Concepts and principles for tackling social inequities in ...

1 Concepts and principles for tackling social inequities in health : Levelling up part 1. World health Organization Regional Office for Europe Concepts and principles for Scherfigsvej 8, DK-2100 Copenhagen , Denmark tackling social inequities in health : Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. Levelling up Part 1. E-mail: Web site: Margaret Whitehead G ran Dahlgren WHO Collaborating Centre for Policy Research on social Determinants of health University of Liverpool Studies on social and economic determinants of population health , No. 2. WHOLIS E89383. Concepts and principles for tackling social inequities in health : Levelling up Part 1. Margaret Whitehead G ran Dahlgren The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves.

2 The European Region embraces some 870. million people living in an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of the Russian Federation. The European programme of WHO therefore concentrates both on the problems associated with industrial and post-industrial society and on those faced by the emerging democracies of central and eastern Europe and the former USSR. To ensure the widest possible availability of authoritative information and guidance on health matters, WHO secures broad international distribution of its publications and encourages their translation and adaptation. By helping to promote and protect health and prevent and control disease, WHO's books contribute to achieving the Organization's principal objective the attainment by all people of the highest possible level of health .

3 WHO European Office for Investment for health and Development The WHO European Office for Investment for health and Development, which coordinated the activities leading to this publication, was set up by the WHO. Regional Office for Europe, with cooperation and support from the Ministry of health and the Veneto Region of Italy. One of its key responsibilities is to provide evidence on and act upon the social and economic determinants of health . The Office systematically reviews what is involved in drawing together the Concepts , scientific evidence, technology and policy action necessary to achieve effective investment for the promotion of health and synergy between social , economic and health development.

4 The Office fulfils two interrelated main functions: to monitor, review and systematize the policy implications of the social and economic determinants of population health ;. and to provide services to help Member States in the WHO European Region increase their capacity to invest in health by addressing these policy implications and integrating them into the agenda for development. Concepts and principles for tackling social inequities in health : Levelling up Part 1. Margaret Whitehead G ran Dahlgren Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8. DK-2100 Copenhagen , Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site ( ).

5 World health Organization 2006, reprinted 2007. All rights reserved. The Regional Office for Europe of the World health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World health Organization in preference to others of a similar nature that are not mentioned.

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7 DELIVERY OF health CARE ECONOMICS, MEDICAL . health POLICY EUROPE. Contents V. CONTENTS. Acknowledgements VII. Foreword VII. Part A: Concepts 1. What is the difference between variations in health and social 2. inequities in health ? Fairness and human rights 3. Inequality and inequity are synonymous 4. So what is equity in health ? 5. Widespread inequities throughout Europe 5. A widening health divide 5. The phenomenon of the social gradient 7. social inequities in access to health services 8. What does inequitable health care look like? 11. Different goals for equity in health and in health care 12. Part B: Ten principles for policy action 15. 1. Policies should strive to level up, not level down 16.

8 2. The three main approaches to reducing social inequities in 16. health are interdependent 3. The dual purpose of promoting health gains and reducing 18. health inequities 4. Actions to tackle the social determinants of health inequities 18. 5. The possibility of actions doing harm must be monitored 19. VI Concepts and principles for tackling social inequities in health : Levelling up Part 1. 6. The selection of appropriate tools for measuring and 20. monitoring 7. Giving voice to the voiceless 20. 8. Analysing social equities in health separately for men and for 21. women 9. Relating differences in health by ethnic background or 22. geography to socioeconomic background 10. Building health systems on equity principles 22.

9 Summary 23. References 25. Annex: Relative and absolute measures 33. Acknowledgements VII. ACKNOWLEDGEMENTS. This report was prepared in close cooperation with senior staff of the WHO. European Office for Investment for health and Development in Venice and with advice from their Expert Group on Poverty, health Inequalities and Related social and Economic Determinants of health . Drafts of this paper, and its companion paper on strategies, have been presented at various meetings of WHO staff and at European consultations held in the Venice Office for advice. These drafts have also been subjected to anonymous peer reviews. Revisions have been made according to the comments gratefully received, but the authors alone are responsible for the final text and any errors it contains.

10 We are grateful to Jerome M. Rosen for copy editing and to Antonella Biasiotto and Cristina Comunian for administrative support. VIII Concepts and principles for tackling social inequities in health : Levelling up Part 1. FOREWORD. In 1990, the WHO Regional Office for Europe published two technical documents: The Concepts and principles of equity and health (Whitehead, 1990), followed by a companion paper on policies and strategies (Dahlgren & Whitehead, 1992). The purpose of both documents was to clarify the concept of equity, in the context of health , and its implications for policy development in this field. These documents were intended for a non-technical audience of policy-makers and practitioners.