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Review of social determinants and the health divide in the WHO European Region: final report

This study 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 European policy framework for health and well-being, Health 2020 (1). 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 (2). This European study builds on the global evidence.

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-, middle- 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 review comes at an important moment in European history. The Region includes countries with close to the best health and narrowest health inequities in the world. The 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, increasingly affluent, with developed welfare states and high-quality education and health services. All these have created the conditions for people to have the freedom to lead lives they have reason to value. Remarkable health 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. 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. The economic crisis since 2008, more profound and extended than most people 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.

This review 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 to addressing health inequities open to all is to ensure universal coverage of health care. Another is to focus on behaviour – smoking, diet and alcohol – that cause much of these health inequities but are also socially determined. The review endorses both these responses. But the review recommendations 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 them.