highest mortality rate from all causes. Meanwhile, the Southern district, a leafy, spacious suburb of predominantly wealthy, white English speakers, has the lowest mortality rate from all causes. Notably, in all districts of Cape Town, non-communicable diseases account for a higher proportion of deaths than communicable diseases, including HIV/AIDS. Deaths from injuries exceed deaths from HIV/AIDS. It is not just poor health for the poor; where there is data, we see a gradient in health from the top to the bottom of the social hierarchy. Inequities in health are also evident by gender, race and ethnicity, between indigenous groups and the population as a whole, and by area of residence (e.g. urban/rural). Reducing incountry health inequalities would accelerate progress in average life expectancy gains in Commonwealth countries. Strategies Health inequities arise from inequalities in the conditions in which people are born, grow, live, work and age, and the underlying unequal distribution of power, money and resources that drive these inequalities (CSDH, 2008). Social disadvantage in early life affects health at older ages. The CSDH took the position that health inequalities that are avoidable by reasonable means are inequitable, and that addressing these inequities in health is a matter of social justice. The CSDH recommended holistic action across government and society on the economic, political, environmental and cultural determinants of health, which together comprise the social determinants of health (SDH). Countries and local regions around the world are taking action on SDH, but progress remains highly variable (Marmot, 2012). The phrase ‘do something, do more, do better’ used by the WHO European Review of Social Determinants and the Health Divide (WHO/Europe, 2013) applies equally to Commonwealth countries. By this we mean that where there is very little coherent strategic action on SDH – do something; where some action is happening – do more; where policies and interventions are in place – do better. Measurement and monitoring can drive equity Measurement and monitoring can drive equity. Typically, though, there is an information paradox – less data is available and analysed where the need for action on SDH is greater. Yet everywhere policy-makers need good quality information on health and social determinants of health. There is a need to measure what matters: civil registration (including births and deaths as a minimum), access to health care, communicable and non-communicable disease rates, and causes of death. There is also the need to measure and monitor social determinants of health. Where action on SDH is implemented – for example to increase access to quality education, a key determinant of health – there is a need to know the impact of action, in this example of education, whether inequalities in educational attainment are being reduced as a result, and not just how many more children are enrolling in school, important though this information is. S o c i a l d e t e rmi n a n t s a n d h e a l t h y a g e i n g Context matters Inequalities are at the heart of the current global development discourse. The proposed post-2015 Sustainable Development Goals include equality-focused targets for poverty and hunger, health, education and lifelong learning, gender, water and sanitation, economic growth, employment and decent work, cities and human settlements, justice and society, as well as a specific goal to reduce inequality within and among countries (UN, 2014). Inequalities in wealth and income are a prominent feature of the economic landscape in countries around the world. Where there is lack or inadequate public provision of services and social protection systems, inequalities in income and wealth all too often translate into unequal access to nutritious food, clean water and sanitation, quality education, secure employment opportunities, health care and decent housing. These social inequalities drive inequities in healthy ageing. Those groups whose wealth and incomes fail to keep pace with others in society are at risk from becoming excluded from the social and health benefits that increasing national prosperity brings. They are also at greater risk from environmental disasters, extreme weather conditions and global financial crises. Policy implications Countries at all stages of development need to adapt to the demographic transition: to have policies in place to ensure that the needs of older people are met, that their human rights are respected, and that they are enabled to live fulfilling lives and participate in society. Staying healthy at older ages depends on the conditions experienced across the life course as well as present living conditions, and access to good quality health care and preventive services. Reviews of the social determinants of health advocate coherent, integrated action across the life course to prevent the accumulation of disadvantage that leads to inequalities in healthy ageing (CSDH, 2008; Marmot Review Team, 2010; IHE, 2013). It is a matter of human rights and social justice that all countries develop policies that support current and future cohorts of older people. It is also a matter of universal enlightened self-interest – everyone is ageing and many of us hope to reach older ages and enjoy good health. The cost in human lives of doing nothing to reduce health inequities is enormous – in the UK, 2.6 million years of life are potentially lost to health inequities (Marmot Review Team, 2010). The economic costs of health inequities are potentially large, but depend on the country context. It has been estimated that in the UK illnesses associated with health inequities account for productivity losses of £31 billion to £33 billion per year, lost taxes and higher welfare payments in the range of £20 billion to £32 billion per year, and additional National Health Service costs well in excess of £5.5 billion per year (ibid). As governments around the world consider what universal health coverage means in their own national contexts, the health and well-being of present and future generations of their older citizens must be integral to their plans. Financial barriers to access to health care for older people need to be addressed. Early preventive action to delay the onset of mental and physical disabilities associated with ageing should be a planning priority in order to enable older people to live healthy, active and independent lives for longer. Commonwealth Health Partnerships 2015 19
Commonwealth Health Partnerships 2015
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