The Commission on Social Determinants of Health (4)
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Part 4 of 4
2.2.4 Evidence, political processes and the CSDH "story line"
Scientific evidence is surely important to persuade constituen-
cies sceptical about the value of health policy oriented to SDH.
But evidence by itself it is rarely if ever sufficient to cata-
lyse political action. In political terms, what may be at least
as crucial as the evidence itself is the "story" in which it is
embedded.
This idea is of course not new. Indeed, it is as old as politics
itself. However, the importance of this theme has been strongly
confirmed in recent public health history. The primary health
care movement that arose in the 1970s was able to draw on evi-
dence from successful community-based health programmes in the
preceding decade. Yet what enabled PHC and Health for All to be-
come the rallying cries of a global movement was not the evi-
dence presented (which in the 1970s was relatively scant).
What drove this change was the compelling narrative of justice,
human flourishing and social transformation told by PHC's propo-
nents and embodied by the epic figure of Mahler. In the same
way, the subsequent victory of selective PHC was less a matter
of evidence per se than of shifting political interests coupled
with the emergence of a new and in some ways even more compel-
ling (because simpler) "story line". This new story switched
from a narrative about social justice to one focused on dying
children and how quick action could save their lives. The SPHC
narrative was essentially reducible to a set of "before and af-
ter" images often used in the promotion of the "child survival
revolution". The first showed a small child desperately ill with
diarrhea, weak and dehydrated, the second the same child re-
stored to vibrant life by the administration of oral rehydration
salts14. The SPHC/GOBI story elided or glossed over many of the
political and economic complexities with which the proponents of
the Alma- Ata vision had tried to grapple. But precisely this
elemental, human simplicity made the force and marketability of
SPHC and the child survival agenda.
The importance of the story element to policy change in health
has recently been confirmed by an intriguing research exercise.
A team of leading public health experts studied the way scien-
tific information is actually used (or ignored) in policymaking
processes by exploring this issue in a qualitative residential
workshop with senior policy advisers. Their findings should push
public health scientists to renounce the belief that they can
influence policy simply by providing government officials with
scientifically solid evidence. Policymakers interviewed for the
study stressed the need for simple messages unclouded by jargon
and argued that researchers should be more attentive to the
timeframes within which governments operate. Sound evidence does
not possess an inherent power to spur change, if it is not pre-
sented compellingly and in a timely manner, and if its relevance
to decision-makers' current concerns is not made clear.
Many policymakers emphasized the "value of a good story". As one
UK health policy adviser observed: "[What is important is] how
convincingly the evidence is presented, and how interesting you
make it. The face validity of a 'good story' is an example of
how presentation style can influence politics"138. Participants
argued that the importance of stories is not antithetical to the
idea of evidence-based policymaking. As one informant stressed,
it is not a case of either/or. "Stories themselves can be used
in a credible way along with the evidence". Indeed, the story is
the humanizing vehicle through which the evidence takes on its
full significance. A social determinants "story line" must be
able to capture the attention of political decision-makers and
other stakeholders, inspiring them with the sense that SDH are
important and that action to address these factors is feasible
and timely. It must enable and encourage policymakers to "sell"
the SDH agenda to their colleagues and constituents. Creating
and collectively "owning" this compelling, coherent story line
is arguably the most important challenge facing the CSDH.
Main strategic question:
What story does the CSDH want to tell about social conditions
and human well-being? What narrative will capture the imagina-
tions, feelings, intellect and will of political decision-makers
and the broader public and inspire them to action?
CONCLUSION
Today an unprecedented opportunity exists to tackle the roots of
suffering and unnecessary death in the world's poor and vulner-
able communities. The roots of most health inequalities and of
the bulk of human suffering are social: the social determinants
of health. Over the past decade, scientific knowledge on SDH has
advanced dramatically, and today the political conditions for
action are more favourable than ever before. This opportunity is
too important to let slip away. To seize it will require leader-
ship based on a mastery of the relevant science, but also moral
vision and political wisdom. This is why the Commission on So-
cial Determinants of Health has been constituted now. This ex-
ceptional opportunity has emerged through a long historical
process. Strongly affirmed in the 1948 WHO Constitution, the so-
cial dimensions of health were eclipsed during the subsequent
public health era dominated by technology-based vertical pro-
grammes.
The social determinants of health and the need for intersectoral
action to address them reemerged in the Alma-Ata period, and
were central to the model of comprehensive PHC proposed to drive
the Health for All agenda. During this period, some countries
made important strides in addressing key social determinants
such as nutrition and women's education. However, like other as-
pects of comprehensive PHC, action on determinants was weakened
by the neoliberal economic and political consensus dominant in
the 1980s and beyond, with its focus on privatization, deregula-
tion, shrinking states and freeing markets. Under the prolonged
ascendancy of variants of neoliberalism, state-led action to im-
prove health by addressing underlying social inequities appeared
unfeasible in many contexts. Recently, however, the tide has
again begun to turn. The flaws of neoliberal policy prescrip-
tions have been exposed and the need for alternative development
approaches widely recognized. Concern with health inequalities
between and within countries has increased, while progress in
the scientific understanding of the social determinants of
health accelerated in the 1990s. In a growing number of coun-
tries this scientific evidence is being applied to shape bold
new public policy approaches. For the moment, this trend remains
largely concentrated in high-income countries, but several de-
veloping countries have begun to take innovative action on SDH,
and more could be poised to do so.
The Millennium Development Goals adopted by 189 countries in
2000 set a new integrated framework for global development that
has once again focused attention on the interwovenness of devel-
opment challenges and the need for simultaneous, coordinated ac-
tion across a range of sectors including macroeconomic policy,
food and agriculture, education, gender, and health. Without
strong policy action on SDH, the health-related MDGs will not be
attained in most low- and middle-income countries. This moment
of "tidal shift" constitutes a historic opportunity for action
on social determinants and a chance to change theory and prac-
tice about what constitutes health policy -- as opposed to poli-
cies concerned with the delivery of health care services. As the
CSDH embarks on its mission, a sense of history will be a valu-
able resource. To maximize its chances of success, the Commis-
sion must craft its strategies with an awareness of past SDH ef-
forts and the lessons these experiences can teach.
This paper has attempted to provide a selective historical over-
view of major efforts to address SDH. It has traced in broad
outlines the growth of knowledge on SDH and, equally important,
some of the political dynamics that shaped efforts to intervene
on the social dimensions of health and contributed to their suc-
cess or frustration. The paper has not tried to offer prescrip-
tions. It will have fulfilled its function if it brings into
clearer focus some of the urgent issues with which the Commis-
sioners must grapple, as the CSDH establishes its identity,
fixes its objectives and frames its strategies.
In conclusion, we recall the key strategic questions identified:
1. How will the CSDH position itself on the "Mahler-Grant prob-
lem": i.e., choosing (or compromising) between: (1) a far-
reaching structural critique based on a social justice vision
and (2) promoting a number of tightly focused interventions that
may produce short-term results, but risk leaving the deeper
causes of avoidable suffering and health inequities untouched?
If a more comprehensive, values-oriented approach is taken, the
CSDH may sacrifice short-term efficacy and measurable results.
If a more selective, intervention-focused, pragmatic stance is
adopted, critics may well wonder why a global Commission was re-
quired for this job, rather than a much less costly technical
working group. This issue fundamentally concerns how Commission-
ers understand their political role, and the place they assign
to moral values in an undertaking that aims to leverage policy
action and bring concrete, measurable results rapidly.
2. What evaluation structure will the CSDH put in place to iden-
tify appropriate policy entry points for different coun-
tries/jurisdictions?
3. To interest political leaders, a SDH policy agenda will have
to offer opportunities for some "quick wins". This principle ap-
plies to country-level political processes and at the global
level to the Commission itself. What might "quick wins" look
like, for countries tackling social determinants and for the
CSDH?
4. How will the Commission develop its relationship with the ma-
jor international financial institutions, in particular the
World Bank?
5. How can the CSDH most effectively position itself within the
global and national processes connected to the Millennium Devel-
opment Goals (MDGs)?
6. 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?
7. Can the CSDH operate strategically to get "buy-in" from the
business community, without losing credibility with other key
constituencies, including civil society organizations? How will
potential conflicts among these interests be mediated within the
Commission as its work proceeds?
8. Drawing together all these and other issues is the question
of "story". This is not a mere footnote to the scientific and
political problems the Commission must confront, but is at the
heart of the CSDH's effort to catalyse change. What story do the
members of the CSDH collectively want to tell about social con-
ditions and human well-being? What narrative will capture the
imaginations, feelings, intellect and will of political deci-
sion-makers and the broader public and inspire them to action?
...end