Tackling health inequalities on all levels

Where you live and your ethnic and socio-economic background can have a big impact on your health and how long you are likely to live. We look at some of the ways in which these so-called health inequalities can be tackled on both local and worldwide scales.

Health inequalities are often mentioned by health professionals, epidemiologists and policy makers – but what exactly are they? They’re essentially the unfair and avoidable differences in health across the population, and between different groups within society.

The term ‘health inequalities’ can also mean the differences between the healthcare people receive, how much access they have to health services, their experience of the care and its quality, and the opportunities (or the lack of them) people have to lead healthy lives.

The conditions in which we are born, grow, live, work and age – referred to by public health professionals as the ‘wider determinants of health’ – are strongly linked with health inequalities.

Also important are the ‘social determinants of health’: the economic and social conditions that shape individual people’s health and group differences in health. Rather than behavioural risk factors (eg smoking, alcohol or exercise), the social determinants of health include the unequal distribution of wealth and power and are often factors that can be shaped by public policy.

Global disparities in health 

What are some of the health inequalities that exist worldwide? According to the World Health Organization (WHO), there is a 34-year difference in life expectancy between the wealthiest and poorest countries in the world. In low-income countries, the average life expectancy is 62, while in high-income countries it’s 81. For example, a child born in Japan can expect to live 84 years, whereas their counterparts born in Sierra Leone can expect to live for just 50 years.

Some other striking findings from WHO data include:

• 16,000 young children die every day, with lives claimed by treatable and preventable diseases such as pneumonia, malaria, diarrhoea. In sub-Saharan Africa, children are 14 times more likely than their peers in the rest of the world to die before their fifth birthday.
• Maternal mortality is the ‘canary in the coalmine’ for health inequalities. Deaths of mothers are a health indicator for the huge disparities between rich and poor, both between and within countries. Of all mothers who die each year, 99% are in developing countries. For example, a mother in Chad’s odds of dying are one in 16, while a Swedish mother faces a risk of less than one in 10,000.
• The lion’s share (87%) of premature deaths from cardiovascular disease, obesity, diabetes and other so-called ‘non-communicable diseases (NCDs)’ happen in low- and middle-income countries (LMICs). Exorbitant healthcare costs for these diseases can push millions of people into poverty, harming economic development.
• Health inequities are a huge financial burden: The European Parliament has estimated that losses linked to health inequities – such as through losses in productivity, tax, and the cost of welfare payments and healthcare – costs around 1.4% of GDP within the EU; almost as high as the EU’s total spend on defence.

National and local health inequalities

Health inequalities exist on all scales, from the global level, down to national levels and even down to the local level of individual cities, or marginalised communities. For example, there are health inequalities between Scotland and England, Wales and Northern Ireland within the UK, despite all being served by the National Health Service (NHS) healthcare system. 

Life expectancy and access to healthcare can vary dramatically between wealthy and lower income postcodes or within different communities living in the same place, such as people with disabilities, different ethnic groups or biases between genders. For example:

• In the UK, twice as many women die of coronary heart disease each year than of breast cancer, yet women aren’t always aware of this risk and can delay seeking urgent medical help. Even those who do seek help are more likely than men to be given the wrong initial diagnosis, and less likely than men to be prescribed drugs to prevent further heart attacks, according to British Heart Foundation research.
• In the USA, African Americans make up around 13% of the population but account for nearly 50% of all new HIV infections – without any evidence of any underlying biological or genetic cause within black population groups to account for the increased morbidity in this group, according to the WHO.
• Men from the most deprived areas of Ruchill and Possilpark in Glasgow have a life expectancy of 66.2 years, whereas in the well-heeled Cathcart and Simshill areas of the city, male life expectancy is 81.7 years – a difference of 15.4 years just within the boundaries of a single city.
• A year of life expectancy is lost for the local communities at each London tube stop as you travel east from Westminster, according to the London Health Observatory’s findings.

Some strategies to address health inequalities

Case study: a national approach

In 2010, the Marmot Review, ‘Fair Society, Healthy Lives’ was published. This landmark independent review reported on health inequalities in England led by Professor Sir Michael Marmot, an internationally recognised British expert on the social determinants of health and on health inequalities. A 10-year follow-up report in 2020 showed that in the intervening years, life expectancy in the country had stalled, for the first time in at least 100 years.

The review recommended a range of urgent actions and policy changes that could tackle health inequalities and reduce them, including:

• Intervening as early as possible to give every child the best start in life and young people the greatest capabilities, along with a healthy standard of living, fair employment and good work for all.
• Creating and developing a national strategy for action on the social determinants of health, aiming to reduce inequalities in health.
• Developing country-wide interventions and policy implementation that can be ‘dialled up’ in intensity in areas of highest need (such as in the North East of England), raising overall levels of health and flattening the ‘social gradient’.
• Engaging the public with health inequalities. The review recommended moving away from a focus on individual health behaviours and healthcare in public and political debate and re-focusing initiatives and investment on the social determinants of poor health and good health.
• Developing ways to monitor the whole system and accountability for health inequalities. Monitoring is essential for progress and National Government needs to be accountable for health inequalities, and for the range of policies outside the health care sector that are needed to address the problem.

Responding to the challenges highlighted in the report, NHS England has five key priority areas within its ‘Core20plus5’ approach to address health inequalities which underpin the National Healthcare Inequalities Improvement Programme: to restore post-pandemic NHS services inclusively; prevent digital exclusion; ensure ethnicity datasets are complete and timely; accelerate preventative programmes that engage groups of people with the greatest risk factors for ill health; and to strengthen leadership and accountability.

Case study: a global approach

To tackle health inequalities effectively it’s essential to gather more data for the best, evidence-based policy decision-making. To this end, in April 2023 the World Health Organization launched the Health Inequality Data Repository (HIDR); the most comprehensive publicly available global collection of disaggregated data and evidence on population health. Its data allows stakeholders to track health inequalities across population groups and over time, by breaking down data according to group characteristics, such as education level or ethnicity.

Data on over 2000 indicators are included on topics including the sustainable development goals (SDGs) to Covid-19, maternal child health, malaria and tuberculosis, broken down by 22 dimensions of inequality, including demographic, socio-economic and geographical factors.

Announcing its launch, Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said: “The ability to direct services to those who need them the most is vital to advancing health equity and improving lives. Designed as a one-stop-shop for data on health inequality, the Repository will help us move beyond only counting births and deaths, to disaggregating health data according to sex, age, education, region and more. If we are truly committed to leaving no one behind, we must figure out who is being missed.”

There’s some good news in the data: they show that in just a decade, the rich-poor gap in health service coverage among women, newborns and children in low- and middle-income countries has nearly halved. The data also provide the evidence to show that in these countries, eliminating wealth-related inequality in mortality rates for the under-fives could help save the lives of 1.8 million children.

The WHO is now calling on countries to routinely monitor health inequality, make data publicly available, expand data collection and analyse and report it regularly, with health inequality monitoring integrated into global and national goals, indicators and targets.

Be part of the solution to tomorrow’s global health challenges

From global health inequalities to infectious disease outbreaks, the 100% online, fully flexible MSc Global Health at Queen Margaret University provides a grounding in the theoretical and professional analysis of the most important issues in global health and development. Study on this master’s degree and you will deepen your understanding of the links between health and development, the social determinants upon which health and wellbeing depend, and the importance of coupling evidence-based strategies with interventions that are grounded in local realities. You’ll take part in critical debate on the positives and negatives of development, public health, equity, quality and health outcomes for people and the communities in which they live; a key part of the UN SDGs and global health. Further information