Review www.thelancet.com Vol 380 September 15, 2012 1011 Lancet 2012; 380: 1011–29 Published Online September 8, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61228-8 See Editorial page 950 See Comment page 951 UCL Institute of Health Equity, UCL Department of Epidemiology and Public Health, UCL, London, UK (Prof Sir M Marmot FRCP, J Allen PhD, R Bell PhD, E Bloomer MSc, P Goldblatt PhD) Correspondence to: Prof Sir Michael Marmot, UCL Institute of Health Equity, UCL Department of Epidemiology and Public Health, UCL, London WC1E 7HB, UK m.marmot@ucl.ac.uk WHO European review of social determinants of health and the health divide Michael Marmot, Jessica Allen, Ruth Bell, Ellen Bloomer, Peter Goldblatt, on behalf of the Consortium for the European Review of Social Determinants of Health and the Health Divide The European region has seen remarkable heath gains in those populations that have experienced progressive improvements in the conditions in which people are born, grow, live, and work. However, inequities, both between and within countries, persist. The review reported here, 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 health policy framework for Europe: Health 2020. 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. The European review builds on the global evidence and recommends policies to ensure that progress can be made in reducing health inequities and the health divide across all countries, including those with low incomes. Action is needed—on the social determinants of health, across the life course, and in wider social and economic spheres—to achieve greater health equity and protect future generations. Introduction This report presents the recommendations of the Review of Social Determinants of Health and the Health Divide, which addressed inequities in health between and within countries across the 53 Member States of the European region. The review was commissioned to support the development of the new health policy framework for Europe: Health 2020. 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-income, middle-income, 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 European region includes countries with some of the best levels of health and narrowest health inequities in the world. 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, which are increasingly affluent, with developed welfare states and high-quality education and health services, have created the conditions for people to have the freedom to lead lives they have reason to value. Remarkable heath 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 (figure 1). Furthermore, 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 (figure 2). Since 2008, the economic crisis, which was more serious than most 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. The Review of Social Determinants of Health and the Health Divide 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 open to all is to ensure universal coverage of health care. Another is to focus on types of behaviour (smoking, diet, Highest Second Third Fourth Lowest Life expectancy quintiles Figure 1: Life expectancy in countries in the WHO European region, 2010 (or latest available data) Data from WHO health for all database. 1