Sir Michael Marmot Keynote speech

Global Context for Health Equity
UCL October 2024
@MichaelMarmot
http://www.instituteofhealthequity.org
Why treat people and send them back to the conditions that
made them sick?
1948
WHO
Constitution
Universal
Declaration
human rights
1978
Alma
Ata
Health for all
album25
2008
Commission on
Social Determinants
of
Health
WHO
PHC report
Movement for
health equity
Social Justice
Empowerment
•Material
•Psychosocial
•political
Creating conditions for
people to lead flourishing
lives
The Commission on
Social Determinants of
Health (CSDH) – Closing
the gap in a generation
Strategic Review of Health
Inequalities in England:
The Marmot Review – Fair
Society Healthy Lives
Review of Social
Determinants of Health and
the Health Divide in the
WHO European Region
CSDH Conceptual Framework
SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES
SOCIOECONOMIC
& POLITICAL
CONTEXT
Governance
Policy
Macroeconomic
Social
Health
Cultural and
Societal norms
and values
Education
Occupation
Income
Gender
Ethnicity / Race
Social Position
Material Circumstances
Social Cohesion
Psychosocial Factors
Behaviours
Biological Factors
Health Care System
DISTRIBUTION
OF HEALTH
AND
WELL-BEING
Source: CSDH Final Report, WHO 2008, adapted from Solar & Irwin, 2007
The UK Context
Life expectancy at birth, England, 1999-2001 to 2020-22
Source: ONS (2024) National life tables; England
A decade+ of
austerity
George Osborne still defends the legacy of Austerity
• “There’s a simple truth, if you have a very large crash or economic
crisis, the country pays the price…
• The basic truth… a country has to live within its means…
• The economic policies we pursued after 2010 meant that we
actually had the strongest growth in the G7, more jobs were
created… there’s a lot to be proud of. Britain in 2016 was
buzzing… people were looking at the UK and saying that’s the
example we want to follow.”
Source: The Rest is Politics –
Leading
11
12
Public sector expenditure (% of GDP) declined in the UK
13
0
5
10
15
20
25
30
35
40
45
50
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21
Percent
Social protection
Education
Recreation, culture and
religion
Health
Housing and community
amenities
Environment protection
Economic affairs
Public order and safety
Defence
General public services
Proportionate
Universalism
Change in government funding per head of population by 2019/20 by male
life expectancy in 2010-12, local authorities in England
Source: NAO (2023 and ONS (2024)
Health
Inequalities, Lives
Cut Short
Excess deaths in each quintile of area deprivations, based on the Index of
Multiple Deprivation, by sex, England, 2011-2019
Source: ONS population estimates and death rates for deprivation deciles in England
Note: See statistical appendix Health Inequalities, Lives Cut Short (2024) for method of calculation of excess deaths
Excess deaths in each decile of area deprivations, based on the Index of
Multiple Deprivation, by sex, England, 2011-2019
Source: ONS population estimates and death rates for deprivation deciles in England
Note: See statistical appendix Health Inequalities, Lives Cut Short (2024) for method of calculation of excess deaths
Excess deaths in each year 2009 to 2020, based on area deprivation deciles
using the Index of Multiple Deprivation
Source: ONS population estimates and death rates for deprivation deciles in England
Note: See statistical appendix Health Inequalities, Lives Cut Short (2024) for method of calculation of excess deaths
England’s
widening health
gap: local places
falling behind
Change in spending power per head of population by source, England,
2010/11-2019/20
Source: NAO (2021) Financial sustainability
of local authorities visualisation: update
Healthy life expectancy by sex and region, 2017-19
Source: ONS (2024) All data related to Health state life expectancies in England,
Northern Ireland and Wales: between 2011 to 2013 and 2020 to 2022
Report of Commission of the Pan American Health Organization on
Equity and Health Inequalities in the Americas
Life expectancy at birth by
gross domestic product, 2016 or latest
56th Directing Council
Washington, D.C., 23 –
27 September 2018
Inequalities in mortality in US & Costa Rica 1990s
Source: Roserio-Bixby and Dow, PNAS 2016
26
27
28
Social inequalities in cardiovascular deaths at ages 45 – 64:
Porto Alegre, Brazil
CVD deaths per 100,000
inhabitants
Socioeconomic level of districts
Source: Bassanesi, Azambuja & Achutti, Arq Bras Cardiol, 2008
BUILD BACK FAIRER ACHIEVING HEALTH EQUITY IN THE EASTERN
MEDITERRANEAN REGION
• Report of the Commission on Social Determinants of Health in the
Eastern Mediterranean Region
• March 2021
Framework for the social determinants of health
Do something, do more do better: Taking action
Governance and political cultures
Policies
Research and monitoring
Structural Drivers
Conflict and
Consequences
Economic and
commercial
Culture and society
The natural
environment
Conditions of Daily Life
Maternal and child health, Early
years, Education
Employment and quality of work
Healthy Aging
Built environment
Health systems
Health
equity and
dignified
lives
Stratifiers: Position of migrants, refugees and gender
Life expectancy by Gross National Income (2019)
Afghanistan
Yemen
Sudan
Pakistan
Djibouti
Morocco
Jordan
Tunisia
Iraq
Egypt
Iran (Islamic Republic
of)
Lebanon
Libya
Oman
Bahrain
Saudi Arabia
Kuwait
United Arab Emirates
Qatar
Syrian Arab Republic
60
65
70
75
80
85
0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000 100 000
Life expectancy
at birth (years)
GNI per capita (2017 PPP $)
Note: No GNI per capita data available for Somalia and occupied Palestinian territory
Source: UNDP Human Development Report (2020) and WHO Global Health Observatory Data Repository
(2020)
33
Give Every Child
the Best Start
Child poverty rates 2019-2021
Source: UNICEF Innocenti
0 5 10 15 20 25 30 35 40
Colombia
United States
Italy
United Kingdom
Portugal
Switzerland
Sweden
Australia
Germany
Ireland
Norway
Denmark
Children in relative income poverty (%)
Change in child income poverty rates, 2012-2014 to 2019-2021
Source: UNICEF Innocenti
-50 -40 -30 -20 -10 0 10 20
United Kingdom
Norway
France
Germany
Australia
Italy
United States
Mexico
New Zealand
Ireland
Canada
Poland
Proportional change in child income poverty rate (%)
Public spending early child education and care
37
OECD Family Database
Mean performance in reading, by international decile of
socio-economic status
0
100
200
300
400
500
600
700
France OECD Average US Hong Kong Macao UK Israel
Bottom decile Second decile Middle decile Ninth decile Top decile
38
PISA, 2018
Gap in life expectancy at age 30 between people with the highest and lowest
level of education, 2017 (or nearest year)
Effects of cash transfer programmes on mortality
Source: Richterman, A., Millien, C., Bair, E.F. et al.
(2023)
41
44%
90%
69%
43%
31%
29%
24%
21%
14%
28%
6%
18%
31%
26%
39%
40%
33%
53%
20%
4%
7%
20%
28%
26%
23%
39%
28%
8%
0%
6%
6%
15%
6%
13%
7%
5%
GLOBAL AVERAGE
NIGERIA
PAKISTAN
UNITED STATED
UNITED KINGDOM
HUNGARY
FRANCE
SWEDEN
SLOVENIA
DO YOU THINK CHILDREN TODAY WILL HAVE A BETTER, WORSE OF
ROUGHLY THE SAME LIFE TO YOU?
A better life A worse life Roughly the same DK/NR
Source: Gallup
Social mobility: How many generations does it take to go from low income to middle
income in different countries
42
Source: OECD
COVID-19
Age-standardised mortality rates from all causes, COVID-19 and other causes per
100,000, by sex and deprivation deciles (IMD 2019), England, Mar 2020 – Apr 2021
44
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Age standardised mortality rate (per 100,000)
All causes
Due to COVID-19
Other causes than COVID-19
Female
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Age standardised mortality rate (per 100,000)
All causes
Due to COVID-19
Other causes than COVID-19
Male
Change in LE, 2019-21, US and 19 peer countries
45
Masters, Aron and Woolf medRxiv preprint April 29, 2022
Impacts of Covid on life expectancy by ethnicity in New York
Source: UNAIDS
Source: UNAIDS
Taking action
51
Health Equity/Marmot Places – 40+ local authorities
• Coventry
• Greater Manchester
• Cheshire and Merseyside
• Lancashire and Cumbria
• Luton
• Waltham Forest
• Gwent
• Leeds
• Southwest region
• Wokingham
• Medway
• Northumberland
Scotland x national plus 3
places
October 2024
• Kent
• Oxford
• West Norfolk
• 5 places in the pipeline
Within places and nationally – sectoral action:
• Local Government – engine of change in places
• Health Care – moving to the causes of the causes of ill health
• The VCS – representing, delivering services and supporting
• Public services – education, CJS, transport
• Business and the private sector – employees, goods and services,
social impact
• National government and national institutions
Key partners:
Businesses
How businesses shape health: the IHE Framework
Key partners:
Health care
• The East London Foundation Trust
• Three Integrated Care Systems
• Workforce
• The NHS and accountability for health inequalities
Our service users The wider Luton
community
ELFT as a training
& employment
provider
Universal
Targeted
Partner with VCS
organisations to conduct
community outreach for
employment support to
vulnerable groups
Engage with young people to
raise aspiration and promote
access to healthcare careers
ELFT’s Marmot Mountain: Potential actions in line with our vision
Establishing good working relationships with community partners & employers
Bring meaningful employment &
apprenticeship opportunities to
local people
Promote access to employment &
apprenticeships at ELFT for SUs
and other disadvantaged groups by
addressing potential barriers in our
recruitment processes
Provide training/a skills academy
for local people for jobs in health
and social care
Improve SU satisfaction with
employment support services
provided by ELFT
Monitor and increase the
number of SUs supported
into good employment
Engage with public & private sector
employers to advocate for good quality
work, mentally healthy workplaces &
equitable access to volunteering and
employment opportunities
Marmot Places
“Once the ICB and the Health and
Care Partnership went live in July
2022 it started to bring together
people and organisations focusing
on health inequalities, then the
recommendations that came out
of Cheshire and Merseyside’s All
Together Fairer Partnership, in
effect, gave us our action plan for
the next 5-10 years.”
“Being a Marmot Place brings stakeholders together around health equity
and is a part of our journey to the Luton town-wide 2040 vision. You could
almost overlay the Marmot Eight Principles onto the vision.”
“Making Manchester Fairer, which began out of the Greater Manchester
Marmot Review, is owned by all partners, focuses on the wider
determinants of health and is the beginning of a long-term ambition to
put health inequalities and health equity at the forefront of people’s
minds.”
“If central government said the whole country was to
become a Marmot Country it would be very helpful
because then council leaders would understand that
we have to stop working in silos and bring all sectors
together around the health equity system.”
“Partners advocate for ‘living’the Marmot
Principles as a culture and value base, working
together to embed equity in all policies. At times
teams may not recognise their work has
contributed to the Marmot approach, even when it
does.”
The future of Marmot places?
« The next Labour government…will amplify the approach of
‘Marmot Cities’ like Greater Manchester and Coventry by making
England a Marmot country, tackling the social inequalities that
influence health. We will ensure that children have the best start
possible to give them the building blocks for a healthy life, build
on Labour’s legacy towards a smoke-free Britain, and empower
people to take responsibility for their own health. »
“Rise up with me
…
against the organisation of misery.”
From: The Banner by
Pablo Neruda