Commission on Social Determinants of Health:
Good Diagnosis – Now for the Prescription….
David Woodward
From the media coverage of the report of the Commission on Social Determinants of Health, one might think it said nothing new. There are considerable inequalities in health, particularly between rich and poor. These arise from differences in incomes, access to health services, clean water, sanitation and education. There is a moral imperative to act on this social injustice. All of this could have been said at any time over the last 20 or 30 years.
In fact, the report is – by the standards of such global commissions – little short of revolutionary. One can only suppose that those reporting on it have read no further than the report's formal recommendations and executive summary.
The Commission does not limit itself to the immediate causes of health inequalities, come up with a wish-list, and pretend governments could simply wave a magic wand and make the problem go away if they really wanted to. It recognises that there are reasons why governments, especially in the developing world, have been unable to secure health for all; and it traces through what needs to happen to increase health equity from the local level to the global.
Governments in the developing world are constrained by lack of resources, limited infrastructure, weak administrative capacity and limited bargaining power in international negotiations. These are, to a great extent, a result of global economic constraints and pressures. And these constraints and pressures, in turn, result from a system of global governance which skews power towards the developed world, and therefore prioritises their economic concerns over the desperate needs of the majority of the word's population. All this is highlighted throughout the report.
The Commission's formal recommendations are inevitably constrained by its mandate. Its report specifically states that "It was beyond the remit, and competence, of the Commission to design a new international economic order that balances the needs of social and economic development of the whole global population, health equity, and the urgency of dealing with global warming". But this is clearly what its findings imply.
The report is peppered with stinging criticisms of globalisation, market integration, trade liberalisation, IMF and World Bank economic policies, WTO Agreements and recent health sector reform programmes. It emphasises that its recommendations on employment policies and social protection depend critically on major changes in the operation of the global economy. And it highlights the need for a major reform of global governance, not only raise the profile of health, but also to ensure "genuine equality of influence" for rich and poor.
This is an extraordinarily radical agenda. And, in the best traditions of the health profession, it is backed up by an impressive array of evidence, compiled by nine knowledge networks, bringing together leading global experts in relevant fields. The Commission may not have had the remit to design a new international economic order – but they have presented an overwhelming case for the need for it, and an invaluable starting point for developing it.
Now it is up to civil society, as a key part of the "global movement for change" which the Commission hopes to foster, to take up the gauntlet and translate the needs the Commission identifies into a concrete programme. Then, perhaps, we can really hope to "close the gap in a generation".
David Woodward is an independent development consultant, and a member of the Knowledge Network on Globalisation and Health established under the auspices of the CSDH, as well as a member of PHM.
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Claudio Schuftan
mailto:cschuftan@phmovement.org