Canada

Understand the problem and evaluate action

Action on the social determinants of health will be more effective if basic data systems are in place and there are mechanisms to ensure that the data can be understood and applied to develop more effective policies, systems, and programmes. Education and training in social determinants of health are essential.

Lack of data often means that problems are unrecognised. Good evidence on levels of health and its distribution, and on the social determinants of health, is essential for the scale of

Conclusion

Is closing the gap in a generation possible? This question has two clear answers. If we continue as we are, there is no chance at all. If there is a genuine desire to change, if there is a vision to create a better and fairer world where people's life chances and their health will no longer be blighted by the accident of where they happen to be born, the colour of their skin, or the lack of opportunities afforded to their parents, then the answer is: we could go a long way towards it.

Action can

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