Thursday, 17 May 2012

Marmot: Policy Making With Health Equity at Its Heart

From current issue of JAMA.

Viewpoint | May 16, 2012

Policy Making With Health Equity at Its Heart

Michael G. Marmot, FRCP
Author Affiliation: UCL Institute of Health Equity, University College London, London, England.

In India, there is a cabinet minister for social justice. Would that it were catching, and spread to all government ministers. What a thought: social justice at the heart of all government policy. It would be a radical change from the current set of arrangements, in which many governments are unashamed apostles of self-interest—of their countries, of their partisan supporters or, indeed, of self-interest as a political creed. Given the link between social and economic policy and the health of populations, all ministers should see themselves as ministers of health. Putting these arguments—health and social justice—together implies that health equity should be at the heart of all policy making, national and global.

Economic and financial issues have been dominating global policy making. Health and inequalities in health should feature more strongly. This should be done not to enable physicians or ministers of health to have greater authority, but because economic and social developments have profound effects on health inequalities. Moreover, so crucial are economic and social policy decisions for health and the fair distribution of health, health equity should be an important measure of the effectiveness of social and economic policy making. Progress toward achievement of health equity is a measure of success.

I use the term health equity to have a specific meaning: systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means.1 Therefore any policies that retard action to reduce these avoidable health inequalities are unfair.

Global and national health inequities are substantial—life expectancy varies by almost 40 years between countries. Within countries, too, there are dramatic differences. In the London borough of Westminster, for example, there is a 17-year gap in male life expectancy between the most and least advantaged.2 These inequalities in health within rich countries emphasize that the problem is not simply with the ill-health effects of destitution—serious as they are. More than 40% of the world's population live on US $2 per day or less.3 Few Londoners live on so little, yet there is a stark social gradient in health—the higher the position in the social hierarchy, the better the health. In middle- and low-income countries, similarly, ill-health is not confined to those worst off but there are marked social gradients in health. The implications of the gradient are profound. It means that attention should be focused not only on reduction of poverty, but on improving social and economic conditions across the whole of society to reduce health inequities.

The World Health Organization's Commission on Social Determinants of Health (CSDH) in its report, Closing the Gap in a Generation, stated that such inequities result from inequities in power, money, and resources; a toxic combination of unfair economic arrangements, poor policies and programs, and bad governance are responsible for most of the health inequities in the world.4 In other words, although traditionally efforts to prevent ill health have focused on causes—such as inadequacies in sanitation, nutrition, and shelter in deprived populations, and on unhealthy environments and behaviors among those not deprived—focus should shift to the causes of the causes.

Putting health equity at the heart of policy making is not as utopian as it sounds. The conclusions of the CSDH are that health and health equity are determined by the conditions in which people are born, grow, live, work, and age, and the structural drivers of those conditions. All of these are influenced by economic and social policy. There is fierce debate over economic policy in the face of huge debts faced by rich countries. On one side, the Keynesians argue that to reduce government deficits, a country needs economic growth. On the other side, the notion of expansionary fiscal contraction argues that economic growth will not return until the deficit is reduced by strong fiscal austerity. There are Nobel laureates in economics on the Keynesian side and esteemed economists on the expansionary fiscal contraction side. The criterion of success seems to be return to growth of GDP. This is wholly unsatisfactory. An alternative worthy of consideration is the report of the Commission on the Measurement of Economic Performance and Social Progress (established by the French government and led by Joseph E. Stiglitz, Amartya Sen, and Jean-Paul Fitoussi) that argues for broader measures of social and economic progress than simply GDP.5 Following the commission, I propose that there be examination of the effects of economic policy choices on the lives people are able to lead, and hence the likely effect on health equity.

All over Europe, governments are pursuing the deficit reduction alternative. The result of this economic experiment is great physical and mental illness and possibly death. Fiscal austerity leads to unemployment and unemployment leads people to take their own lives,6 among other health disbenefits. In Greece and Spain, more than 1 person in 5 is unemployed. There is evidence that government social spending can mitigate the effects of unemployment on suicide,7 but the governments of Greece and other European countries are being instructed that the price of debt relief is cutting government spending.

Thus, there is a set of policies in place that, predictably, will increase unemployment and damage health. The Greek population is not pleased by this, judging by recent street demonstrations. A German finance minister mused that it might be a good idea to postpone national elections in Greece to avoid derailing the austerity policies.8 Depriving the population of their democratic rights should not be among the solutions to the Greek crisis.

The CSDH places empowerment at the heart of its policy recommendations to enhance health equity globally: empowerment of individuals, communities, and nations. By having material and social resources to have control over their lives, people can lead lives of dignity. To achieve empowerment, there are recommendations on early child development, education, employment and working conditions, health systems, healthy living places, gender equity, market regulations, and fair financing.

Pursuing policies that create unemployment and reduce social protection makes it far less likely that people can lead lives of dignity. When governments cut social expenditures, the effect is greatest on those at the lower end of the social hierarchy, those who are most dependent on cash and in-kind government expenditures. It should be of the highest priority to ensure that government policies do not unfairly increase avoidable health inequalities.

What applies to policies of governments should also apply to global decision making whether on trade, overseas development assistance, or financial flows—put health equity at the heart of all policy making.

Corresponding Author: Michael G. Marmot, FRCP, UCL Institute of Health Equity, University College London, 1-19 Torrington Pl, London WC1E 6BT, England (

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Marmot M, Allen J, Bell R, Goldblatt P. Building of the global movement for health equity: from Santiago to Rio and beyond. Lancet. 2012;379(9811):181-188
London Health Observatory. Marmot indicators for local authorities in England, 2012. Accessibility verified April 23, 2012
Chen S, Ravallion M. An Update to the World Bank's Estimates of Consumption Povery in the Developing World: Briefing Note. Washington, DC: Development Research Group, World Bank; 2012
Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Final Report. Geneva, Switzerland: World Health Organization; 2008
Stiglitz JE, Sen A, Fitoussi J-P. Report by the Commission on the Measurement of Economic Performance and Social Progress. Accessibility verified April 23, 2012
Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet. 2011;378(9786):124-125
Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet. 2009;374(9686):315-323
Hope K, Spiegel P. Greek rhetoric turns into a battle of wills. Financial Times. February 16, 2012

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