The Commission on Social Determinants of Health
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Part 1 of 4
Dear friends,
Here is part 1 of 4 of what I think is a very important document
that just came out from WHO which, as I have commented in this
list before, has set up the Commission on the Social Determi-
nants of Health. This is an excerpt of the launching document
(courtesy of Alec Irwin). It is longish, but well worth every
minute of your reading!
Claudio Schuftan
mailto:claudio@hcmc.netnam.vn
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TAKING IT TO THE NEXT LEVEL: THE COMMISSION ON SOCIAL DETERMI-
NANTS OF HEALTH
2.1 Aims of the CSDH
The CSDH has been constituted at a time when momentum for action
on SDH is rising. A convergence of factors related to the scien-
tific evidence base, the mobilization of concerned constituen-
cies and the broader politics of development has created condi-
tions in which unprecedented advances in health policy to ad-
dress SDH are within reach. But many countries and communities
remain excluded -- particularly in parts of the world where
health needs and the negative impacts of SDH are greatest. A ma-
jor push is needed now to capture the existing momentum on SDH
and take it to the next level: brokering a wider understanding
and acceptance of SDH strategies among decision-makers and
stakeholders, particularly in developing countries; translating
scientific knowledge into pragmatic policy agendas adapted to
countries' levels of economic development; identifying success-
ful interventions and showing how they can be scaled up; and en-
suring that social determinants are lastingly anchored in health
policy approaches at WHO and among other global actors. These
are the tasks the CSDH will take on.
During its three-year span of activity, the Commission aims for
changes whereby the societal relationships and factors that in-
fluence health and health systems will be visible, understood
and recognized as important. Based on this the opportunities for
policy and action, and the costs of not acting, will be widely
known and debated. A growing number of institutions working in
health at local, national and global level will be using this
knowledge and implementing relevant public policy affecting
health. Leadership, public interest and capable institutions
within and beyond the health sector will sustain this transfor-
mation. The social determinants of health will be incorporated
into the planning, policy and technical work of WHO.
The aims of the CSDH are ambitious. To achieve them, it will
have to build on the work of predecessors, understand their
limitations and obstacles, and go farther. To do this will in-
volve strategic decisions guided by an understanding of history.
Key issues for the CSDH
The preceding historical overview brings into focus both some of
the challenges the CSDH can expect to face, and the reasons why
this effort is so vital now. It offers lessons for the CSDH and
raises questions Commissioners may debate as they define their
objectives and strategies more precisely. In the following
pages, we focus on four issues the historical survey has shown
to be particularly crucial. In each of these four areas, we
identify a specific question or questions on which the Commis-
sion will need to achieve clarity.
2.2.1 The scope of change: defining entry points
Efforts to promote change in health policy can be more or less
ambitious in scope. This issue is illustrated historically by
the contrast between comprehensive and selective primary health
care, i.e., between the Health for All agenda as protagonized by
Mahler at Alma-Ata and the Child Survival Revolution led by
Grant and UNICEF in the 1980s. The CSDH will face its own ver-
sion of the challenge and the choice embodied in these two fig-
ures and their respective strategies. On the one hand, the Com-
mission could understand itself as leading a "Copernican revolu-
tion" in thinking and action on health policy, with far reaching
implications for social structures and for how governments do
business in exercising their responsibility for the health of
populations. On the other hand, the CSDH could set its sights
more modestly and aim simply to develop and promote a "toolkit"
of interventions that states can implement swiftly, without sig-
nificant changes to their existing governance and budget struc-
tures or their relationships with international financial insti-
tutions and donors (the SDH equivalent of the GOBI strategy).
And of course the choice need not be cast as a binary alterna-
tive. Various compromise positions might be sought that could
combine some of the strengths of both approaches. Yet the fact
remains that the CSDH will inevitably have to "come down some-
where" on what might be termed the Mahler-Grant problem. This
positioning should be the result of a conscious, reasoned and
collective choice, rather than simply emerge haphazardly from
the Commission's day-by-day interactions with partners and the
media.
At the communications level, this decision is about a choice of
vocabulary for the Commission (e.g., "social justice" vs. "effi-
ciency" or "reducing disparities"). At the level of country op-
erations and policy, it is about entry points. Decisions about
language are not "mere" linguistic subtleties, but have implica-
tions for the way the CSDH will work with countries and the
types of policies it will seek to promote. As shown in the coun-
try examples above (section 1.8.3), policies and interventions
to address SDH can engage social structures at a variety of lev-
els. The most ambitious policies may seek dramatically to reduce
gradients of wealth and power among different groups in society
through redistributive processes.
At the other end of the spectrum, healthcare interventions tar-
geted at disadvantaged groups seek to repair or palliate the
damage inflicted by social inequality, once such inequality has
already translated itself into physical illness affecting the
bodies of disadvantaged individuals. Along this spectrum, it
will be crucial for the CSDH to identify the level(s) at which
it will seek to promote change. A typology or mapping of entry
points for policy action on SDH and health inequities was
sketched earlier. It presented the following entry points for
policies and interventions on SDH:
. Decreasing social stratification itself, by reducing "ine-
qualities in power, prestige, income and wealth linked to dif-
ferent socioeconomic positions";
. Decreasing the specific exposure to health-damaging factors
suffered by people in disadvantaged positions;
. Lessening the vulnerability of disadvantaged people to the
health-damaging conditions they face;
. Intervening through healthcare to reduce the unequal conse-
quences of ill-health and prevent further socioeconomic degrada-
tion among disadvantaged people who become ill.
In essence, this framework asks at what point(s) along the chain
of social production of health/illness it is desirable (and fea-
sible) to intervene in a given context: through broad redis-
tributive policies that aim to alter fundamental social ine-
qualities; through less ambitious, intermediate policies that
seek to shield members of socially disadvantaged groups against
the worst health consequences of their increased exposure to
health threats (examples would include anti-smoking programmes
targeted at low-income groups and occupational safety regula-
tions that reduce health risks connected with specific forms of
low prestige work); or by providing fairer medical care at the
end of the "social production chain".
Linked to the question of entry points is the issue of universal
versus targeted programmes. Graham and Kelly recall that evi-
dence on the links between people's socioeconomic circumstance
and their health has thus far generated two kinds of policy re-
sponses. The first focuses on those in the poorest circumstances
and the poorest health: on the most socially excluded, those
with most risk factors and those most difficult to reach. This
focus has been important in linking health inequalities to the
social exclusion agenda, and in focusing policies at local and
community level. In policy and intervention terms, this leads to
approaches that attempt to lift the worst off out of the extreme
situation in which they find themselves. In effect, such inter-
ventions help only a relatively small part of the population.
The second approach recognizes that, while those in the poorest
circumstances are in the poorest health, this is part of a
broader social gradient in health. This means that it is not
only the poorest groups and communities who have poorer health
than those in the most advantaged circumstances. In addition,
there are large numbers of people who, while they could not be
described as socially excluded, are relatively disadvantaged in
health terms. Preventive and other interventions could produce
major improvements in their health and proportionate savings for
the healthcare system. Because universal programmes may be seen
as too costly, there is a risk that strategies will focus pri-
marily on targeted interventions addressing intermediary deter-
minants, which simply manage the consequences of poverty, while
the processes that cause it remain unchanged. Indeed, some crit-
ics argue that an unintended effect of targeted interventions
may be to legitimize poverty, making it both more tolerable for
individuals and less costly for society.
Commissioners will want to reflect carefully about the level(s)
at which they want to promote change; the desirabil-
ity/feasibility of selecting various policy entry points; the
forces and capacities for action that must be aligned at the
various levels; and the appropriate political strategies for ob-
taining results. Determinations about policy entry points and
the content of recommended policies will vary with the speci-
ficities of national contexts. Successful health policy to ad-
dress SDH cannot adopt a "one-size-fits all" character. Differ-
ent countries and jurisdictions find themselves at very differ-
ent stages of readiness for action on SDH and of openness to
more fundamental redistributive approaches. The particularities
of national and local contexts will show which social determi-
nants need to be addressed most urgently to improve population
health, and which policy tools are most appropriate. National
and local specificities, in particular economic and political
power relations, will define the opportunities and constraints
for action and indicate which constituencies may align them-
selves with an SDH agenda, and which may offer resistance. Thus,
the key question becomes not only "What entry point(s) will be
chosen?" but also and more fundamentally, "How will you decide?"
That is, what criteria will be utilized to make decisions about
the level of policies/interventions to be recommended in par-
ticular cases? Presumably, in addition to a framework of entry
points for SDH interventions and policies, the CSDH will need to
develop a typology of countries and/or subnational jurisdictions
with respect to their capacities for action on SDH. Elaborating
this typology will be an important task for the Commission's
scientific team and lies well beyond the scope of the present
paper. Some key points can be noted, however. National income
will be an important differentiator, and wealthy countries will
presumably in most cases have considerably greater facility for
implementing comprehensive SDH policies than will poor coun-
tries. However, as Good health at low cost made clear in the
1980s, and as many subsequent studies have confirmed, income is
not the only relevant factor. Countries with roughly equivalent
levels of national income exhibit very different levels of per-
formance in areas of social achievement with relevance for
health, such as access to adequate food for all members of the
population; housing quality; water and sanitation; and educa-
tion. The CSDH typology will thus have to group countries not
only by income level, but with reference to the other, in some
cases less easily quantifiable factors that will shape opportu-
nities for action. In exploring contextual influences on health
systems, Roemer, Kleczkowski and Van Der Werff have proposed a
typology of countries that points toward what may be relevant
variables.
They classify countries based on three criteria:
. The extent to which health is a priority in the governmental/
societal agenda, reflected in the level of national resources
allocated to health;
. The degree to which responsibility for financing and organiz-
ing the provision of health services to individuals is assumed
as (1) a collective social responsibility or (2) primarily the
responsibility of the individuals concerned;
. The extent to which society (through political authorities)
assumes responsibility for an equitable distribution of health
resources.
As the GHLC analyses acknowledged, but as technical planners
sometimes forget, a country's political, economic and social
history is deeply relevant to understanding what policies will
be appropriate and effective there. The WHO Health Equity Team
has recently argued for a more historically and politically con-
textualized understanding of health systems. This principle ap-
plies a fortiori to efforts to mobilize constituencies, engage
policymakers and implement interventions on SDH.
Down the line, the issue of national specificities and appropri-
ate modes of engagement will raise a range of important strate-
gic questions for the Commission. These include how the CSDH
will co-operate with countries whose political structure is fed-
eral (see Canada example above), and what sorts of policy recom-
mendations and support the CSDH may seek to provide to constitu-
encies in countries whose economic and political situations (in-
cluding conflict and/or highly authoritarian, unresponsive gov-
ernance) make major national health policy action on SDH ex-
tremely unlikely in the near and medium term. Will such coun-
tries be (tacitly) "written off" by the CSDH as cases in which
Commission resources and energy cannot sensibly be invested, or
will some effort be made to develop recommendations and policy
dialogue in these settings that could begin to lay foundations
for long-term change?
Main strategic questions:
. 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.
. What evaluation criteria will the CSDH put in place to iden-
tify appropriate policy entry points for different coun-
tries/jurisdictions?
...to be continued.