The magnitude of the unnecessary ill health and death caused by social factors and widening inequalities give priority to reducing poverty and achieving the Millennium Development Goals (11) (see p. 47). In this context, WHO has re-emphasized that interventions succeed in reducing disease and saving lives only when they take adequate account of the social determinants of health (10). Although much is known about these causes of the causes of ill health, this knowledge still needs further development, consolidation and communication, so that more effective action can follow. To meet this need, WHO launched the Commission on Social Determinants of Health in March 2005; its task is to develop practical recommendations on how to improve health by acting on its social determinants, for presentation in 2008 (81).
Need to tackle poverty and inequality
The most effective way to protect and improve child health in all countries is to eliminate poverty, socioeconomic inequality and their consequences (58). The health effects of material deprivation – for example, poor nutrition, unhealthy environments and lack of access to high-quality health care – have been discussed. Although absolute poverty that directly threatens people’s lives has almost been eliminated in the more affluent countries in the Region, relative poverty remains, in which certain members of society do not enjoy the living standards available to their fellow citizens. Any attempt to define overall poverty needs therefore to take account of both absolute and relative poverty.
In the low- and middle-income countries in the eastern half of the Region, absolute child poverty is frequently observed, but appropriate individual-level statistics are difficult to obtain.
As an alternative, UNICEF (82) assessed the risks of poverty for children at the macro level, defining it as a gross national income (GNI) per head of US$ 765 or less in 2003, or a stagnant or negative average annual growth rate in GDP per head in 1990–2003. Six CIS countries were assessed to have met the criteria for poverty as a threat to childhood around 2003: Georgia, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. The UNICEF report
(82) emphasizes, however, that poverty is more than material deprivation and has different dimensions and implications in children than adults.
As one moves westward, towards the higher-income countries in the Region, the form and statistical indicators of poverty change. A 2005 review of child poverty in rich countries by UNICEF (83) found that the proportion of children aged under 18 years living in relative poverty in the industrialized world actually rose over the last decade, no matter which of the commonly used measures of poverty was applied. Fig. 11 shows the percentage of children living in relative poverty (households with income below 50% of the national median income) in 20 countries in the Region designated as affluent by UNICEF.
Fig. 11 shows rates of child poverty ranging from under 5% in Scandinavia to over 15% in Ireland, Italy and the United Kingdom. Such variation reflects differences in national policies, interacting with social changes. Higher government spending on family and social benefits is clearly associated with lower rates of child poverty. In the countries with the lowest levels, governments reduce by 80% or more the child poverty that would result from leaving market forces to themselves (83).
Moreover, there is a social gradient in health from the poorest to the richest. Where material deprivation is severe, a social gradient could arise from degrees of absolute deprivation, but the gradient in the more affluent countries reflects relative deprivation, which restricts people’s right to realize their health potential in terms of capabilities and functioning. Both physical and psychosocial needs are therefore likely to be important to the gradient in health (84).
In particular, there is strong evidence that diet, smoking, alcohol use and physical activity are associated with social and economic circumstances, and ultimately with health outcomes
Fig. 11. Children living in relative poverty in selected affluent countries in the WHO European Region, 2005
0 2 4 6 8 10 12 14 16 18
16.6 15.7 15.6 15.4 13.3
12.7 12.4 10.2
10.2 9.8 9.1 8.8 7.7 7.5 6.8 6.8 4.2
3.4 2.8 2.4 Italy
Ireland Portugal United Kingdom Spain Poland Greece Germany Austria Netherlands Luxembourg Hungary Belgium France Switzerland Czech Republic Sweden Norway Finland Denmark
Percentage Source: data from UNICEF
Innocenti Research Centre (83).
in adults. As far as children’s health is concerned, solid knowledge is available on the role of the proximate determinants of children’s health (9), especially in mortality, malnutrition and other problems in early childhood. The causes of the disparities in these proximate determinants are clear: social inequalities, which interact with other determinants. In addition, the evidence suggests that some mental health problems – such as aggressive behaviour, low self-esteem and inability to cope with life’s challenges – are indirectly related to low socioeconomic status.
Thus, socioeconomic conditions may also influence health through the psychosocial impact of relative poverty.
Taking action on the social determinants of health is imperative for all countries. Such action should include the relief of poverty but also pursue the broader aim of improving people’s living and working conditions. The task also requires knowledge of the health effects of the social and economic policies of all sectors that can be translated into action; the WHO Commission on Social Determinants of Health is expected to add to this knowledge. While the health sector will continue to have a pivotal role, action is required from many sectors of government and society.
Health is a multisectoral endeavour, which will yield multisectoral benefits. The aim is to make healthy choices the easier choices for people to make.
Making effective policy depends on a number of factors, which determine the usefulness, effectiveness and efficiency of any subsequent plans for implementation. Evidence-based policy is now more feasible than ever before. A number of recurring themes emerge from the knowledge about how best to improve the health and development opportunities for children.
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Accurate and reliable information must provide the basis for planning, monitoring and evaluation of policies and programmes.•
Policy without implementation is meaningless.The capacity to deliver must be considered when policy is formulated.