The Commission on Social Determinants of Health (3)
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Part 3 of 4
2.2.3 Identifying allies and political opportunities
The level of the Commission's success will depend to a consider-
able extent on its ability to construct a network of alliances
and partnerships with influential actors at various levels, in-
cluding: global institutions, national governments and policy-
makers, the business sector and civil society organizations.
Fortunately, while the CSDH can expect to encounter resistance
from certain influential constituencies (and must be prepared
with appropriate strategies), the Commission will also enjoy
distinctive opportunities. It will work in a political context
which, if managed appropriately, offers chances for success be-
yond the reach of previous efforts.
Arguably, Commissioners' most pivotal responsibility will be us-
ing their personal networks and links to various spheres of in-
fluence (political, business, academic, media, civil society) to
build and maintain an expanding web of alliances that will sup-
port and publicize the Commission's work, disseminate its mes-
sages, and drive implementation of its policy recommendations.
To be fully effective, this network must be operative on several
levels simultaneously. Global actors Buy-in and ongoing support
from major global institutions, including the relevant UN agen-
cies, will be essential to creating sustained momentum around
the SDH agenda and ensuring that it is durably integrated into
international health policy and development models.
The history of the PHC vs. SPHC debate in the 1980s suggests
that the increasing divergence in strategy between WHO and UNI-
CEF was a significant factor in weakening global commitment to
the Health for All vision and to comprehensive PHC, with its in-
tersectoral action component. Fortunately for the Commission,
the SDH agenda appears strongly aligned with the current main
thrust of UN and international development policy, built around
the MDGs. Indeed, while certain aspects of the MDG programme are
of course criticisable from a health perspective (absence of
noncommunicable diseases, lack of explicit focus on health sys-
tems), the overall MDG framework provides an admirable opportu-
nity both to secure the central place of health in development
work generally and, more particularly, to promote understanding
of the linkages between health outcomes and underlying so-
cial/economic/political conditions.
Most importantly, the MDGs by definition constitute a framework
for coordinated international action, with commitment from major
players already built in. To the extent the CSDH can align its
policy recommendations with the MDGs, it can capitalize on the
momentum of global and national commitment to the goals. The
work of the UN Millennium Project, whose final report was pub-
lished in January 2005, has highlighted the interwovenness of
the broad range of economic, health and environmental issues in
international development under the MDGs8. A renewed sense of
the urgent need for coordinated multisectoral action to improve
the lives of the world's most vulnerable citizens has emerged,
along with the model of a "global compact" between developed and
developing countries that would dramatically increase investment
in key sectors of direct interest to an SDH agenda, such as pov-
erty and food security, education, women's empowerment, water
and sanitation and living conditions in urban slums, as well as
improved medical services.
The CSDH must give a high priority to positioning itself within
the various international fora and policy processes connected
with the MDGs, and to opening channels of dialogue with key
players that can ensure that the CSDH is strongly profiled
within these processes. Relevant fora and institutions would in-
clude the UN Economic and Social Council; the advisory teams
around the UN Secretary-General; the Millennium Campaign effort;
and the High Level Forum on MDGs; as well as the various UN spe-
cialized agencies contributing to the MDG effort and aligning
their work according to MDG priorities. The importance of out-
reach to the major international financial institutions has al-
ready been underscored. Contestation around the policies of the
IFIs remains strong. Debates continue concerning the effects of
PRSPs on developing countries' capacity to strengthen their
health care systems and to implement social policies that pro-
mote health and health equity. Yet attitudes and practices at
the World Bank and some regional development banks may be chang-
ing in ways that could facilitate the uptake of Commission mes-
sages and the implementation of CSDH-recommended policy meas-
ures. Importantly, the World Bank is publicly committed to the
MDGs, and relations between WHO and the Bank have been strength-
ened through collaboration in the High-Level Forum on MDGs.
Meanwhile, the World Bank and IDB have been instrumental in the
success of programmes such as Mexico's PROGRESA/Oportunidades.
The profile the World Bank is now giving to equity as a key con-
cern in international development presents an opportunity for
the CSDH to press its message that if countries and the global
community are serious about attacking health inequities, the
most effective way is via SDH. A key strategic advantage for the
CSDH, in comparison with efforts to promote intersectoral action
on health determinants during the 1990s, is the strong and visi-
ble commitment to the SDH agenda from top leadership at WHO, in-
cluding the Director-General. This high-level institutional buy-
in within WHO increases the chances that an SDH approach to
health policy design can be "mainstreamed" within WHO during the
life of the Commission and can become a permanent dimension of
the Organization's technical work and policy dialogue with Mem-
ber States. On the other hand, across the global health commu-
nity and even within WHO itself, some constituencies will cer-
tainly greet an SDH approach with scepticism. The architecture
of the Commission and its Knowledge Networks, including special
focus on health systems and diseases of public health priority,
is designed to provide maximum chances to bring traditionally
more biomedical constituencies "on board" with SDH, showing them
how SDH approaches can improve results within their own pro-
grammes and contribute to the strengthening of integrated, sus-
tainable health systems.
A high-level WHO Reference Group linked to the Commission will
develop a specific WHO-internal action agenda to incorporate the
Commission's key recommendations into WHO policy and programming
in a durable way. International fora such as the G-8, regional
bodies and more or less formalized political alliances around
specific issues such as global hunger will also be key potential
linkages for the Commission. The concern of the G-8 nations with
economic and health inequalities offers an important entry point
for the CSDH, which the Commissioners and their support staff
should work to capitalize upon. African-led development initia-
tives such as NEPAD, though criticized in some quarters as ex-
cessively influenced by neoliberal models, signal creativity and
fresh commitment to a comprehensive development approach that
could offer opportunities for action on SDH. Development initia-
tives such as the global alliance against hunger recently
launched by the Presidents of Brazil, Chile, France and Spain
relate directly to Commission themes and may enable synergies.
The recent proposals by the UK on debt cancellation and a possi-
ble "Marshall Plan" for Africa also underscore the degree to
which at least some sectors of the global policy and development
community are willing to envisage new strategies and to weigh
bold innovations. National actors At national level, the Commis-
sion begins its work at a time when, as noted above, momentum
for concerted action on SDH is building. A number of politically
and economically influential countries have enacted bold poli-
cies on SDH, and others may soon be ready to act. The problem of
socially-conditioned health inequalities has emerged as an im-
portant political issue in an increasing number of jurisdic-
tions88. The most substantial policy advances have so far been
made in high-income countries, but as the Oportunidades example
shows, some developing countries are also introducing pioneering
programmes.
At the January 2005 session of the WHO Executive Board, strong
endorsements of the CSDH were expressed by developing countries
currently represented on the Board, including Bolivia, Ghana,
Lesotho and Thailand. Many developing countries appear ready to
consider serious, pragmatic proposals for policies and interven-
tions that can reduce health inequality gaps through action on
social factors. A close relationship to country-level processes
and the policymakers involved in them will be vital for the Com-
mission's success. Here again, Commissioners will make maximal
use of their personal networks and will play a role that is
above all political. An important function for the Commission
will be brokering policy dialogue and knowledge-sharing between
countries on the "leading edge" that have already enacted health
policies addressing SDH and countries that want to implement
such policies but have not yet done so and are seeking practical
advice and insights on how to proceed.
The private sector we have already discussed the challenge that
may be posed to the CSDH by possible tensions between its mes-
sages and the interests of influential private sector actors, in
particular transnational corporations. Clearly, finding appro-
priate modes of engagement with the business sector will be a
major strategic concern for the Commission. Recommendations for
structural change to reduce social inequality through large-
scale, government-led redistribution of resources are unlikely
to find favour with the business community. However, certain in-
termediate-level policies and interventions aimed to improve
health through action on SDH may indeed be appealing to private
sector actors, and may enable the Commission to bring some in-
dustries and firms "on board" with CSDH proposals.
The recent ILO-sponsored World Commission on the Social Dimen-
sion of Globalization, which included Taizo Nishimuro, Chairman
of the Board of Toshiba Corporation, may provide lessons. Some
policies and interventions recommended by the Commission can be
cast as "business friendly". For example, investment in early
child development and in education is highly advantageous for
creating the healthier, more skilled, more adaptable workforce
required by many modern industries in the technology and service
sectors. Likewise, housing improvement projects in urban slums
could mean profits for the construction industry. Two recent re-
ports on national business competitiveness (by the World Eco-
nomic Forum and World Bank) have found Nordic countries to be
among the world's most competitive economies. These countries'
strong investments in social equity and programmes addressing
SDH do not hinder their ability to compete in the global econ-
omy. On the contrary, according to an author of the World Bank
study, "We found that social protection is good for business, it
takes the burden off of businesses for health care costs and en-
sures a well-trained and educated work force". Such findings may
open up useful lines of argument for the CSDH.
On the other hand, deeper methodological and ethical questions
underlie the issue of relations with the business sector and
with governments anxious about the financial "bottom line". The
Commission must consider if and how to use cost-savings and
cost-effectiveness arguments to promote health policies that em-
brace SDH. Recourse to such arguments could of course be quite
advantageous when promoting SDH approaches to political deci-
sion-makers. As one senior policy adviser remarked in a recent
workshop on evidence-based policymaking: "What makes evidence
talk? Definitely financial impact.. What is the best argument
for getting government to listen? Answer: Money!" As we have
noted, the impact of the Commission on Macroeconomics and Health
owed much to the CMH's decision to justify its policy recommen-
dations primarily in terms of economic gains, rather than via
ethical arguments. Similarly, cost-savings arguments have been
advanced by partisans of SDH policy approaches in a number of
countries that have begun to implement or at least consider pub-
lic health strategies oriented towards health determinants. Yet
the scientific robustness of these arguments may be question-
able. (Extending the lives of people over 50 will not necessar-
ily result in substantial long-term savings for health systems;
much of course depends on the type and quantity of health care
and other services people require over their longer life-
spans.). Is it economically credible to present SDH policies as
tools that will enable governments and health systems to save
money? Is it morally right to do so? The Commission will need to
reflect carefully about how possible economic arguments for SDH
policies relate to arguments based on equity, social justice
and/or human rights.
Civil society
Since the pre-Alma-Ata era of community based health programmes,
the active participation of civil society groups has regularly
been cited as a key success factor, in cases where intersectoral
policy on health determinants has worked well at local and na-
tional levels14,27,42. Since the CSDH aims to generate results
and not just words, it must take this correlation seriously and
shape its strategies accordingly. The CSDH may benefit from the
evolving role of civil society at global, national and local
levels. The influence of civil society organizations has grown
in many parts of the world, as has the ability of such organiza-
tions to gather and share knowledge and to support each other's
efforts, increasingly linking across political and spatial
boundaries through the use of new communications technologies.
Civil society mobilization has been a crucial factor in some of
the key political processes of recent years (from the toppling
of apartheid to the "Orange Revolution" in Ukraine). In health,
the impact of the Bangladesh Rural Advancement Committee (BRAC),
South Africa's Treatment Action Campaign and other civil society
organizations has transformed traditional relationships between
the medical establishment, government, industry interests and
communities. Several major international NGOs have expressed
strong support for a SDH agenda, indeed some did so well before
the announcement of the Commission. If the CSDH does engage
civil society groups as active partners in the various phases of
its work, the Commission can hope to harvest strength from the
growing voice and influence of civil society in leveraging pol-
icy change and ensuring the translation of good ideas into con-
crete results. Recognizing the strategic importance of this is-
sue, the CSDH secretariat is developing a comprehensive strategy
for partnership with civil society organizations that will en-
sure space for civil society participation in all aspects of the
CSDH process, including partner countries and Knowledge Net-
works. CSDH presence at the upcoming Second People's Health As-
sembly in Cuenca, Ecuador, in June 2005, is one important step
in opening a substantive dialogue.
Main strategic questions:
. How can the CSDH most effectively position itself within the
global and national processes connected to the Millennium Devel-
opment Goals (MDGs)?
. Is it scientifically credible, strategically desirable and/or
ethically acceptable for the CSDH to argue that health policies
tackling social determinants are a wise investment that will
"pay off" in terms of enhanced economic performance and/or cost
savings to health systems down the line?
. Can the CSDH operate strategically to get "buy-in" from the
business community, without losing credibility with other key
constituencies, including civil society? How will potential con-
flicts among these interests be mediated within the Commission
as its work proceeds?
...final tomorrow.