Closing the Gap in a Generation – Executive Summary Notes

Commission Overview

  • Origins & Mandate
    • Set up by WHO in 2005 to: marshal evidence, recommend action, and catalyze a global movement for health equity.
    • Final Report (Executive Summary) released 2008; product of policy-makers, researchers, civil-society leaders from both Global North & South.
  • Ethical Stance
    • Health inequity = a social injustice; “Social injustice is killing people on a grand scale.”
    • Inequities judged avoidable by reasonable action are deemed unfair and unethical.
  • Scale of the Problem
    • New-born girl’s life expectancy: >80 yrs (Japan/Sweden) vs <45 yrs (some African states).
    • Within nations, a social gradient: lower socioeconomic position → worse health.
    • Example dispersion: age-adjusted mortality in Korea rises steadily from university to elementary education (rate-ratio \approx 5.5 in men).
    • \approx 200\text{ million} children globally fail to reach full developmental potential.

Three Foundational Principles of Action

  1. Improve the Conditions of Daily Life – where people are born, grow, live, work, age.
  2. Tackle the Inequitable Distribution of Power, Money, Resources – structural drivers at global, national, local levels.
  3. Measure the Problem, Evaluate Action, Build Knowledge & Capacity – surveillance, training, public awareness.

Overarching Recommendations (Mapping to the 3 Principles)

  • Improve Daily Living Conditions
    • Focus on women/girls, early child development (ECD), education, decent work, supportive social protection, healthy ageing.
  • Tackle Distribution of Power, Money, Resources
    • Strong, accountable public sector; equity-oriented governance from local → global; gender and other power asymmetries addressed.
  • Measure / Understand / Assess Impact
    • National + global health-equity surveillance; routine equity impact assessments; research & workforce training on social determinants.

1. Improve Daily Living Conditions

1.1 Equity From the Start – Early Child Development (ECD)

  • Rationale
    • ECD shapes lifelong cognitive, social-emotional, and physical health → influences obesity, cardiovascular disease, mental health, criminality.
  • Evidence
    • Jamaica study: combined nutrition + psychosocial stimulation raised development quotient by \approx 15 points over 24 months.
  • Actions
    • Commit to comprehensive prenatal-to-8-yrs policies; inter-agency ECD coordination.
    • Universal, quality antenatal & post-natal care; continuum \text{pre-pregnancy} \rightarrow \text{early years}.
    • Abolish primary-school user fees; guarantee compulsory quality primary & secondary education for all children.

1.2 Healthy Places, Healthy People

  • Urban Focus
    • \sim 1\text{ billion} slum dwellers; urban poor face infectious + non-communicable disease, injuries, climate-risk.
    • Call for slum upgrading: water, sanitation, electricity, paved streets.
    • Active-transport & retail zoning to curb unhealthy food/alcohol outlet density.
  • Rural Focus
    • Address land tenure, rural poverty, displacement; invest in rural infrastructure to slow inequitable urban migration.
  • Climate Change
    • Integrate health-equity aims with low-carbon development; transport & agriculture are \approx 21\% & 20\% of \text{CO}_{2} respectively.

1.3 Fair Employment & Decent Work

  • Health Links
    • Insecure or hazardous work raises coronary heart disease risk by >50\%; temporary contracts linked to higher mortality & poor mental health.
  • Key Measures
    • Make full & fair employment a core macro-economic goal; living wage reflecting real cost of healthy living.
    • Global application of ILO core labour standards; balanced work–home life policies.
    • Strengthen workplace safety; regulate precarious employment.

1.4 Social Protection Across the Lifecourse

  • Coverage Gaps
    • 4/5 of world population lacks basic social-security cover; \ge 71\% of births in least-developed countries unregistered.
  • Policy Directions
    • Universal, comprehensive social protection floor (income support, child/family benefits, unemployment, disability, pensions).
    • Include informal, precarious, and care workers; progressively raise benefit levels to “healthy-living” threshold.

1.5 Universal Health Care (UHC)

  • Position: Health care = common good, not a commodity.
  • Financing
    • Prefer general taxation/mandatory universal insurance; minimize out-of-pocket spending (now pushes \approx 100\text{ million} people into poverty yearly).
  • Coverage Gaps
    • Across 50+ countries, rich–poor coverage gap for attended delivery 91.6\% vs 34.5\%; full immunization 71.2\% vs 39.8\%.
  • PHC Emphasis
    • Primary Health Care model balancing prevention, promotion, and referral.
  • Health Workforce
    • Invest to correct rural-urban imbalances; tackle “brain drain” via bilateral agreements + scaled training.

2. Tackle the Inequitable Distribution of Power, Money, Resources

2.1 Health Equity in All Policies (HiAP)

  • Elevate health-equity accountability to head-of-state level; use equity impact assessments across all sectors.
  • Strengthen intersectoral action (ISA); engage civil society for transparency & participation.

2.2 Fair Financing

  • Domestic
    • Progressive taxation; build capacity before tariff-cutting trade deals.
  • International
    • Honour 0.7\%\,\text{GDP} aid target; expand multilateral debt relief.
    • Allocate aid through social-determinants framework with clear equity indicators.
  • Trends
    • 1961!\rightarrow 2002: donor GNI per-capita nearly quadrupled, aid per-capita stagnated (only \$61 \rightarrow \$67).

2.3 Market Responsibility

  • Regulation Priority
    • State leadership to ensure universal access to essential services (water, health care) and to control harmful commodities (tobacco, alcohol, ultra-processed food).
  • Health Impact in Trade
    • Institutionalize equity impact assessments before entering trade/investment agreements; include opt-out clauses if health harmed.
  • Pricing Example
    • Johannesburg water tariff: ideal pro-poor block tariff subsidizes first 6 kl/month, escalates thereafter to discourage high use.

2.4 Gender Equity

  • Structural Reforms
    • Anti-discrimination laws; central gender-equity units in governments/IGOs; include unpaid care work in national accounts.
  • Economic Participation
    • Enforce pay-equity; vocational training; family-friendly workplace policies.
  • Reproductive Health
    • Universal sexual & reproductive services; tackle maternal mortality.
  • Wage Gap Snapshot
    • Women’s non-agricultural wages = 70\%–81\% of men’s across multiple world regions.

2.5 Political Empowerment – Inclusion & Voice

  • Human-Rights Basis: Legal identity & protection, especially for Indigenous Peoples & marginalized groups.
  • Participation
    • Community engagement in health decision-making; support bottom-up social movements; safeguard civil-society space.

2.6 Good Global Governance

  • Make health equity a core development goal; UN ECOSOC & WHO to monitor via social-determinant indicators.
  • Establish multilateral working groups on: ECD, gender equity, decent work, UHC, participatory governance.
  • Strengthen WHO’s capacity & stewardship for social-determinant action.

3. Measure & Understand – Monitoring, Research, Training

3.1 Surveillance & Vital Registration

  • Universal free birth registration; national health-equity surveillance linking social determinants to outcomes.
  • Global health-equity observatory coordinated by WHO.

3.2 Research & Evidence

  • Dedicated budgets for social-determinant studies; value diverse methodologies (beyond RCTs).
  • Address gender bias in research teams/questions; open-access data sharing.

3.3 Capacity & Awareness

  • Incorporate social-determinants content into medical, nursing, public-health curricula.
  • Train policy-makers in health-equity impact assessment; launch public‐awareness campaigns.

Key Actors & Their Roles

  • Multilateral Agencies: Align on shared health-equity indicators; streamline financing; ensure equitable member-state voice.
  • WHO: Lead global stewardship; embed SDH across departments; support country capacity; convene periodic equity reviews.
  • National / Local Governments: Advance HiAP; expand social protection; invest in ECD, jobs, UHC; raise progressive revenues; institutionalize equity monitoring.
  • Civil Society: Advocate, participate, monitor service quality & rights compliance, hold duty-bearers accountable.
  • Private Sector: Uphold labour standards, fair wages, gender equity; regulate health-damaging products; invest in R&D for neglected diseases.
  • Research Institutions: Generate SDH knowledge, train workforce, maintain global knowledge networks, counter brain drain.

Feasibility & Urgency

  • Without change: closing the gap is impossible.
  • With coordinated, multi-level action: significant reduction within one generation (~30 yrs) is achievable.
  • Requires early-life investment, structural economic reform, empowered communities, and steadfast political will.
  • Failure to act will represent “failure on a grand scale” for which future generations will judge harshly.