Health promotion and the need to accelerate advocacy for health equity

It has been 15 years since the final report of the WHO Commission on Social Determinants of Health (CSDH)—‘Closing the Gap in a Generation’ (CSDH, 2008)—was published. While there have been gains in overall health since then, improvements in health have not been equitably distributed and there is evidence of increasing inequities within OECD countries (Hu et al., 2016; Mackenbach et al., 2018). Reports from Oxfam and the World Inequality Lab have documented global increases in economic inequality which have been exacerbated by COVID-19 (Chancel et al., 2022; Christensen et al., 2023). Increasing inequities illustrate that political, economic and social factors can be harmful to health (World Health Organization, 1986), and highlight the importance of health promotion advocacy that calls for more equitable conditions. This is reflected in the 1986 Ottawa Charter for Health Promotion’s emphasis on the fundamental conditions and resources for improving health, including social determinants of health and equity (World Health Organization, 1986). The drivers of increasing health inequities in OECD countries highlight the urgent need for the health promotion community to match these with an acceleration of advocacy for health equity.

NATURE AND QUALITY OF DATA ON SOCIAL DETERMINANTS OF HEALTH INEQUITIES

Socioeconomic health inequities have increased since the 1980s in OECD countries, including Europe, the USA and Australia (Hu et al., 2016; Mackenbach et al., 2018; Flavel et al., 2022b). The absence of good-quality data on social determinants of health equity is an issue hindering the monitoring of progress on health inequities internationally (Flavel et al., 2022a). The lack of appropriate data in other OECD countries is one reason why much research on health inequities and social determinants of health inequity is concentrated in Europe and North America, with Australia also having some centres for population health research (Flavel et al., 2022a). Limitations of data availability worsen when considering data by gender, sexuality, socio-economic status and ethnicity.

EXAMPLE OF AVAILABLE AUSTRALIAN DATA ON HEALTH INEQUALITY

The main source of data on health and social inequities in Australia is from the Public Health Information Development Unit (PHIDU) which has been continually monitoring trends since the 1980s including through the provision of a regularly published Social Health Atlas. Australian data are available by quintile of socioeconomic area disadvantage for 1987–91 and 2016–20 for premature mortality and for 1997–2000 and 2016–20 for deaths from avoidable causes (Public Health Information Development Unit, 2023). These data allow for measurement of the social gradient in health outcomes in Australia, and an assessment of the reduction in premature mortality and avoidable mortality by quintile of socioeconomic disadvantage.

Analyses of PHIDU data have found that inequality in premature mortality and avoidable mortality has increased in Australia (Flavel et al., 2022b, 2024). Reductions in premature and avoidable mortality have favoured the least disadvantaged: reductions in mortality were larger for the least disadvantaged, with comparatively smaller reductions with increasing disadvantage and the smallest reduction in mortality for the most disadvantaged (Flavel et al., 2022b, 2024).

PHIDU data on key social determinants of health show the same trend by quintile of socioeconomic area disadvantage as the health measures, with increases in labour force participation and participation in higher education being larger for the least disadvantaged and decreasing with increasing disadvantage (Flavel et al., 2024). There have also been smaller increases in rental stress for the less disadvantaged in comparison with more disadvantaged quintiles. The trends in health inequities are consistent with the runaway economic class at the top of the income and wealth distribution accumulating a much larger share of wealth and income. The Australian Council of Social Service (a peak body for the social care sector in Australia) analysis of growth in wealth has found much higher increases in wealth between 2003–04 and 2017–18 for the top 10%, the already wealthy, and much lower increases in wealth for people in the bottom 60% (Davidson and Bradbury, 2022). This is also a global phenomenon as highlighted by the Oxfam inequality reports (Christensen et al., 2023).

Similar trends of reductions in mortality being higher for higher social class were found in other OECD countries, for all-cause mortality and for mortality from coronary heart disease in England and Wales between the 1970s and the 1990s (Marmot, 2001). There were higher reductions in premature mortality for the least deprived decile compared with the most deprived decile in England between the early 2000s and 2015–18 (Lewer et al., 2020). Relative inequalities in mortality have widened in almost all European countries due to smaller percentage declines in lower socioeconomic groups (Mackenbach et al., 2018).

GROWING INEQUITIES AREN’T INEVITABLE, THEY ARE A RESULT OF GOVERNMENT POLICIES AND PRIORITIES

The steepening social gradient for measures of mortality in Australia, England, Wales and Europe is partly a result of the gains in health and the social determinants of health favouring the most advantaged. The result has been a widening gap between the least and most disadvantaged. The key drivers of these changes are structural determinants of health such as economic and social policies that impact on social determinants of health. Reductions in government spending on welfare and social programs in OECD countries, as well as policies that confer benefits that largely flow to the already wealthy, have reversed the reductions in inequities from the 1960s and 1970s (Labonté and Stuckler, 2016).

There are historical examples of achievements in reducing health inequities. These include in Sweden, Denmark, Norway and Finland from the 1960s to 1980s, the USA from 1966 to 1980, Brazil from the 1980s to 2000s and England in the 2000s (Bambra, 2022). Each of these examples involved improvements in the provision of social determinants of health, and investment in programmes targeting social inequities (Bambra, 2022). The emergence of neoliberalism and cuts to spending on social programmes ended progress in reducing health inequalities in Europe and the USA in the 1980s, and improvements in population health in England and Brazil came under threat due to austerity measures following economic recessions from 2010 onwards in England and from 2015 onwards in Brazil (Bambra, 2022). These examples illustrate the key role of structural determinants that can harm or improve health.

ROLE OF PUBLIC POLICY IN INCREASING AND ENTRENCHING INEQUITIES

A strong progressive taxation system is required to fund social programs, public infrastructure and welfare and, in turn, should result in reduced health and social inequities. Post-World War II, highly progressive income taxes were implemented in many OECD countries, but the average highest marginal tax rates fell in the 1980s from around 60% to under 40% (Hope and Limberg, 2022). Tax cuts for high-income earners entrench inequities and have the impact of not just increasing social inequities but also leading to cuts in services that support health and social equity. The fall in the highest marginal tax rates partially explains the increasing accumulation of income and wealth for the top 10% in many OECD countries.

The housing crisis some countries are experiencing is another example of how policies can result in increasing inequalities. The reduction in investment in social housing in a number of countries has decreased housing affordability and security for many segments of the population (Fields and Hodkinson, 2018). Australia is an extreme case in point: investment in public housing has failed to keep pace since 1996 with social housing only growing by 4% between 1996 and 2016, and much lower than population growth of 30% over the same period (Per Capita, 2022). The capital gains tax discount was introduced in 1999, providing a 50% discount for tax on capital gains on assets sold by Australian residents as long as the asset was held for at least 12 months. The introduction of the capital gains tax discount and increased generosity of negative gearing was only three years after funding for public housing was cut and resulted in a sharp increase in house prices (Per Capita, 2022). Three-quarters of an estimated $5 billion per year from the capital gains tax discount goes to the top 10% of income earners (Centre for Equitable Housing, 2023). These housing policy changes to capital gains taxation and negative gearing in the 1990s have redistributed wealth towards the already wealthy and made housing in Australia unaffordable for many to rent or buy.

Income support payments which are designed to alleviate poverty prevent poor health and reduce health inequities (Arno et al., 2011). However, many countries have introduced punitive welfare where payment conditions have negative effects on the health of the unemployed who are marginalized and stigmatized (Williams, 2021).

Regressive policies distort the distribution of income, housing and wealth, conferring lower taxes or tax revenues to high-income earners and taking benefits from the lowest-income earners, and go some way to explaining why the increase in health and social inequities in many OECD countries is characterized by much larger gains in health and access to key social determinants of health for the most advantaged.

THE ROLE OF HEALTH PROMOTION RESEARCH AND ADVOCACY IN APPLYING PRESSURE FOR ACTION ON HEALTH EQUITY

Most health promoters are not working at a level where they can address structural determinants of health, but that does not mean they cannot act to promote and advocate for more equitable conditions. The persistence of policies that increase health inequities globally can be discouraging for advocates, but the historical achievements that were made towards health equity in Sweden, Denmark, Norway, Finland, Brazil, the USA and England not so long ago show that policies can change (Bambra, 2022). Challenging and resisting policies that increase health inequities through advocacy is vital. The current conditions globally that have led to rising health and social inequities in many countries require an acceleration of advocacy which health promoters could lead.

Effective strategies for health promoters include coordinated political action between advocacy groups and countering negative narratives about groups targeted by spending cuts such as the unemployed to encourage resistance to such cuts (O’Campo et al., 2019). The effectiveness of such strategies is underpinned by accumulating compelling evidence and vivid sharing of stories based on lived experiences of the harms to health of cuts to social and health programs, punitive welfare schemes and other policies distorting the distribution of social determinants. In addition, health promoters can also facilitate the capacity of communities they work with to advocate for themselves and join advocacy efforts of other community and civil society groups. Calls to action to empower those impacted by lack of political action on social and commercial determinants of health have highlighted the importance of involving young people and women in advocacy and policy-making (Arnot et al., 2023; McCarthy et al., 2023; Pitt et al., 2024).

Evidence produced by health promotion researchers is vital as health promotion researchers can give voice to the lived experience of those harmed most by inequities. They can enumerate the harm done by providing qualitative and quantitative evidence that can be used to support advocacy for changes to public policy to reduce inequities. An accumulation of compelling evidence and the joining of disparate voices to coalitions advocating on the same issue can be effective in influencing policy actors.

The challenge is even greater when considering inequities between countries and within-country inequality in low- and middle-income countries (LMICs). Data on trends in health inequities for LMICs are limited and mainly focus on child mortality, but available evidence indicates many LMICs are also facing challenges in reducing health inequities (Eozenou et al., 2021). Nonetheless, advocacy has an important role globally. Vital advocacy is already being undertaken by international organizations such as the People’s Health Movement, WHO, Oxfam and Global Health 50/50 but this advocacy is up against difficulties in generating political will and corporations lobbying for pro-business policies that undermine health equity (Lacy-Nichols et al., 2023). An acceleration of evidence-based advocacy would align with the Ottawa Charter’s call to action almost four decades ago—it is through advocacy that conditions can be made favourable for achieving equity in health (World Health Organization, 1986).

FUNDING

This work was supported by a grant from the National Health and Medical Research Council, grant number GNT 2009323.

CONFLICT OF INTEREST STATEMENT

Joanne Flavel is a member of the Editorial Board of Health Promotion International.

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