CLOSING THE GAP:

PoLicY inTo PracTice on sociaL

DeTerMinanTs oF HeaLTH
| Discussion PaPer |
 CLOSING THE GAP:
PoLicY inTo PracTice on sociaL
DeTerMinanTs oF HeaLTH
| Discussion PaPer |
Acknowledgements
closing the gap: policy into practice on social determinants of health: Discussion paper for the World conference on social Determinants of Health was produced under
the overall direction of rüdiger Krech (Director). The principal writer and editor was Kumanan rasanathan. Funding to assist in the preparation and production of this
discussion paper was received from the Government of Brazil.
significant contributions in the form of text, figures, and boxes were provided by carmen amela Heras, ilona Kickbusch, Bernardo Kliksberg, Taru Koivisto, Jennifer
Lee, rene Loewenson, Belinda Loring, Miranda MacPherson, Michael Marmot, Don Matheson, Lorena ruano, Victoria saint, Jeanette Vega, and David Woodward.
Key inputs and peer review for drafts of the discussion paper were provided by the advisory Group, the organizing committee and WHo regional Focal Points for the
World conference on social Determinants of Health. The members of these groups included silvio albuquerque, carmen amela Heras, Mohammed assai, eduardo
Barbosa, anjana Bhushan, Jane Billings, Paulo Buss, nils Daulaire, Maria Luisa escorel, Kira Fortune, Luiz a. c. Galvão, suvajee Good, ilona Kickbusch, Bernardo
Kliksberg, Taru Koivisto, rüdiger Krech, Michael Marmot, alvaro Matida, Malebona Precious Matsoso, abdi Momin, Davison Munodawafa, Jai narain, Luiz odorico,
rômulo Paes de sousa, alberto Pellegrini, Felix rigoli, carlos santos-Burgoa, Tone Torgersen, agis Tsouros, eugenio Villar Montesinos, susan Watts, and erio Ziglio.
Valuable comments, suggestions, criticisms, and assistance were also received from Daniel albrecht, Francisco armada, alanna armitage, Jim Ball, Leopold Blanc,
ashley Bloomfield, Ludo Bok, Josiane Bonnefoy, Matthias Braubach, Danny Broderick, chris Brown, Kevin Buckett, andrew cassels, Genevieve chedeville-Murray,
Maggie Davies, Barbara de Zalduondo, Marama ellis, sharon Friel, Michelle Funk, Peter Goldblatt, Volker Hann, Patrick Kadama, rania Kawar, Meri Koivusalo, Theodora
Koller, Jacob Kumaresan, ronald Labonté, eero Lahtinen, Pierre Legoff, Michael Lennon, Margot Lettner, Bridget Lloyd, Knut Lönnroth, Brian Lutz, Peter Mamacos,
nanoot Mathurapote, Hooman Momen, Davide Mosca, carles Muntaner, Benjamin nganda, Monireh obbadi, eeva ollila, Jeffrey o'Malley, cyril Pervilhac, Maravand
Pinto, sandy Pitcher, amit Prasad, Mario raviglione, Marilyn rice, Katja rohrer, ana Lucia ruggiero, Xenia scheil-adlung, Gerard schmets, Ted schrecker, claudio
schuftan, Hani serag, alaka singh, anand sivasankara Kurup, Zsofia szilagyi, Martin Tobias, Peter Tugwell, nicole Valentine, Vivian Welch, Deborah Wildgoose,
carmel Williams, Holly Wong, ilcheong Yi, and Hongwen Zhao.
Further valuable contributions were gratefully received through the submissions made to WHo during the public web consultation held on the first draft of this
discussion paper during May and June 2011. The discussion paper also strongly builds on the prior work of the commission on social Determinants of Health.
editorial production and the public consultation were managed by Victoria saint. The paper was copy edited by Julie Mccoy.
administrative support in the preparation of the discussion paper was provided by nathalie chenavard, Lucy Mshana, susanne nakalembe, Joyce oseku and nuria Quiroz.

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closing the gap : policy into practice on social determinants of health : discussion paper.
"This discussion paper aims to inform proceedings at the World conference on social Determinants of Health [rio de Janeiro, Brazil 19-21 october, 2011]"
1.socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. i.World Health organization.
isBn 978 92 4 150240 5 (nLM classification: Wa 525)

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TaBLe oF conTenTs
FOREWORD VII
ABBREVIATIONS 1
EXECUTIVE SUMMARY 2
INTRODUCTION 6
CONCEPTUAL BASIS AND RATIONALE FOR ACTION ON SOCIAL DETERMINANTS 7
POLITICAL CONSIDERATIONS FOR IMPLEMENTING ACTION ON SOCIAL DETERMINANTS 9
Progress, obstacles, and the effect of crises 9
Principles and requisites for action 10

1. GOVERNANCE TO TACKLE THE ROOT CAUSES OF HEALTH INEQUITIES:

IMPLEMENTING ACTION ON SOCIAL DETERMINANTS OF HEALTH
Building good governance for action on social determinants
11
13
implementing intersectoral action 15

2. PROMOTING PARTICIPATION:
COMMUNITY LEADERSHIP FOR ACTION ON SOCIAL DETERMINANTS
creating the conditions for participation
17
18
Brokering participation and ensuring representativeness 21
Facilitating the role of civil society 21

3. THE ROLE OF THE HEALTH SECTOR, INCLUDING PUBLIC HEALTH PROGRAMMES,

IN REDUCING HEALTH INEQUITIES
executing the health sector‘s role in governance for social determinants
23
24
reorienting health care services and public health programmes to reduce inequities 25
institutionalizing equity in health systems governance 26

4. GLOBAL ACTION ON SOCIAL DETERMINANTS:

ALIGNING PRIORITIES AND STAKEHOLDERS
aligning global stakeholders
29
30
aligning global priorities 32

5. MONITORING PROGRESS: MEASUREMENT AND ANALYSIS TO INFORM POLICIES

AND BUILD ACCOUNTABILITY ON SOCIAL DETERMINANTS
identifying sources and collecting data
35
36
Disaggregating data 37
selecting indicators and targets 37
Moving forward despite unavailability of systematic data 38
Disseminating information on health inequities and social determinants to inform action 39
integrating data into policy processes 39
assessing the health and equity impacts of different policy options 39

CONCLUSION: URGENT STEPS 42

GLOSSARY 44
REFERENCES 46

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| Discussion PaPer | |V
VI | World Conference on Social
Determinants of Health (WCSDH)
ForeWorD

i
n the time it takes to read this discussion paper, hundreds of need to build upon and accelerate these efforts. since the launch of
people will die needlessly as a result of health inequities – unfair the commission’s report in 2008, the world has faced a number of
and avoidable or remediable differences in health outcomes crises that have exacerbated global health inequities. Therefore, it
between different population groups. Health inequities cause is urgent that we — in governments, in civil society, in the private
unnecessary suffering and result from adverse social conditions and sector, and in international organizations — redouble our efforts to
failing public policies. These inequities are sentinels of the same act on social determinants to address health inequities.
factors that undermine development, environmental sustainability,
the well-being of societies, and societies' capacity to provide fair in this context, the World conference on social Determinants
opportunities for all. Health inequities are a problem for all countries of Health represents a tremendous opportunity. This discussion
and reflect not only differences in income and wealth, but also paper aims to inform the proceedings and contribute to fulfilling
differences in opportunity on the basis of factors such as ethnicity the purpose of the World conference, as mandated by resolution
and racism, class, gender, education, disability, sexual orientation, 62.14: to share experiences on how to address the challenges
and geographical location. These differences have profound posed by health inequities and to mobilize commitment to the
consequences and represent the impact of what we know as social urgent implementation of feasible actions on social determinants
determinants of health. in all countries. The paper does not provide a blueprint, but instead
lays out the key components that all countries need to integrate in
Yet health inequities, by definition, are not inevitable. Millions of their own context in implementing a social determinants approach.
people need not die of preventable causes each year. in 2008, The discussions at the World conference will further consider these
the WHo commission on social Determinants of Health compiled themes and show how, in all contexts, it is possible to put policy into
recommendations to create an extensive prescription of what is practice on social determinants of health to improve health, reduce
required to “close the gap” through action on social determinants health inequities, and promote development.
across all sectors of society. after considering the commission’s
report at the 2009 World Health assembly, Member states resolved
to put these recommendations into practice, adopting resolution
62.14, "reducing health inequities through action on the social
determinants of health."

accordingly, many countries are implementing action on social

determinants, with encouraging progress in reducing health
inequities in a few cases. in recent years, many countries have taken
important steps in moving towards universal coverage of health
care. There is improved understanding of the contribution of health Dr Marie-Paule Kieny
to other goals such as social cohesion and economic development, assistant Director-General
along with the need to coordinate the efforts of different sectors in innovation, information, evidence
improving health. More countries are disaggregating data to uncover and research
health inequities masked by national averages. There is, however, a World Health organization

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | |VII
aBBreViaTions
aiDs acquired immune Deficiency syndrome
commission commission on social Determinants of Health
cso civil society organization
DHs Demographic and Health survey
eu european union
GDP Gross Domestic Product
GnP Gross national Product
Hia Health impact assessment
HiaP Health in all Policies
HiV Human immunodeficiency Virus
iLo international Labour organization
isa intersectoral action
MDGs Millennium Development Goals
Mics Multiple indicator cluster survey
ncDs noncommunicable Diseases
nZDep new Zealand Deprivation index
oecD organization for economic cooperation and Development
social determinants social Determinants of Health
sPF-i social Protection Floor initiative
uHc universal Health coverage
un united nations
unasur union of south american nations
unDP united nations Development Programme
unesco united nations educational, scientific and cultural organization
urban HearT urban Health equity assessment and response Tool
WHo World Health organization
World conference World conference on social Determinants of Health

1| World Conference on Social

Determinants of Health (WCSDH)
eXecuTiVe suMMarY

T
his discussion paper aims to inform proceedings at the important determinants are those that produce stratification within
World conference on social Determinants of Health (“World a society — structural determinants — such as the distribution
conference”) about how countries can implement action on of income, discrimination (for example, on the basis of gender,
social determinants of health (“social determinants”), including the class, ethnicity, disability, or sexual orientation), and political and
recommendations of the commission on social Determinants of governance structures that reinforce rather than reduce inequalities
Health (“the commission”). evidence from countries that have made in economic power. These structural mechanisms that affect the
progress in addressing social determinants and reducing health social positions of individuals constitute the root cause of inequities
inequities shows that action is required across all of five key building in health. The discrepancies attributable to these mechanisms shape
blocks, which have been selected as the five World conference individual health status and outcomes through their impact on
themes: intermediary determinants such as living conditions, psychosocial
circumstances, behavioural and/or biological factors, and the health
1. Governance to tackle the root causes of health inequities: system itself.
implementing action on social determinants of health;
2. Promoting participation: community leadership for action The rationale for action on social determinants of health rests on
three broad themes. First, it is a moral imperative to reduce health
on social determinants;
inequities. second, it is essential to improve health and well-being,
3. The role of the health sector, including public health promote development, and reach health targets in general. Third, it
programmes, in reducing health inequities; is necessary to act on a range of societal priorities — beyond health
4. Global action on social determinants: aligning priorities and itself — that rely on better health equity.
stakeholders;
5. Monitoring progress: measurement and analysis to inform Political considerations in implementing
policies and build accountability on social determinants.
action on social determinants
While relevant action needs to be adapted to the specific needs and Poor progress in the implementation of a social determinants
context of each country, together these components represent the approach reflects in part the inadequacy of governance at the
constituent parts of a “social determinants approach” reflecting the local, national, and global levels to address the key problems of
need for action on social determinants to be undertaken across society. the 21st century. Health inequities challenge the traditional division
of societies and their governments into sectors for organizational
Both this discussion paper and the World conference will build purposes. rather than such divisions, the reduction of these
on the extensive work of the commission, as endorsed in World inequities demands coherent policy responses across sectors and
Health assembly resolution 62.14. The proposed focus is on how across countries, with firm political commitment by all parties.
to implement the commission’s recommendations (see Table 1), General principles, which must be adapted to each country’s needs
which were grouped under three goals: to improve daily living and context, can be identified for overcoming the political and
conditions; to tackle the inequitable distribution of power, money, technical obstacles to action on social determinants. First, action on
and resources; and to measure and understand the problem and social determinants to reduce health inequities requires long-term,
assess the impact of action. sustained implementation. Benefits can become apparent in the
short term, however, and the sooner countries start to implement
conceptual basis and rationale for action a social determinants approach, the better. second, the initial step
is to build public understanding of health inequities and social
on social determinants determinants of health. Third, equitable health and well-being need
The bulk of the global burden of disease and the major causes of to be placed as a priority goal for government and broader society.
health inequities, which are found in all countries, arise from the Fourth, ensuring coordination and coherence of action on social
conditions in which people are born, grow, live, work, and age. determinants is essential. Fifth, a social determinants approach
These conditions are referred to as social determinants of health, a cannot be a “programme” that is rolled out, but rather requires a
term used as shorthand to encompass the social, economic, political, holistic approach incorporating all of the five building blocks applied
cultural, and environmental determinants of health. The most across society.

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | |2
Priority strategies for implementing action encouraging “shadow reports”, and recognizing the potential for
civil society organizations to provide data to inform policy-making.
on social determinants of health
Priority strategies for action can be identified in each of the five 3. The role of the health sector, including public
building blocks:
health programmes, in reducing health inequities
execute the health sector’s role in governance for social determinants.
1. Governance to tackle the root causes of health
There are four broad, interrelated functions through which the health
inequities sector can make a useful contribution to governance for action on
Build good governance for action on social determinants. coherent social determinants: advocating for a social determinants approach
policy responses to reduce health inequities require establishing and explaining how this approach is beneficial across society and
governance that clarifies the individual and joint responsibilities of for different sectors; monitoring health inequities and the impact
different actors and sectors (for example, the roles of individuals, of policies on social determinants; bringing sectors together to
different parts of the state, civil society, multilateral agencies, and the plan and implement work on social determinants; and developing
private sector) in the pursuit of health and well-being as a collective capacities for work on social determinants.
goal linked to other societal priorities. unDP’s five principles of good
governance (legitimacy, vision and strategic direction, performance, reorient health care services and public health programmes to
accountability, and equity and fairness of processes) are useful in reduce inequities. Health care service providers in all sectors need
framing what is required. to contribute to reducing health inequities by measuring how
existing services perform through the continuum of care for different
implement collaborative action between sectors (“intersectoral population groups; addressing factors that cause differential
action”). Many necessary policies for action on social determinants performance (for example, funding, location, and timing of services
require intersectoral action. successful implementation of and the competencies and attitudes of health workers); and working
intersectoral action requires a range of conditions, including the with other sectors to address other barriers.
creation of a conducive policy framework and approach to health;
an emphasis on shared values, interests, and objectives among institutionalize equity into health systems governance. Governments
partners; the ability to ensure political support and build on positive can reform health system governance through a primary health
factors in the policy environment; the engagement of key partners at care approach towards a publicly led system, with equity as
the outset, with a commitment to inclusivity; sharing of leadership, an institutionalized priority. The aim must be to move towards
accountability, and rewards among partners; and facilitation of universal health care coverage that is accessible, affordable,
public participation. available, equitable, and of good quality for all and that is funded
through taxation, social insurance, or another prepayment pooling
mechanism.
2. Promoting participation
create the conditions for participation. The governance required to
4. Global action on social determinants: aligning
act on social determinants is not possible without a new culture of
participation. The essential elements are institutionalizing formal, priorities and stakeholders
transparent, and public mechanisms through which civil society align global stakeholders and priorities. Given the interconnectedness
organizations can contribute to policy development; providing of the modern world, national action on social determinants is not
resources for participation in the form of incentives and subsidies; sufficient. international organizations, nongovernmental agencies,
considering the impact of previous policies and practices on the and bilateral cooperation partners need to align their efforts on
ability of communities to participate; and building knowledge and social determinants broadly with those of national governments.
capacity by providing accessible information and training for all There is also a need for better alignment among global priorities.
stakeholders. For example, the challenges of achieving the MDGs, building
social protection, addressing climate change, and tackling
Broker participation and ensure representativeness. Governments
noncommunicable diseases are closely linked. all require action
have a role in brokering participation with the aim of facilitating
empowerment, in working towards equitable public representation on social determinants and have impacts on health inequities. in
through targeted mechanisms to reach underrepresented groups, addressing these challenges, national governments, international
and in ensuring the legitimacy and addressing conflicts of interest of organizations, nongovernmental agencies, and bilateral cooperation
those who claim to be community representatives. partners can strive for coherence among global governance
endeavours (including international agreements) in a manner that
Facilitate participation by civil society. Governments can facilitate promotes a social determinants approach. This effort needs to be
the key role of civil society by formalizing civil society organization underpinned by a consistent focus on equity, with the positioning
involvement in policy-making (particularly in ensuring accountability), of health equity as an overarching development goal for all sectors.

3| World Conference on Social

Determinants of Health (WCSDH)
5. Monitoring progress: measurement and analysis inaction. By making use of surveys and of input from communities
to inform policies and build accountability on and civil society organizations and by prioritizing the strengthening
of systems to capture the most vital required data, governments
social determinants can develop policies that are reflective of population needs and
identify sources, select indicators, collect data, and set targets. informed by the best available information.
effective action on social determinants requires monitoring and
measurement to inform policy-making, evaluate implementation, Disseminate data on health inequities and social determinants,
and build accountability. inequities in health outcomes, social and integrate these data into policy processes. The existence of
determinants, and the impact of policies must be monitored. Key data by itself does not automatically translate into action. rather,
requirements are collecting and monitoring indicators of social data must be formulated so that different audiences can use it and
determinants from different sectors, linking with health outcomes, must be linked to the policy-making process. To ensure that data
and monitoring inequities; establishing whole-of-society targets catalyse action on social determinants, governments and academic
towards the reduction of health inequities; and disaggregating data institutions can institutionalize mechanisms to integrate analysis of
to better understand baseline levels and potential impacts of policies. social determinants into the policy development process in order to
develop evidence-informed policies; improve sharing of information
Move forward despite unavailability of systematic data. in many across sectors; and conduct health and equity assessments of all
settings, the availability of data for integrated action on social policies before implementation, using tools such as health impact
determinants is poor. However, lack of data is not an excuse for assessment.

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| Discussion PaPer | |4
Table 1. Summary of recommendations of the Commission on Social Determinants of Health1

1. Improve Daily Living Conditions

• Improve the well-being of girls and women and the circumstances in which their children are born
- Strongly emphasize early childhood development and education for both girls and boys
• Manage urban development
- Increase the availability of affordable housing
- Invest in urban slum upgrading, especially provision of clean water, sanitation, electricity, and paved streets
• Ensure that urban planning promotes healthy and safe behaviours equitably
- Promote walking, cycling, and the use of public transport
- Undertake retail planning to manage access to unhealthy foods
- Implement good environmental design and regulatory controls (e.g. the number of alcohol outlets)
• Ensure that policy responses to climate change consider impacts on health equity
• Make full and fair employment a shared objective of international institutions and a central part of national policy agendas and development
strategies
- Strengthen representation of workers in the creation of employment policy, legislation, and programmes
• Use international agencies to support countries’ efforts to protect all workers
- Implement core labour standards for formal and informal workers
- Develop policies to ensure a balanced work–home life
- Reduce negative effects of insecurity among workers in precarious work arrangements
• Progressively increase social protection systems
- Ensure that systems include those in precarious work situations, including informal work and household or care work
• Build quality health care services with universal coverage, focusing on a primary health care approach
- Strengthen public sector leadership in equitably financing health care systems and ensuring universal access to care regardless of ability to pay
- Redress health brain-drain, focusing on investment in increased health-related human resources and training and on bilateral agreements to
regulate gains and losses

2. Tackle the Inequitable Distribution of Power, Money, and Resources

• Place responsibility for action on health and health equity at the highest level of government and ensure its coherent consideration across all policies
- Assess the impact of all policies and programmes on health and health equity
• Strengthen public finance for action on social determinants of health
• Increase global aid towards the 0.7% target of GNP and expand the Multilateral Debt Relief Initiative
• Develop coherent social determinants of health focus in Poverty Reduction Strategy Papers
• Institutionalize consideration of health and health equity impact in national and international economic agreements and policy-making
• Reinforce the primary state role for basic services essential to health (such as water/sanitation) and regulation of goods and services with a major
impact on health (such as tobacco, alcohol, and food)
• Create and enforce legislation that promotes gender equity and makes discrimination on the basis of gender illegal
• Increase investment in sexual and reproductive health services and programmes, building towards universal coverage and rights
• Strengthen political and legal systems
- Protect human rights
- Assure legal identity and support the needs and claims of marginalized groups, particularly Indigenous Peoples
• Ensure fair representation and participation of individuals and communities in health-related decision-making
• Facilitate the role of civil society in the realization of political and social rights affecting health equity
• Make health equity a global development goal

3. Measure and Understand the Problem and Assess the Impact of Action

• Ensure routine monitoring systems for health equity locally, nationally, and internationally
- Ensure that all children are registered at birth
- Establish national and global health equity surveillance systems
• Invest in generating and sharing new evidence on social determinants and health equity and on effectiveness of measures
- Create dedicated budget for generation and global sharing of evidence
• Provide training on social determinants of health to policy actors, stakeholders, and practitioners, and invest in raising public awareness
- Incorporate social determinants of health into medical and health training
- Train policy-makers and planners in health equity impact assessment
- Strengthen capacity within WHO to support action on social determinants

5| World Conference on Social

Determinants of Health (WCSDH)
inTroDucTion

T
his discussion paper aims to inform proceedings at the The primary audience for this paper consists of policy-makers at the
World conference on social Determinants of Health (“World national level. other audiences who may find this document useful
conference”) about how countries can implement action on include municipal leaders, civil society groups, multilateral agencies,
social determinants of health (“social determinants”), including the and bilateral development agencies. Both this paper and the World
recommendations of the commission on social Determinants of Health conference will build on the extensive work of the commission, as
(“the commission”) (Table 1).1 The paper is organized into three sections. endorsed in World Health assembly resolution 62.14,2 and on the
First, it explains the conceptual basis of the social determinants and substantial body of literature on social determinants. in line with
establishes why the implementation of coherent policy responses is its length and scope, the paper focuses on how the commission’s
essential to development, to progress in alleviating health inequities, recommendations can be implemented rather than extensively
and to other national and global priorities. second, it addresses some considering specific issues or health conditions or repeating in
of the political challenges that will be faced in moving forward on detail what the commission has already established (particularly, for
social determinants and that will need to be considered by the World example, on the causes of health inequities).
conference in leading up to the “rio Declaration” — a commitment for
action — and in subsequently implementing action. Third, it aims to Figure 1. The relationship of the five themes of the World
provide a relatively technical overview of how to implement action on Conference
social determinants of health, highlighting key strategies based on the
five World conference themes:
AL PRIORITIES
1. Governance to tackle the root causes of health inequities: GLOB
implementing action on social determinants of health; Governance
2. Promoting participation: community leadership for action
on social determinants; HEALTH
SECTOR
3. The role of the health sector, including public health ECONOMY EDUCATION
programmes, in reducing health inequities; AND TRADE

4. Global action on social determinants: aligning priorities and

HEALTH EQUITY
stakeholders; EMPLOYMENT AND JUSTICE
DEVELOPMENT
5. Monitoring progress: measurement and analysis to inform
policies and build accountability on social determinants.

Par
Mon

HOUSING AND

t ic
TRANSPORT
ENVIRONMENT
These five closely interrelated themes (Figure 1) have been selected i
i to

AGRICULTURE p ati
because they emphasize key mechanisms by which countries can
rin

AND FOOD
o
n
g

incorporate action on social determinants into policy goals and can

implement such policies in all sectors. evidence from countries that
have made progress shows that holistic action is required on all
GLO
of these themes, which together represent the building blocks for BAL STAKEHOLDERS
a “social determinants approach”, reflecting the need for action
on social determinants across society. The inclusion of a separate
theme on the role of the health sector is not intended to diminish
the vital role of other sectors, but reflects the large health-sector
constituency expected at the World conference and highlights some
of this sector’s key responsibilities.

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| Discussion PaPer | |6
concePTuaL Basis anD raTionaLe For acTion
on sociaL DeTerMinanTs

i
t has long been known that social conditions decisively influence education systems; market structures for labour and goods; financial
health3 and therefore that action across all sectors is required to systems; attention to distributional considerations in policy-
promote well-being – as highlighted in the Declaration of alma making; and the extent and nature of redistributive policies, social
ata adopted in 1978 by the international conference on Primary provision, and social protection. These structural mechanisms that
Health care4 and in the 1986 ottawa charter for Health Promotion.5 affect the differential social positions of individuals are the root
The bulk of the global burden of disease and the major causes of cause of inequities in health. These differences shape individual
health inequities, which are found in all countries, arise from the health status and outcomes through their impact on intermediary
conditions in which people are born, grow, live, work, and age.1 determinants such as living conditions, psychosocial circumstances,
These conditions are referred to as social determinants of health, a behavioural and/or biological factors, and the health system itself.
term used as shorthand to encompass the social, economic, political, The commission’s final report used this framework6 (Figure 2) to
cultural, and environmental determinants of health. inform its recommendations.

not all determinants are equally important. The most important The social determinants approach requires coordinated and coherent
are those that produce stratification within society — structural action in the sectors of society that influence structural determinants
determinants — such as the distribution of income; discrimination to improve health and reduce inequities. in return, it is now well
on the basis of factors such as gender, ethnicity, or disability; and recognized that better health contributes to other important societal
political and governance structures that reinforce rather than reduce priorities, such as increased well-being, education, social cohesion,
inequalities in economic power. These determinants establish a set environmental protection, increased productivity, and economic
of socioeconomic positions within hierarchies of power, prestige, development.7 in this “virtuous circle”, improvements in health
and access to resources. Mechanisms that produce and maintain and its determinants feed back into each other, providing mutual
this stratification include formal and informal governance structures; benefits.8

Figure 2. Conceptual framework of the social determinants of health

SOCIOECONOMIC
POLITICAL

CONTEXT
• Governance

• Macroeconomic Socioeconomic Position Material Circumstances

Policies (Living and Working
conditions, Food
IMPACT ON
• Social Policies availability, etc.)
Social Class EQUITY IN
Labour Market,
Gender Behaviors and Biological HEALTH AND
Housing, Land
Ethnicity (racism) Factors WELL-BEING
• Public Policies Psychosocial Factors
education, Education
Health, social
Protection Social Cohesion & Social Capital
Occupation
• Culture and
Societal Values Income
Health System

STRUCTURAL DETERMINANTS
INTERMEDIARY
OF HEALTH INEQUITIES
DETERMINANTS OF HEALTH

source: solar and irwin, 20106

7| World Conference on Social

Determinants of Health (WCSDH)
 all sectors have an interest in and responsibility for creating fairer
and more inclusive societies by implementing coherent policies
that increase opportunities and promote development. Health is
a defining factor of good governance.9 efforts are increasing to
broaden the definition of what is important in evaluating societal
goals beyond narrow economic indicators such as gross domestic
product (GDP).10 The success of societies must be measured not only
in terms of economic growth but also in terms of sustainability and
the increased well-being and quality of life of citizens.

Health is a key contributor to this wide range of societal goals. The

social determinants approach therefore identifies the distribution of
health, as measured by the degree of inequity in health, as a key
indicator not just of a society’s fairness and social justice, but also of
its overall functioning. Health inequities constitute a clear indicator
underpinning the social determinants approach is therefore an of a lack of success and coherence of a society’s policies across many
appreciation of the broader value of health to society and the domains.
dependence of health on actions far beyond the health sector. The
commission’s call for broad actions reflects the occurrence of risks for addressing social determinants is also essential for improving health
health and the benefits of action at all levels of governance — local, in general. Without action on social determinants, the health-
national, and global. as both problems and solutions are systemic, related Millennium Development Goals (MDGs) cannot be attained
public policies are centrally important — for example, transport and and targets for combating ncDs cannot be met, nor can prevention
housing policies at the local level; fiscal, environmental, educational, strategies be effectively implemented to reduce suffering and
and social policies at the national level; and financial, trade, and unsustainable health care spending on technologies for the treatment
agricultural policies at the global level. of chronic diseases. care must be taken, however, that such action
on social determinants does not, in fact, increase inequities by more
The social determinants approach also reflects the reality that rapidly improving conditions for those better off; hence the need for
health inequities cannot be addressed without addressing social a clear focus on equity. Health and social systems that aim to reduce
inequalities. coordinated action to achieve good health is essential health inequities by delivering better performance and improving
in sustaining a strong economy and preserving social stability and outcomes more rapidly for disadvantaged groups may, in fact,
national and global security. adopting a focus on social determinants perform more effectively for people in all societal strata.
supports the integration of coherent action across a number of
priorities, including, for example, building social protection and in conclusion, the rationale for action on social determinants of
addressing climate change. Moreover, the social determinants health rests on three broad themes. First, it is a moral imperative
approach considers intergenerational equity, which has often been to reduce health inequities. second, it is vital to improve health and
ignored but is now central to public policy challenges. climate well-being, promote development, and achieve health targets in
change, which is symbolic of environmental degradation as a whole, general. Third, and most important, action on social determinants is
significantly threatens the well-being of future generations. Trends required to achieve a range of societal priorities, which benefit from
such as increasing rates of noncommunicable diseases (ncDs) and reducing health inequities.
diminishing economic opportunities and welfare entitlements,
which are being seen in countries at all income levels, are already
resulting in intergenerational inequalities, decreasing expectations
of health, and social unrest.

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | |8
PoLiTicaL consiDeraTions For iMPLeMenTinG
acTion on sociaL DeTerMinanTs
implementing a social determinants approach requires addressing
Progress, obstacles, and the effect of crises influential sectors whose interests do not always coincide with
Many countries are moving forward to implement a social improving health equity. For example, the private sector is crucial to
determinants approach. Their experiences inspired and informed most determinants, yet many private sector activities are damaging
the recommendations of the commission. since the launch of the to health and the environment. addressing this challenge requires
commission’s report, further progress has been made. Brazil, the moving beyond the corporate social responsibility paradigm that up
host of the World conference, convened a national commission to now has delivered far less than it has promised. Governments
on social Determinants of Health11 and has continued to achieve have an important role in setting up a regulatory framework for
reductions in inequities in childhood mortality and stunting that private sector activities that aligns with health and development and
parallel its progress in reducing income inequality and poverty rates to enforce these rules if commercial enterprises act in a manner that
and in expanding its universal health system.12 in response to the undermines these goals.
commission’s report, a review of health inequities in england led
to action at the local and central government levels.13 countries as Moreover, poor progress in implementing a social determinants
diverse as china,14 india,15, 16 the united states of america,17 and sierra approach partly reflects the inadequacy of governance at local,
Leone have taken gradual but significant steps towards universal national, and global levels in addressing the key problems of the
health care coverage. spain championed social determinants as one 21st century. Health inequities are illustrative of a complex problem
of its priorities during its presidency of the european union in 2010.18 that demands coherent policy responses — across sectors and
The european region is currently reviewing social determinants to across countries — based on firm political commitment by all parties.
guide future regional health policy, while the african region last These interconnected problems challenge the traditional division
year endorsed a regional strategy on social determinants at its WHo of societies and their governments into sectors for organizational
regional committee meeting.19 in south america, unasur’s council purposes. The social determinants approach requires reorientation
of Ministers of Health has identified tackling social determinants in of policies and policy coherence so that, instead of working at cross-
the region as one of five priorities in the organization’s 2010–2015 purposes, different sectors, different types of actors, and different
plan of action.20 levels of governance (global, national, and local) are aligned to
mutually contribute to sustainable human development and promote
These examples show that the lessons of the commission have been one another’s goals. Governments need to take responsibility for
taken to heart – that is, that there are solutions to the problems this realignment, including the use of regulation where necessary.
that cause health inequities and that action on social determinants
is feasible in moving towards the commission’s vision of a world This approach also requires greater consideration of each society’s
where social justice is taken seriously. Yet, despite many examples key goals. economic growth has long been pursued as the
such as those described above, progress among countries has been highest priority, but this principle is starting to be questioned.
slow in general. in most cases, the countries that are continuing to Broader measures of societal well-being are closely related to
make progress are those in which efforts had already started before health, as shown, for example, by the report of the commission
the commission’s report. acknowledging this lag in progress, the on Measurement of economic Performance and social Progress
World conference aims to mobilize political commitment among established by the Government of France.10 a healthy population is
countries to the implementation of necessary actions as part of important for economic growth, but it does not follow that economic
national policies on social determinants. growth necessarily improves general health, enhances societal
happiness and well-being, or reduces health inequities. While a
Moving forward requires addressing the obstacles to implementing strong economy can contribute to health, it is well documented that
a social determinants approach. These obstacles include a lack this correlation becomes weaker once GDP per capita increases over
of technical knowledge and capacity. The World conference a threshold of $5000.21
provides an opportunity for countries to share experiences and
build awareness of the available knowledge and tools. subsequent The need to implement a social determinants approach has been
sections of this paper provide an overview of priority strategies to brought into sharper relief by new or exacerbated crises in realms such
implement the commission’s recommendations. as finance, food, public health, and the environment since 2008.22
as these crises have clearly demonstrated, the interconnectedness
The greater challenges, however, are political. These political of the modern world means that countries cannot confront these
challenges are the context within which any technical approach challenges on their own or through action in single sectors. rather,
to the implementation of action on social determinants operates. a consistent, focused effort is required at all levels, from local to

9| World Conference on Social

Determinants of Health (WCSDH)
global. These emergencies have also uncovered failures of regulation must be explained in language that enables sectors beyond health
and the problems of an overemphasis on narrow indicators of to understand their relevance and potential contribution to the
economic stability, demonstrating the need for coordinated action general good.
and a strong state. For example, despite prevailing doctrine over
the past 30 years, those who have suffered most from these crises Third, equity in health and well-being need to be placed as a
have often been those who contributed least to the problems that priority goal for government and broader society. Positioning
caused them. Governments have come together to coordinate health and well-being as key features of successful, inclusive, and
policy and have raised funding to stabilize economic systems in an fair societies implies endorsement of a set of values that includes a
unprecedented manner. in so doing, they have highlighted the need commitment to human rights and health equity, democratization of
for and feasibility of action on social determinants. By opening space health and well-being, and solidarity for health at the national and
for real debate on policy issues and objectives, these multiple crises international levels. investment in social determinants and reduction
have therefore created an unprecedented opportunity to adopt a of health inequities — to realize the right of all people to have equal
social determinants approach. opportunities for health and to pursue lives that they value — is a
moral imperative that coincides with the commitments all countries
at the same time, these same crises have paradoxically intensified have made to health and human rights through international human
the political challenges to implementing a social determinants rights treaties. even if human rights–based and social determinants
approach in some countries, especially aspects that relate to approaches are not always completely aligned,23 they are strongly
redistribution, rights, and regulation. in response to reductions in complementary.24 While different societies prioritize different aspects
fiscal space, calls have been made for reductions in social services of fairness and justice, all countries can agree on the equality of
that have significant impacts on social determinants. This trend risks opportunity that health equity entails.
repeating errors of the past that had serious and extensive negative
Fourth, as discussed further in the section on building governance,
effects on health equity. Lessons need to be learned from countries
ensuring coordination and coherence of action on social
that have protected and even expanded spending on key social
determinants is essential. Key political considerations include (1)
determinants in times of crisis.
combining central stewardship with conditions that enable different
sectors to collaborate and (2) prioritizing action. a central message of
Principles and requisites for action the social determinants approach is that other sectors can contribute
in this complex context, the World conference provides a forum for to health by doing their own work well and in a way that promotes
consideration of how, with the help of international organizations, their own goals. However, in each context, there is a need to identify
countries can assist one another in managing these political the areas in which action is most important and to focus on these.
challenges. The political statement to be issued from the World While implementing a social determinants approach will sometimes
conference, the “rio Declaration”, will reflect the outcome of require new resources, existing government expenditures can also
these deliberations. There is no blueprint for how a country can be evaluated in terms of how they can be realigned. Furthermore,
overcome political and technical obstacles to implementation of a coherence between social and economic policies is a key priority. even
social determinants approach. each country will need to proceed in countries where social policies actively aim to reduce inequities,
according to its own priorities and circumstances. However, some economic policies often pull in the opposite direction. consideration
general principles and key requisites for action can be identified. and monitoring of the consequences (both intended and unintended)
of policy decisions on health and health equity can be institutionalized
First, action on social determinants to reduce health in policy-making. To this end, significant improvements are required
inequities requires long-term, sustained implementation. in the capacity within governments to undertake these analyses.
Benefits can become evident in the short term, however, and are
likely to accrue in other sectors in which policies are applied to Fifth, a social determinants approach cannot be a
determinants before becoming apparent in reduced health inequities. “programme” that is rolled out. instead, it requires systematic
For countries that have yet to implement a social determinants implementation and learning from the resulting experience in each
approach, the message is that the sooner they start, the better. context. countries that have been successful have started with high-
countries whose efforts have already begun have the opportunity to priority issues and have made progress based on their experiences.
expand and deepen those efforts. acting on social determinants implies a different mode of policy-
making and implementation. Monitoring and evaluation (as discussed
second, the initial step is to build public understanding of further below) are crucial in determining whether an approach is
health inequities and social determinants of health. civil making a genuine difference in terms of social determinants and
society organizations can play an important role in raising awareness. health equity. Better methods and tools are required to evaluate
Public understanding of the importance of these issues will generate which specific policies are most useful in each context. While there
a demand for action. starting to measure health inequities and is evidence for the effectiveness of acting on social determinants to
social determinants by key factors that stratify populations (such as reduce health inequities, more research and knowledge are needed
geographical location, ethnicity, income, or sex) can assist with this to better inform policy-makers of what works best in their particular
task and lay the foundation for further work. social determinants context.25

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 10
1. GoVernance To TacKLe THe rooT
causes oF HeaLTH ineQuiTies:
iMPLeMenTinG acTion on sociaL
DeTerMinanTs oF HeaLTH

11 | World Conference on Social

Determinants of Health (WCSDH)
T
aking a social determinants approach requires governments priority, complex problems that demand an integrated policy
to coordinate and align different sectors and different types response across sectors. This strategy considers the effects of
of organizations in the pursuit of health and development policies on social determinants as well as the beneficial impact of
— for all countries, rich and poor — as a collective goal. Building improvements in health on the goals of other sectors. examples of
governance, whereby all sectors take responsibility for reducing this type of policy response are shown in Table 2. While HiaP is a
health inequities, is essential to achieve this goal. intersectoral useful strategy, it needs to be adapted to each country’s specific
action — that is, effectively implementing integrated work between historical and cultural context.27
different sectors — is a key component of this process.
This section focuses on governance at the national level. However,
Health in all Policies (HiaP) is a policy strategy that illustrates how many promising examples of a social determinants approach come
health can be established as a shared goal across the whole of from the municipal and subnational levels (for example, in states 1.
government and as a common indicator of development.26 HiaP or provinces, as shown in the box below on south australia).
highlights the important links between health and broader economic similar principles apply in these cases, and indeed it can be easier
and social goals in modern societies, and it positions improvements to integrate policy-making towards social determinants in these
in population health and reductions in health inequities as high- smaller-scale jurisdictions.

Table 2. Examples of policies integrating a social determinants approach

Sectors and issues Interrelationships of health and other societal goals

Economy and • Economic resilience and growth are stimulated by a healthy population. Healthier people can increase their household
employment savings, are more productive at work, can adapt more easily to work changes, and can remain in the workforce for longer.
• Work and stable employment opportunities improve health for all people across different social groups.

Security and justice • Rates of violence, ill health, and injury increase in populations whose access to food, water, housing, work opportunities,
and a fair justice system is poorer. Justice systems within societies must deal with the consequences of poor access to these
basic needs.
• The prevalence of mental illness (and associated drug and alcohol problems) is associated with violence, crime, and
imprisonment.

Education and early • Poor health of children or family members impedes educational attainment, reducing educational potential and abilities to
life solve life challenges and pursue opportunities.
• Educational attainment for both women and men creates engaged citizens and directly contributes to better health and the
ability to participate fully in a productive society.

Agriculture and • When health is considered in food production, manufacturing, marketing, and distribution, food security and safety are
food enhanced, consumer confidence is promoted, and more sustainable agricultural practices are encouraged.
• Healthy food is critical to people’s health; good food and security practices reduce animal-to-human disease transmission
and support farming practices that have a positive impact on the health of farm workers and rural communities.

Infrastructure, • Optimal planning of roads, transport, and housing requires the consideration of health impacts, which can reduce
planning, and environmentally costly emissions and improve the capacity of transport networks as well as their efficiency in moving
transport people, goods, and services.
• Better transport opportunities, including cycling and walking opportunities, build safer and more liveable communities and
reduce environmental degradation, enhancing health.

Environment and • Optimizing the use of natural resources and promoting sustainability, which can best be achieved through policies that
sustainability influence population consumption patterns, can also enhance human health.
• Globally, one quarter of all preventable illnesses are the result of the environmental conditions in which people live.

Housing and • Housing design and infrastructure planning that take health and well-being into account (e.g. insulation, ventilation, public
community services spaces, refuse removal) and involve the community can improve social cohesion and support for development projects.
• Well-designed, accessible housing and adequate community services address some of the most fundamental determinants
of health for disadvantaged individuals and communities.

Land and culture • Improved access to land can support improvements in health and well-being for Indigenous Peoples, as their health and
well-being are spiritually and culturally bound to a profound sense of belonging to land and country.
• Improvements in indigenous health can strengthen communities and cultural identity, improve citizen participation, and
support the maintenance of biodiversity.
source: adapted from WHo and Government of south australia, 20109

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 12
Building good governance for action The united nations Development Programme (unDP) has established
five principles of good governance that are useful in framing
on social determinants what is required.28 First, the implementation of policies on social
The term governance has to do with how governments (including determinants needs to be part of a process that has legitimacy
their different constituent sectors) and other social organizations and provides a voice for all parties. central government agencies
interact, how these bodies relate to citizens, and how decisions are — at the executive level — have a key role in driving action and
taken in a complex and globalized world.28 Governance represents a framing health as a shared goal as well as in mediating conflicts
process whereby societies or organizations make decisions, ascertain and building consensus among sectors. Governance is particularly
who should be involved in these decisions, and determine how demanding when there are no mutual policy interests. Governments
accountability for actions can be ensured. coherent policy responses must adhere to key principles and confront interests that actively
to reduce health inequities require establishing governance that undermine health equity rather than adopting a stakeholder
clarifies the individual and joint responsibilities of different actors approach in which each interest is equally weighted. The need
and sectors (for example, the roles of individuals, different parts for and the value of true participation in policy-making for social
of the state, civil society, multilateral agencies, and the private determinants are discussed further below.
sector) in the pursuit of health and well-being as a collective goal
linked to other societal priorities. other necessary features of second, work on social determinants requires direction and a strategic
governance include political leadership and long-term commitment, vision for the sustained action needed to reduce health inequities and
an engaged civil society, human resources with appropriate skills in particular to tackle the “short-termism” that often leads to rapid
and knowledge, and a “learning environment” that allows policy implementation of inadequate measures. understanding the common
innovation and conflict resolution. Finally, consistency among benefits across society that accrue from work on social determinants is
different policy-making spheres is required. a key part of the necessary vision. The formulation of national strategies
or plans is a useful opportunity to establish a process to develop and
Building governance for action on social determinants is a complex implement policies utilizing a social determinants approach. in terms
task that is highly dependent on each country’s political system and on of building governance, the process employed in doing so can be more
who needs to be involved in each context. While there is no ‘one-size- important than the final document.
fits-all’ recipe, common issues need to be addressed by the differing
models of governance that may be used to institutionalize health Third, there is a need to ensure performance in both the
as a shared goal across society, with health equity as a measure. process and its outcomes. The mechanisms for decision-making
These issues include establishing who drives the action and takes the on social determinants should be responsive to all stakeholders,
initiative; clarifying the roles of different sectors and groups; ensuring and the process and resultant implementation of policies need to
the participation of disadvantaged groups; ensuring accountability be effective and efficient, making best use of resources in terms
for the shared goal; and considering how to monitor progress. useful of the common goals identified. Budgeting approaches, such as
tools and instruments in this regard are listed in Table 3. participatory budgeting, can increase both responsiveness and
performance.
Table 3. Useful tools and instruments for implementing
policy on social determinants Fourth, accountability must be clear. all actors, whether in
different sectors of government, civil society, or the private sector,
• Inter-ministerial and inter- • Cross-sector action teams
need to be held accountable for decisions made with regard to the
departmental committees shared goals that have been identified and the impact of these
decisions on health and health equity. accountability for health and
• Integrated budgets and • Cross-cutting information and equity outcomes cannot be limited to the health sector. Targets can
accounting evaluation systems
be useful in addressing particular policy problems; there must be
• Integrated workforce • Community consultations and specific targets for each sector in line with the social determinant
development Citizens’ Juries30 upon which it acts. Transparency of the process is vital in terms of
• Partnership platforms • Health lenses29
who makes decisions and who is responsible for the implementation
of agreed-upon policies and their outcomes. The use of health
• Impact assessments • Legislative frameworks lenses, which make joint decision-making explicit and identify
source: adapted from WHo and Government of south australia, 20109 common benefits, can clarify accountabilities.29

13 | World Conference on Social

Determinants of Health (WCSDH)
 “Our government is moving towards health and environment based taxation. Our
earlier experience shows that fiscal means are very effective in increasing health in
general and especially in increasing health equity. This government will raise the
taxes on, for example, alcohol and tobacco, sweets, chocolates, and ice cream. The
economic situation is uncertain and it is good to have measures that work both for
increasing revenues and for improving health equity.”
Ms Jutta Urpilainen, Minister of Finance, Finland 1.

IMPLEMENTING HEALTH IN ALL POLICIES IN FINLAND

Finland has a long history of intersectoral action for health. in 1972, the Finnish economic council published a report on health policy
simultaneous with the initiation of public health action across Finnish society aimed at reducing mortality rates from cardiovascular
disease. in 1986, Finland became a pioneer for WHo’s “Health for all” policy, launching a national strategy. subsequent national health
policies have included intersectoral policies for health. since 1997, there has been an intersectoral advisory Board for Public Health,
nominated by a council of state, whose mandate is to foster intersectoral policy-making for health among the various administrative
sectors, organizations, and other relevant bodies.

in 2006, Finland consolidated its experiences in implementing a “Health in all Policies” (HiaP) approach, positioning HiaP as the core
public health theme during the Finnish presidency of the european union (eu). The HiaP approach in Finland — and also as approved
within the context of eu policies — applies to government (as the executive) as well as to broader political decision-making and
accountability at all levels of governance. it emphasizes the need for both public support and political leadership. The health sector
is important in advocating for health and providing its expertise for intersectoral policy-making. implementation of HiaP on local and
regional levels is now legally required in Finland.

While Finland has continued to implement its own national HiaP approach, its eu presidency resulted in HiaP also becoming one of
the four overarching principles of the eu’s new health strategy, “Together for Health: a strategic approach for the eu 2008–2013”.

More information on the Finnish experience can be found at http://biturL.net/bwxq or by consulting the following publications:

ollila e et al. Health in all Policies in the european union and its member states. Policy brief available from http://biturL.net/bye6.
Puska P, ståhl T. Health in all Policies - The Finnish initiative: background, principles, and current issues. annual review of Public Health, 2010, 31:27.1–27.14.

Fifth, processes in decision-making on social determinants and decisions – a position referred to as “genuine equality of influence”
implementation of these decisions, with the aim of reducing health in the commission’s report. These organizations should provide
inequities, need to be fair. Progress on health inequities is unlikely direction and strategic vision for concerted global efforts to promote
without equitable processes and access to interventions. Legal social determinants and should seek ways of overcoming the short
frameworks — for example, the enshrining of rights to health and time horizons that inevitably arise from political cycles. They should
its determinants in national constitutions — can be helpful, but only seek to ensure that such efforts are both effective and responsive
if they are enforced fairly. to the needs and priorities of those affected. Their governance
structures should ensure effective accountability to the global
These principles apply equally to and are at least as important in population as a whole. Finally, international institutions should aim
global governance. international institutions should ensure legitimacy proactively to be fair in all their decision-making processes as well
by affording an equal and effective voice to those affected by their as in the execution of their activities.

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 14
 “South Australia has made "Health in All Policies" more than a catch phrase.
Using the framework of South Australia's Strategic Plan, innovation from our
Thinkers in Residence programme, and leadership from the Department of Premier
and Cabinet, "Health in All Policies" is central to the decisions we make as a
Government.”
Hon Mike Rann, Premier, South Australia

implementing intersectoral action stage of the process requires a sound understanding of each sector’s
interests and objectives. a conceptual model showing the interplay
some actions on social determinants require whole-of-society of various social determinants, with all sectors represented, can be
and whole-of-government approaches with an explicit concern helpful in demonstrating how all sectors concerned have a role to
for health equity through national policy or legislation. others play. necessary steps for successful isa are described in Table 4.
simply require that individual sectors do their own jobs well (for
Lessons can also be learned by adapting innovative intersectoral
example, designing and implementing tax or education policy).
approaches used by other sectors; for example, environmental
However, many necessary policies require collaboration among
impact assessments have strongly influenced the development of
sectors, or intersectoral action (isa).31 For example, communities,
health impact assessment methodologies.
especially the disadvantaged, rarely conceive their needs in terms
of fragmented sectors. Meeting these needs therefore requires Table 4. Necessary steps for successful implementation of
the integrated delivery of services. The idea of isa is not new to intersectoral action
health, having been championed by the primary health care and
health promotion movements over the past 30 years. nevertheless, 1. Create a policy framework and an approach to health that are
the lack of development of the necessary governance and systems conducive to intersectoral action.
to implement coherent policies on social determinants has been a
2. Emphasize shared values, interests, and objectives among partners
significant obstacle to progress. Moreover, isa has often involved and potential partners.
the instrumentalization of resources from other sectors to health
care rather than efforts to mutually improve each sector’s policies.21 3. Ensure political support; build on positive factors in the policy
environment.
Major challenges include deciding which problems require isa
4. Engage key partners at the very beginning; be inclusive.
and identifying common goals for different sectors with differing
interests. not all sectors need to be involved; instead, the priority 5. Ensure appropriate horizontal linking across sectors as well as vertical
sectors for each issue and context should be identified and their linking of levels within sectors.
buy-in sought. central agencies have the main role in this regard, 6. Invest in the alliance-building process by working towards consensus
although many municipal authorities have been particularly at the planning stage.
successful at the local level. all sectors involved need to see the
7. Focus on concrete objectives and visible results.
benefits of collaborative work, and these potential advantages
need to be foremost in identifying and translating common goals 8. Ensure that leadership, accountability, and rewards are shared among
for isa. For work on social determinants, the benefits conferred on partners.
other sectors by improvements in health and health equity need to 9. Build stable teams of people who work well together, with appropriate
be clearly articulated in terms of each sector’s own priorities and support systems.
agendas.
10 . Develop practical models, tools, and mechanisms to support the
implementation of intersectoral action.
This task requires bridging different understandings of the same
problem as well as the divergent language that different sectors use 11. Ensure public participation; educate the public and raise awareness
to describe the same issue. it also involves identifying the sectors about health determinants and intersectoral action.
with vested interests in activities that may address the problem; this source: adapted from Public Health agency of canada, 200732

15 | World Conference on Social

Determinants of Health (WCSDH)
conflicts and trade-offs between short- and long-term goals and
between the interests of different sectors are inevitable. There
are numerous “win-win” possibilities during action on social
determinants, but some necessary actions will result in unsatisfactory
outcomes for some parties. in managing these conflicts, governments
need to consider imbalances in power between different sectors
and determine where the greatest interests for health and health
equity lie. For example, when communities and trade unions are
involved in disputes with corporations over economic development
projects related to concerns about working conditions and
environmental impacts, governments need to consider power 1.
imbalances and possible health impacts and must critically analyse
where any economic benefits will accrue. Governments also have a
responsibility to advocate for those with less power and to confront
interests that undermine health equity.

useful resources (available on accompanying DVD)

• Graham J, Amos B, Plumptre T. Principles for good governance in the health. Ottawa, Public Health Agency of Canada, 2007.
21st century. Policy brief no.15. New York, UNDP, 2003. • Health equity through intersectoral action: an analysis of 18 country case
• Kickbusch I, Buckett K, eds. implementing Health in all Policies: adelaide 2010. studies. Ottawa, Public Health Agency of Canada and WHO, 2008.
Adelaide, Department of Health, Government of South Australia, 2010. • Adelaide Statement on health in all policies. Adelaide, WHO and
• crossing sectors - experiences in intersectoral action, public policy and Government of South Australia, 2010.

IMPLEMENTING HEALTH IN ALL POLICIES IN SOUTH AUSTRALIA

since 2007, the state of south australia has adopted a “Health in all Policies” (HiaP) approach, placing it strategically as a central
process of government to improve health and reduce inequities rather than implementing it as an approach run by and for the health
sector and imposed on other sectors. This approach has been framed as essential in achieving not only health priorities but also a
range of goals in the state’s main planning document, the south australian strategic Plan.

strong intersectoral relationships have been built to explore interconnections of various targets within the strategic Plan and social
determinants and to work towards the joint achievement of individual agencies’ goals and population health improvements. a health
lens analysis process has been used, building on traditional health impact assessment methodology and incorporating additional
methods, such as economic modelling, to improve rigour and flexibility and to accommodate the policy goals of the agencies in the
partnership. as a consequence, the health lens is modified for each project and evaluation is built in. a range of projects involving
different sectors have been undertaken. These projects include water security, migrant settlement, and access to digital technology.
The foundations for the success of the Health in all Policies approach in south australia have been identified as:

• a strong cross-government focus;

• a central government mandate and coordination;
• flexible and adaptable methods of enquiry, using health lens analysis;
• mutual gain and collaboration;
• dedicated health resources for the process;
• joint decision-making and joint accountability.

in 2011, the south australian Government incorporated specific provisions in new public health legislation to strengthen the mandate
and sustainability of this approach. More information on the south australian experience can be found at http://biturL.net/bhsn or by
consulting the following publication:

Kickbusch i, Buckett K, eds. implementing Health in all Policies: adelaide 2010. adelaide, Government of south australia, 2010. available at http://biturL.net/bhsp.

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 16
2. ProMoTinG ParTiciPaTion:
coMMuniTY LeaDersHiP For
acTion on sociaL DeTerMinanTs
17 | World Conference on Social
Determinants of Health (WCSDH)
T
he governance required to act on social determinants is not There is no “magic bullet” to ensure participation in policy-making.
possible without a new culture of participation that ensures Participation that leads to social change arises from social movements
accountability and equity. Facilitating participation can help in specific contexts. However, many government actions can actively
safeguard equity as a principle and ensure its inclusion in public obstruct the ability of communities to raise concerns about their daily
policies. Besides participation in governance, other aspects of living conditions and propose solutions for problems. Furthermore,
participation, such as individual participation in taking up services or there is often resistance among policy-makers and “experts” to
participation of communities in service delivery, are also important participatory efforts. Governments can help overcome these barriers
for reducing health inequities. However, the participation of and create conditions that are conducive to the participation of
communities and civil society groups in the design of public policies, empowered communities in making decisions that affect their health
in the monitoring of their implementation, and in their evaluation is in the context in which they live. in this regard, it is critical to avoid
essential to action on social determinants. There are many examples tokenism. at the same time, civil society organizations can consider
whereby participation has resulted in greater emphasis on health, how best to contribute to action on social determinants, including
ranging from various experiences with participatory budgeting to building awareness of health inequities, helping communities to
youth-driven advocacy such as the “nine is Mine” campaign by organize, advocating for better and more inclusive governance,
children in india.33, 34 and ensuring accountability in the implementation and effects of
policies.
Participation is therefore a key intervention to strengthen
political sustainability at national and global levels and to ensure
that policies and interventions reflect people’s needs. of particular creating the conditions for participation
importance is the involvement of communities in guaranteeing Promoting participation can seem risky for policy-makers, as this
accountability for decisions. countries such as Brazil and Thailand effort implies a shift in power relationships in favour of population
that have had recent success in reducing health inequities have groups that often have historically been excluded and marginalized. 2.
placed renewed emphasis on this dimension of participation (see These are key social determinants upon which action is required to
box below). sustaining necessary action on social determinants reduce inequities. Doing so requires a willingness to transfer real
across a range of sectors, particularly ensuring that services are power to communities and to bear the consequences of people’s
responsive to the needs of disadvantaged populations, is extremely demands for what may be transformative change. Yet participation
difficult without broader societal involvement. also offers many rewards for political leaders who seek reform.
By creating a broader constituency to take ownership for policy
Participation conceived in this way has intrinsic value in respecting processes and credit for changes and their ensuing benefits, the
people’s autonomy and right to be involved in decisions that affect participation of communities can drive difficult reforms and create
them. For action on social determinants, participation is part of a significant legacy that is unlikely unless change can be sustained.
the overall goal itself: improved agency, well-being, dignity, and
quality of life for all members of society. However, the participation Figure 3 depicts how the culture of participation in policy-making
of communities in policy-making can also be instrumental in driving is created between communities and civil society on one side
new initiatives, increasing accountability, and sustaining change. and governments on the other. This culture consists of four key

Figure 3. The context and resources that influence social participation

Previous Policies
and Practices

Communities and
civil society that
Politicians who are
Structures can put issues on
aware and motivated
and Spaces CULTURE Resources
the decision-making
to deal with issues
agenda and then
pursue them

Knowledge

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| Discussion PaPer | | 18
 “The National Health Assembly is a process to develop participatory healthy public
policies involving all stakeholders. Its job is to weave vertical threads representing
top-down decisions with horizontal threads representing the demands and needs of
people into a new harmonious pattern. Its mission is beyond the Ministry of Public
Health because it involves health in all policies.”
Dr Amphon Jindawatthana, Secretary-General of the
National Health Commission Office, Thailand

components: the structures and spaces that allow participation Providing resources
to occur, the resources that stakeholders have to participate,
the knowledge necessary to participate, and the impact of Participation has many benefits, but it is also costly. stakeholders
previous policies and practices on participation. This framework need sufficient time, money, institutional capacity, and human
is not exhaustive, but effectively facilitating participation requires resources to participate effectively in policy-making that promotes
addressing at least these four elements. their interests. Moreover, because policy-making is an ongoing
process, participation requires the availability of resources over a
sustained period.
institutionalizing mechanisms for participation
Political, physical, and institutional structures, along with their Governments can invest in participation by offering incentives,
rules, regulations, and relationships, can either inhibit or promote subsidizing costs, and considering the timing and venue of
participation in policy-making as they define where participation participatory processes to maximize the possibility that people will
occurs and who can access processes. These structures can be be able to attend. civil society organizations can provide resources
either formal or informal. To facilitate participation, processes need required for participation and can help communities identify which
to be as transparent as possible and informal procedures need to issues they should prioritize for action.
be minimized, as they are often less accessible to disadvantaged
communities. stable mechanisms are necessary to institutionalize
considering the impact of previous policies
participation as central to the policy-making process.
and practices
The success of the mechanisms chosen to institutionalize participation
Lack of mechanisms and lack of resources are not the only barriers
is highly dependent on the context and process whereby they are
to participation. People’s previous experiences as well as the
incorporated into governance. assemblies and councils have been
successful in countries where they are closely linked to the decision- political and historical context in dealing with government strongly
making process. in other nations, they have had minimal impact influence their perception and ability to participate in policy-making.
on policy. similarly, decentralization, where funding and resources Groups that face discrimination are especially unlikely to engage
are devolved to subnational bodies, has been useful in encouraging with participatory mechanisms; governments therefore need to
community involvement in many countries. However, there have also proactively facilitate their participation not only by allocating
been many negative experiences, particularly where commitment, resources but also by actively recognizing their culture and their
resources, or knowledge have been insufficient to implement agency to contribute to their own well-being. in many countries,
action in response to heightened expectations. other tools, such as changes must be made in the practices of the government and its
dialogues, participatory budgeting, and citizen juries, are likewise staff, with participation established as a central component in the
only as useful as the extent to which they can influence policy. mission of government agencies.

19 | World Conference on Social

Determinants of Health (WCSDH)
Building knowledge and capacity their capacity and literacy to participate. communities require access
to information, but they also need to be able to interpret and use
effective participation requires knowledgeable and skilled
it. Thus data must be made publicly available, using platforms
stakeholders who understand the process, have a clear vision
that people can access, presenting the information in ways that
of what can be achieved, and have the social and political skills
make sense to communities, and building skills in interpreting this
to navigate through bureaucratic processes while promoting
information. in addition to analytical capacity, communities require
their agenda. addressing inequalities in access to information is
increased “bureaucratic literacy” to demystify the bureaucratic
therefore essential. Knowledge and literacy needed for effective
structures, actors, and processes involved in policy-making; to
participation can be acquired through formal training or through
increase their awareness of the opportunities that exist to influence
advocacy experience. stakeholders who lack the necessary skills
can be assisted in obtaining them through incentives and access to the policy process; and to enable them to participate from a position
information and training. of strength. Government organizations need to build their capacity
to facilitate participation, in particular their responsiveness to
as just mentioned, an essential aspect of ensuring that marginalized community demands and their ability to engage with proposals
groups are adequately represented in policy processes is building expressed in language different from what they may be used to.

INSTITUTIONALIZING PARTICIPATION IN BRAZIL AND THAILAND 2.

Brazil and Thailand are two countries that have shown impressive improvements in health and reductions in health inequities over the
past 20 years. They have also been at the forefront of increasing public participation in policy-making.

in Brazil, participatory approaches to decision-making relevant to health have been inspired by the social movements that drove the
establishment of the universal health system as well as subsequent improvements in primary health care and social protection. The
1988 Brazilian constitution established health — including the right to participate in health governance — as a human right for all.
This commitment provided the space for institutionalizing public participation at the municipal, state, and national levels. Participation
through health councils at each of these levels (including municipal health councils in 5564 cities, where half the councillors represent
health system users) is supplemented by regular national health conferences. innovative models such as participatory budgeting have
also been implemented in some jurisdictions.

in Thailand, civil society assemblies over the last decade have led to the institutionalization of the national Health assembly, which has
been held annually since 2008 as mandated by the new national Health act. adapting the machinery used at the WHo World Health
assembly, the national Health assembly brings together more than 1500 people from government agencies, academia, civil society,
health professions, and the private sector to discuss key health issues and produce resolutions to guide policy-making. Policy impacts
attributable to assembly resolutions have included protection of budgets for universal health coverage, endorsement of strategies
for universal access to medicines, and establishment of national commissions on Health impact assessment and Trade and Health.
Further information can be found at http://en.nationalhealth.or.th/.

More information on the Brazilian and Thai experiences can be found by consulting the following publications:

cornwall a, shankland a. engaging citizens: lessons from building Brazil’s national health system. social science and Medicine, 2008, 66:2173–2184.
rasanathan K et al. innovation and participation for healthy public policy: the first national Health assembly in Thailand. Health expectations, 2011, doi: 10.1111/j.1369-
7625.2010.00656.x.

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| Discussion PaPer | | 20
Brokering participation and ensuring as with other sources of data, there can be issues of rigour, but
civil society certainly can provide access to information that is
representativeness unavailable elsewhere. in settings where government data and
Governments can broker participation in a number of ways, with the information are inadequate, civil society groups can be the principal
aim of facilitating empowerment. Figure 4 provides an overview of source of credible and up-to-date data to inform policy-making on
this continuum, from provision of information to transfer of power. social determinants.
The most disadvantaged groups need to be identified in advance
and a plan developed for ensuring that those groups are adequately Governments can actively facilitate the role of civil society in action
represented. often marginalized groups face additional barriers that on social determinants. They can formalize the involvement of civil
make them less likely to be reached by efforts to engage. This situation society organizations in policy-making processes — for example,
may require flexible, novel approaches – for example, convening by supporting their role in maintaining accountability through
female-only forums, using new communication technologies to reach setting up civil society advisory bodies and formally engaging with
youth, and giving strict attention to cultural appropriateness for ethnic watchdog initiatives. at both the national and global levels, official
minorities and indigenous Peoples. regional processes are critical in bodies can consider and encourage “shadow reports” from civil
strengthening and reinforcing national efforts to seek participation. society organizations – independent assessments that complement
Governments also have a role in working with communities to ensure and often raise issues overlooked in official publications. examples
the legitimacy of those who claim to be community representatives include the civil society shadow reports for the un General
and in addressing conflicts of interest and lobbying by vested interests assembly special session on HiV/aiDs and the civil society report of
at the national and global levels. the commission on social Determinants of Health.36 These examples
emphasize the need for governments to be better informed about
Facilitating the role of civil society the value and utility of knowledge produced by civil society groups
and to build the capacity of these groups to undertake and present
civil society can play a number of important roles in implementing
research in a form that is comprehensible to other audiences.
action on social determinants. a key function is to hold policy-makers
and programme implementers accountable for the responsibilities
they undertake and the commitments they make; this oversight useful resources (available on accompanying DVD)
includes monitoring of spending on budget commitments. civil
• Civil Society Report to the Commission on Social Determinants of Health,
society organizations can influence accountability by encouraging 2007.
institutional checks and balances and, indirectly, by strengthening • International Association for Public Participation. Public participation
institutions of accountability (for example, electoral democracy and tool-box. Available at http://biturL.net/bzdg.
independent media). civil society organizations can also generate • Valentine N et al. Health equity at the country level: Building capacities and
evidence for work on social determinants. Both the accuracy of momentum for action. a report on the country stream of work in the csDH.
information provided by civil society and the ability of these groups social determinants of health implementation discussion paper 3. Geneva,
to be a source of credible research are sometimes questioned. WHO, 2008.

Figure 4. Techniques for seeking community engagement in the policy process

Collaborating
Informing Involving Transferring power
Partnering with
Providing balanced and Consulting Working directly Where communities
communities in
objective information with communities have "the last word"
Seeking feedback from each aspect of the
to assist people throughout the process over the key decisions
affected communities decision including
in understanding to ensure that concerns that affect their
on analysis, alternatives, the development
problems, alternatives, and aspirations are well-being
and decisions of alternatives and
opportunities, and understood and
selection of the
solutions considered
preferred solution

source: adapted from solar and irwin, 20106, itself adapted from international association for Public Participation, 200735

21 | World Conference on Social

Determinants of Health (WCSDH)
PARTICIPATION IN ACTION IN ROSARIO, ARGENTINA
The city of rosario in argentina (population >1 million) has in recent years developed a public health system with a strong emphasis
on primary care in which participation is a central component. co-financed by the provincial and municipal governments, the system
provides free health services to all city residents. it is underpinned by the principles of community participation; the participation
of health workers in management; universal and equitable access; the right to health; decentralized planning; and autonomy and
responsibility for health workers.

The system is based on primary care centres. community organizations have significant influence in these centres and work together
in a federation to analyse and discuss municipal projects. along with this community participation, health workers also participate in
management of the centres.

Through this participatory process, health has become a municipal priority. in 1988, the health budget represented less than 8% of
the municipal budget; by 2003, this figure rose to 25%. infant mortality dropped from 25.9/1000 births in 1988 to 11.4/1000 births
in 2002. consultations in the health centres increased by 314% during the same interval. in 2009, the city opened a new hospital
providing universal access; the hospital’s design took patients’ viewpoints into account.

2.

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 22
3. THe roLe oF THe HeaLTH secTor,
incLuDinG PuBLic HeaLTH
ProGraMMes, in reDucinG
HeaLTH ineQuiTies

23 | World Conference on Social

Determinants of Health (WCSDH)
W
hile implementation of policies across the social
determinants is essential to improve health and reduce
inequities, the health sector has a vital role to play. The
health sector should be instrumental in establishing a dialogue on
why health and health equity are shared goals across society and
identifying how other sectors (with their own specific priorities) can
benefit from action on social determinants. The health sector must
work in this way with other sectors to reduce differences in exposure
and vulnerability to health threats.

Moreover, health systems themselves (the actors, institutions,

and resources that undertake actions primarily to improve health),
including public health programmes, constitute a social determinant.
in fact, instead of reducing health inequities, the health sector often
makes them worse by providing better access and quality of care to
segments of society with comparatively lesser need. Direct payment
for health services drives 100 million people into poverty each year.37
choices about health system financing and the location of health
care services, along with the attitudes of health workers towards
different groups in society, are crucial in determining whether the
health sector has a positive or negative impact on health inequities.
ensuring that the health sector reduces rather than increases health
inequities requires equitable provision of health care services to all
groups in society, at all stages of care. strengthening the competence
of public health programmes to address social determinants is a key
step in this direction.38, 39 if it is not acting to reduce inequities, the executing the health sector‘s role in
health sector is in a poor position to ask other sectors to take action governance for social determinants
on social determinants.
There are four broad, interrelated functions through which the
The primary health care approach holds increasing equity as a central health sector can make a useful contribution to governance for
value for the health sector, along with ensuring universal coverage, action on social determinants. First, the health sector has a key role
undertaking intersectoral action, and facilitating participation and in advocating for a social determinants approach and explaining
how this approach is beneficial both across society and for different 3.
negotiation in leadership of the health sector.21 The primary health
care approach has much in common with a social determinants sectors. in particular, the health sector needs to articulate why
approach and aims at similar goals.3 To compensate for shortfalls in health inequities are a high-priority indicator of a society’s lack of
performance for disadvantaged population groups, any strategy to well-being that justifies an integrated response. second, the health
strengthen health systems and public health programmes needs to sector has particular expertise in and responsibility for monitoring
health inequities and the impact of policies on social determinants.
institutionalize an explicit focus on equity through the continuum of
Third, through marshalling of evidence and successful advocacy,
care and all health system functions. This task entails going beyond
the health sector can play an important role in bringing sectors
average measures of progress to unmask disparities not only in
together to plan and implement work on social determinants — for
health outcomes but also in the use and quality of services. This
example, identifying issues that require collaborative work, building
type of assessment is important not only in improving health equity
relationships, and identifying strategic allies in other sectors as
but also in making progress on health priorities. For example, the potential partners. Fourth, the health sector has an important role in
likelihood of meeting priority health targets such as the MDGs and the development of capacities for work on social determinants. an
the elimination of tuberculosis is lowered by poor service delivery to important caveat is that the health sector should avoid claiming any
“hard-to-reach” populations.40, 41 of these roles as its exclusive function.
The reforms advocated for the renewal of primary health care To effectively undertake these functions, a range of specific
(universal coverage; people-centred care; equitable public policies; responsibilities and tasks can be identified:9
and improved leadership, stewardship, and participation)21 can
facilitate better performance in terms of equity if applied across • understanding the political agendas and administrative
all health system “building blocks” or functions: service delivery; imperatives of other sectors;
health workforce; health information systems; access to medicines, • building the knowledge and evidence base of policy options
vaccines, and technologies; health financing; and leadership.42 and strategies;

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 24
 • assessing comparative health consequences of options identifying ways for health services to reduce their contribution to
within the policy development process; health inequities.
• creating regular platforms for dialogue and problem solving
From this basis, entry points for interventions by health care services
with other sectors;
to alleviate health inequities can be defined.39 once it is known
• evaluating the effectiveness of intersectoral work and which groups benefit from services and programmes and — more
integrated policy-making in partnership with other important — which groups do not benefit or receive poorer-quality
stakeholders; service, the reasons for these discrepancies can be considered
• building capacity through better mechanisms, resources, and the barriers to care, which are concentrated in these groups,
agency support, and skilled and dedicated staff; identified. Many of these barriers will lie outside the health sector
• working with other arms of government to achieve their in other social determinants. However, the health sector can make
goals and, in so doing, advance health and well-being. an important contribution by first addressing those factors within
its control, such as the funding, location, and timing of services
Many of these responsibilities involve new terrain for the health and the competencies and attitudes of health workers. it can also
sector, which therefore needs to build its own capacity to work work with communities to identify barriers and solutions, including
effectively on social determinants. ensuring that care extends beyond curative services to promotion
and prevention activities.
reorienting health care services and public
This strategy provides a basis for the reorientation of services and
health programmes to reduce inequities programmes to reduce inequities and for continued monitoring to
Placing equity at the heart of health care services first requires see whether the changes have the intended effect. it can also be
evaluating the performance of existing health services and aligned with human rights–based approaches to strengthening
programmes in reducing health inequities. This assessment entails health systems, which focus on ensuring that health-related facilities,
understanding the way in which existing services operate, including goods, and services are available; accessible at affordable cost;
their aims, objectives, and targets (that is, the “logic” of services and acceptable; appropriate; and of good quality. after existing services
programmes), and how the activities of these services interact with have been reviewed, specific interventions must be defined in an
the generation of health inequities in a society. analysis of how barriers to care can be reduced. These interventions
can involve not only changes in the delivery of care (for example,
a number of models are useful in considering whether existing health changes in or improved management of services offered) but also
services exacerbate or alleviate health inequities.38, 43, 44 Figure 5
attempts to address social determinants that hamper access. While
shows the Tanahashi model, which considers access to, provision of,
programmes cannot be responsible for all potential interventions,
and use of health care services to conceptualize the necessary steps
they can undertake a range of measures to reduce differences in
a person takes between experiencing a health issue and receiving
exposure and vulnerability to health threats, especially differences
effective care from health services. at each step, “loss” of people
that arise once people become ill. in addition, programmes can
by health services and programmes results in avoidable suffering.
engage partners in other sectors to act on the social differences that
For example, to receive effective care, individuals with high blood
result in health inequities.
pressure need to know that they have a problem, seek care for this
condition, gain access to care, receive appropriate advice, obtain Figure 5. Tanahashi model for service delivery and coverage
the prescribed treatment, adhere to the treatment, and obtain
effective relief from the treatment, with satisfactory resolution of SERVICE DELIVERY GOAL
their problem. Target population who
Effectiveness coverage do not contact services
ensuring that this complex pathway is navigated successfully and
in a timely manner is a major aim across health care services and Contact coverage
Process of service provision

Co
ve

programmes. Failure to ensure this successful navigation results

ra

in poor performance and failure to attain the desired public Acceptability coverage
ge
cu

health outcomes. For almost all health care services, the rates at
rv

Accessibility coverage
e

which people do not receive effective care at each step and the
quality of care received differ according to population groups. This Availability coverage
discrepancy is a key mechanism through which health care services
and programmes increase health inequities. Measuring performance TARGET POPULATION
by disaggregating data for key population groups, especially those
socially disadvantaged according to the context, is a prerequisite in source: WHo, 201043, adapted from Tanahashi, 197845

25 | World Conference on Social

Determinants of Health (WCSDH)
There is potential for collaboration between programmes that addressing these challenges requires clear and transparent planning
identify common issues resulting in differences in exposure or at the central level, with national health ministries acknowledging
difficulties in accessing care. For example, key determinants of the the importance of other providers and stakeholders in health
tuberculosis epidemic are smoking, harmful use of alcohol, diabetes, systems but also asserting their mandate and role to steer the whole
indoor air pollution, and HiV/aiDs.46 These conditions are often system. The development of national health strategies that engage
clustered in disadvantaged population groups, driven by common these other partners provides an opportunity to build the capacity
social determinants such as poverty, discrimination, and poor of national health ministries to steward the entire health system
education and housing. Furthermore, screening for and diagnosis (for example, by setting priorities for addressing inequities) and to
of HiV/aiDs, tuberculosis, and ncDs are often hampered by poor implement mechanisms for negotiation between and regulation of
coverage and quality. reorientation to address social determinants the different stakeholders. The development of strategies can also
in a coherent manner provides these public health programmes with be used to ascertain whether the key issue of equity is addressing
significant opportunities to mutually improve their performance health problems experienced by the most disadvantaged groups,
towards common goals and their own targets. reducing gaps in health status between groups, “levelling up”
across the social gradient for all groups, or a combination of all
institutionalizing equity in health systems three. efforts by the health sector to address health inequities will
vary with the country context, the nature and extent of the health
governance inequities present, and the structure of social and health systems.
reorientation of the delivery of health care services must be Thus the governance of health systems must respond appropriately
supported by reforms in the governance of health systems through in allocating resources and prioritizing disadvantaged groups across
a primary health care approach. This course is necessary to improve all health system functions.
the health sector’s capacity to design policies that improve equity
across all health system functions. institutionalizing equity in Health care financing to ensure equitable universal health coverage
health systems places particularly high demands on the governance (access to and use of quality services through the continuum of care
capacity of national health ministries to usher in change, particularly for all people in a society) also poses particular challenges for health
in countries where a large proportion of health systems are beyond system governance.47 equitable universal health coverage (Figure 6)
the ministries’ direct control. it is difficult to negotiate and steer requires ensuring access and effective coverage for all groups
change in services run by subnational authorities, the private (“breadth”), for all necessary care (“depth”), at affordable costs
sector, and nongovernmental organizations (including faith-based under acceptable conditions, with specific resources to address the
groups). However, progress depends on embedding equity in these differential needs of the least well-off (“height”). achieving universal
services as a primary consideration or at least on evaluating their health coverage is not easy, as has become evident even in high-
contribution to the health system as a whole. Directing resources to income countries. if there is not sufficient emphasis on equity, with
disadvantaged groups who lack political power or making the case prioritization of the worst-off for both existing and new services,
3.
for sufficient funding to provide equitable health care are further increasing coverage can actually worsen inequities.48 However, the
difficult but essential tasks. evidence indicates that moving equitably towards universal health

“We in the health sector have a crucial role to play in acting on social determinants,
even though they mostly lie beyond our direct control. We can ensure that we
ourselves are not making the problem of health inequities worse. We also have
essential tasks in advocating for action, in working across sectors, and in making
the evidence available to decision-makers in all sectors.”
Professor Sir Michael Marmot, President of the British Medical Association 2010-
2011 and former Chair of the Commission on Social Determinants of Health

CLOSING THE GAP: PoLicY inTo PracTice on sociaL DeTerMinanTs oF HeaLTH

| Discussion PaPer | | 26
coverage is possible in countries of all income levels. Financing of even in countries where the conditions for universal health
health systems is a key area for consideration. Point-of-service fees coverage have been broadly created, marked inequities persist
have been shown unequivocally to deter appropriate use of health between socioeconomic, ethnic, and geographical groups. Thus
care, driving millions of people into poverty. all countries therefore other financing mechanisms need to be considered, such as linking
need to implement prepayment pooling mechanisms to fund health provision of health services to wider social-protection schemes and
services from taxation, social insurance schemes, or a mix of both. providing targeted assistance to groups with greater needs. Funding
formulas that take into account needs and social determinants
of course, universal health coverage requires more than just (rather than population numbers only) are a useful tool in this regard.
financing mechanisms or access to a basic package of services. Financial protection is also required to ensure income at times when
it requires consideration of a range of complex issues, including people become ill and are unable to work.
performance, quality, effectiveness, acceptability, and prioritization
of need as well as the impact of the social determinants on these
issues. increasing health literacy of communities and developing
cultural competencies among health workers can reduce inequities
in the quality of services provided.

Figure 6. Achieving equitable universal health coverage (UHC)

Universal health coverage with equity (all groups with need achieve effective coverage)

Height:
Facilitators of
access, which
Reduce user consider the
payments and differential
other barriers, circumstances
enable and Include other and needs of
empower services disadvantaged
groups

Reach all
Universal Health
groups
System or Programme

Depth: All needed services are included

Breadth: Health systems cover all population groups

source: Frenz and Vega, 201049 adapted from WHo, 200821

27 | World Conference on Social

Determinants of Health (WCSDH)
 REORIENTING PUBLIC HEALTH PROGRAMMES IN CHILE
chile has recently embarked on a reorientation of its public health programmes to reduce health inequities. in 2008, equity
assessments using a Tanahashi-based framework were initiated for six major public health programmes: child Health, reproductive
Health, cardiovascular Health, oral Health, Health of Workers, and red Tide (algal blooms). The aims of these assessments were to
identify differential barriers and facilitators to prevention, case detection, and treatment success and to provide guidelines to reorient
each programme so as to improve equity in access to care.

Multidisciplinary teams undertook the assessments, with participation of health workers from all levels of the health system,
communities, health bureaucrats, and decision-makers from other sectors. in 2010, all programmes applied the resulting
recommendations, using intersectoral and participatory strategies. For example, the cardiovascular Health programme implemented
67 good-practice interventions identified by its assessment and assisted all regional health teams in developing specific action plans to
put these interventions into practice. in the red Tide programme, strategies were developed for improved handling of the issue, with
reduction of negative effects on fishermen through temporary diversification and restructuring of working conditions. This process
resulted in the development of a set of indicators and methodologies for assessing equity of access to public health programmes.

More information on the chilean experience can be found at http://www.equidad.cl/.

useful resources (available on accompanying DVD)

• Blas E, Sivasankara Kurup A, eds. equity, social determinants and public • Putting our own house in order: examples of health-system action on
health programmes. Geneva, WHO, 2010. socially determined health inequalities. Copenhagen, WHO Regional
• Frenz P, Vega J. Universal health coverage with equity: what we Office for Europe, 2010.
know, don’t know, and need to know. Background paper for the • Monitoring equity in access to aiDs treatment programmes: a review of
global symposium on health systems research. 2010. Available from: concepts, models, methods and indicators. Geneva, WHO, 2010.
http://biturl.net/bzdv. • World health report 2008: Primary health care: now more than ever.
• Rasanathan K et al. Primary health care and the social determinants of Geneva, WHO, 2008.
health: essential and complementary approaches for reducing inequities • World health report 2010: Health systems financing: the path to universal
in health. Journal of epidemiology and community Health, 2011, 65:656-660. coverage. Geneva, WHO, 2010. 3.
• Narrowing the gaps to meet the goals. New York, UNICEF, 2010.
Available from: http://bitURL.net/bzdw.

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| Discussion PaPer | | 28
4. GLoBaL acTion on sociaL
DeTerMinanTs: aLiGninG
PrioriTies anD sTaKeHoLDers

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a
ction on social determinants is required not only within for the development agenda as well as for issues such as foreign
countries but also internationally. increasing integration of policy, security, and economic growth. Moreover, alignment of the
the global economy has resulted in increasing cross-border different stakeholders involved in development is urgently required
flows of goods, services, money, and people, affecting health and to support countries’ efforts to develop and implement national
health equity both directly and through economic consequences. strategies on social determinants. Development cooperation can act
This trend has also resulted in a major reduction in the policy space as a barrier to work on social determinants if it is fragmented; tied
available to governments for addressing social determinants. There to specific sectors, projects, or procurement sources; or conditional
is growing concern, particularly within civil society, that this process on policies that may be damaging to equity and/or health. similarly,
has prioritized economic considerations over health. stakeholders advancing conflicting aims make it difficult for countries
to undertake the whole-of-government strategies necessary to
increasing the ability of global actors (including bilateral cooperation
address problems like health inequities.
agencies, regional agencies, philanthropic groups, and international
organizations) to contribute to national and local action on social The aid-effectiveness agenda provides a strong platform to build
determinants requires improvements in global governance. also upon. The principles of the Paris Declaration on aid effectiveness50
essential are coherent global policies that do not undermine (that is, country ownership, alignment with national strategies and
each other but instead mutually contribute to development. Like institutions, harmonization of development assistance, managing
national governance mechanisms, global governance mechanisms for results, and mutual accountability) are critical in enhancing
are currently inadequate to address multifaceted problems like the contributions of global actors to country action on social
health inequities along with other global priorities. This situation determinants. The accra agenda for action50 also needs to be fully
challenges global institutions to reform in order to accommodate the implemented.
changing realities of the 21st century.
in addition to improving their own alignment, global actors can
The current circumstances thus make it particularly important to ensure that they build — rather than undermine — governance
ensure that health, health equity, and social determinants are fully capacity in recipient countries to coordinate development
and appropriately integrated into new models of economic policy assistance. This endeavour requires building negotiation and
and global governance as they emerge. This task will require health management skills in governments and mobilizing sufficient will
sectors — both nationally and globally — to engage actively in in development assistance agencies to execute coherent planning
debates relevant to reform of the global system in order to ensure processes that establish and pursue a long-term vision for countries
a coherent policy regime that is oriented towards health equity and in line with their own national priorities. civil society can also play a
social determinants and is supportive of national efforts directed constructive role by monitoring interactions and activities between
to these ends. The technical capacity of the health sector (in government sectors and development assistance agencies and
government and in civil society) to participate meaningfully and by advocating directly for action on health inequities and against
effectively in these debates needs to be expanded. national and international policies with potentially adverse effects
a global system better oriented towards social determinants on social determinants.
will require fulfilment of commitments made (for example, in the There is increasing potential for cooperation between low- and
Monterrey consensus, the Doha Declaration, and the Gleneagles middle-income countries in showcasing initiatives and building
summit) to move towards the 0.7% target for overseas development capacity for integrated action on health inequities. The experiences
assistance by high-income countries, supported by enhanced south- and successes of many of these countries with regard to social
south assistance. complementary improvements in the quality determinants can provide valuable impetus, ideas, and means
and allocation of such assistance, in accordance with the priorities for other countries to address similar concerns and challenges.
of recipients, will also be necessary. reflection on development
such cooperation can increase the flow of information, resources,
considerations, both in the current Doha “development round”
expertise, and knowledge among developing countries at reduced
of multilateral trade negotiations and in post-crisis reforms of
cost. Technology transfers between low- and middle-income 4.
the international financial system, will be indispensable. a key
countries and capacity-building in action on social determinants are
consideration in all these endeavours is to ensure that sufficient
important contributors to development. Global actors can further
policy space is reserved to allow national governments to address
assist this exchange by improving monitoring, evaluation, and
social determinants effectively.
impact-measuring tools. They can also facilitate the provision of
exchange mechanisms (for example, clearing-houses or searchable
aligning global stakeholders databases) to enable countries to identify and access available
Global governance must be aligned across sectors for action on technical resources and networks, and they can foster technical
social determinants, with health equity as a central objective of cooperation arrangements. These initiatives need to be brought
policy and a marker of policy coherence. This effort can build on into the aid mainstream and aligned with cooperation efforts from
recent progress in understanding the strategic importance of health traditional sources.

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| Discussion PaPer | | 30
Global actors can play a vital role in the development of capacity necessary for action on social determinants through capital flight,
for action on social determinants. Two key areas are monitoring tax avoidance, and tax competition. This mobility also contributes
social determinants and increasing access to technology. Global to harmful macroeconomic instability. Furthermore, exposure to
actors can improve access to and use of information technology and international financial markets and international trade agreements
innovation in key social determinants — for example, agricultural can represent important constraints on policy space in relation both
productivity, water management and sanitation, energy security, to development and to social provision. There is growing evidence
and public health. existing efforts can be expanded to facilitate the of the negative effects of the increasing migration flows associated
use of technologies and strengthen national capacity for innovation, with rising global inequality on health and health equity — for
research, and development. example, the migration of health workers to higher-income settings.
unless these issues are addressed effectively and appropriately at
However, aid is only one aspect of global governance for action on the global level and national governments have the policy space and
social determinants. it is also essential that the global governance the necessary external support to manage their effects successfully,
system as a whole is coherent and that potential tensions and progress on social determinants of health within countries may be
conflicts are resolved in a manner conducive to promoting social seriously constrained.
determinants and health equity. relevant aspects of global
governance include international agreements in areas such as trade Health sectors in all countries (both in government and in civil
and security, the international financial system, the regulation of society) need to debate key global issues with potential relevance to
migration, and the role of multilateral agencies. The increasing social determinants and to advocate for global structures and policies
global mobility of capital results in major losses of public revenues consistent with the promotion of health equity at the national and

A CATALYST FOR NATIONAL, EUROPEAN UNION, AND GLOBAL ACTION ON SOCIAL DETERMINANTS:
THE SPANISH PRESIDENCY OF THE EUROPEAN UNION IN 2010
one of the key priorities of the spanish presidency of the european union (eu) in 2010, “innovation in public health: monitoring social
determinants of health and reduction of inequalities in health”, was coordinated by the Government of spain in collaboration with the
european commission and WHo. The promulgation of this strategy followed the identification of health equity and social determinants
of health as a priority, with monitoring as a key first step, by the spanish Ministry of Health in 2007.

During its eu presidency, spain advanced the issues of monitoring social determinants at the national, eu, and global levels and of
considering the role of the eu in contributing to the reduction of global health inequities. The result was the report “Moving forward
equity in health: monitoring social determinants of health and the reduction of health inequalities”, which reviewed existing work
and outlined key priorities for further progress in this area. The other main outcome at the eu level — the conclusions on “equity
and Health in all Policies” — was approved by the eu employment, social Policy, Health and consumer affairs council of Ministers.

at the national level, the spanish eu presidency triggered the development of a national strategy for health equity based on
deliberations by the national commission for the reduction of social inequalities in Health, which was convened for this purpose. The
main strategic themes are:

1. to develop health equity information systems to guide public policies;

2. to promote and develop knowledge and tools for intersectoral work, advancing towards the concept of “Health and equity in
all Policies”;
3. to promote policies aimed at ensuring equity during childhood and youth and a good start in life for all children, regardless
of their parents’ circumstances;
4. to develop a plan for political visibility of the national strategy on Health equity and social Determinants of Health.

These main themes have been implemented at subnational level (through autonomous communities), with ongoing training on how
to integrate a focus on social determinants and health equity into health strategies, programmes, and activities. additional efforts
towards health equity have focused on roma, spain’s largest ethnic minority, who experience a disproportionate burden of ill health.
These efforts have involved engagement with roma civil society at national and local levels.

More information is available at http://biturL.net/byt6.

31 | World Conference on Social

Determinants of Health (WCSDH)
global levels. Both the capacity to take on these challenges and the considerations need to be kept foremost in the final push towards
potential influence of these activities on policy can be enhanced achieving the MDGs but also in framing global priorities in the
through international cooperation and the formation of strategic post-MDG environment to adopt a social determinants approach.
alliances with other constituencies with broadly overlapping it may be possible to use un system mechanisms and governance
objectives (for example, social protection, education, employment, structures to further improve intersectoral coordination for action on
and environmental protection). social determinants.

The united nations (un) system can set an example for policy
coherence and better alignment of global governance by accelerating
aligning global priorities
its own harmonization process to support capacity development Health inequities are among the many complex problems straining 4.
by Member states in addressing social determinants at both the the capacities of global governance to mount an effective response.
global and national levels. in particular, by reorganizing its country Many of these global priorities are closely linked. For example,
presence so that all agencies work together in an integrated manner progress on climate change is necessary to ensure that gains on
on priority issues (including health inequities), the un can greatly the MDGs are not endangered. if coherence is poor, progress on
improve its capacity to help countries tackle complex challenges. one priority can have unintended adverse consequences for other
The recent initiative to implement the un social Protection Floor issues. The failure to consider equity within countries in the original
provides an example of a comprehensive approach to accelerating MDG targets raises the strong possibility that, in some countries,
progress on social determinants (see box below). un agencies improvements in average outcomes have perversely resulted in
can build on these efforts by constructing a common platform to increasing inequities.51, 52 Global actors therefore need to ensure
further social determinants approaches and by incorporating action policy coherence in moving forward on different global priorities,
on social determinants into key agreements and targets. These with initiatives supporting rather than undermining one another.

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| Discussion PaPer | | 32
Positioning health equity as a cross-cutting goal of development finance, trade, agriculture, community planning, transport, and
can facilitate greater alignment, as social determinants are relevant environment. For example, fiscal policies can be used to control ncD
to all major global priorities. For example, achieving the health- risk conditions by reducing tobacco consumption and fat, alcohol,
related MDGs requires public health interventions to tackle specific and salt intake; preventing obesity; and promoting physical activity.
risk conditions accompanied by interventions to reduce poverty and
promote social protection, education, and empowerment. Most of addressing health inequities, tackling ncDs, and preventing harm
the immediate risk factors for tuberculosis, malaria, HiV/aiDs, and from climate change are clearly linked.53 For example, shifting to
maternal and infant mortality are associated with social conditions. cleaner energy sources and more efficient household stoves can
in addition, tuberculosis, malaria, HiV/aiDs, and maternal and reduce emissions of black carbon, a potent greenhouse gas, and
child health share social determinants with other key public health prevent large numbers of deaths from respiratory disease among
conditions. These social determinants encompass other MDGs, such the world’s poorest communities. However, the challenge for global
as those on poverty, gender equity, education, and the environment. governance regarding action on social determinants lies less in
recognizing these “win-win” situations when aligning priorities
noncommunicable diseases (ncDs) are not addressed in the and more in managing tensions. For example, addressing tensions
MDGs but are increasingly recognized as a major threat to social between the reduction of emissions and the creation of equitable
and economic development in all countries. Three weeks before opportunities for health and development requires balancing the
the World conference, the un General assembly will convene a fair sharing of burdens (that is, the “common but differentiated
high-level meeting on ncD prevention and control. Tackling ncD responsibilities” cited by the un Framework convention on climate
epidemics is impossible without acting on social determinants and change) with WHo’s constitutional declaration that all people
considering both the common drivers of health inequities and the have a right to “the highest attainable standard of health”.54 not
conditions addressed in the health-related MDGs. combating these all measures that can be implemented to reduce emissions will
problems requires actions involving a range of sectors including improve development for the most disadvantaged and reduce

IMPLEMENTING THE UNITED NATIONS SOCIAL PROTECTION FLOOR INITIATIVE

extending social protection to all people is a fundamental strategy to support action on health inequities and other global priorities.
a social protection floor approach promotes nationally defined strategies and comprises a basic set of social rights, services, and
facilities that every person should enjoy. The un suggests that a social protection floor could consist of two main elements that help
to realize human rights:

• services: geographical and financial access to essential services such as water and sanitation, health, and education;
• transfers: a basic set of essential social transfers, in cash or in kind, to provide minimum income security and access to
essential services, including health care.

The un social Protection Floor initiative (sPF-i) provides a framework for the systematic build-up of more comprehensive social
protection systems as countries develop further and economies recover from recent crises.

The sPF-i is supporting a growing number of countries in their endeavours to build social protection systems at any stage of the process.
The tools for the planning and implementation of such action have been developed. sPF-i actors have collected evidence, documented
experiences, and developed tools (for example, social Protection expenditure reviews, social budgeting, actuarial models, needs
assessments, costing assessments, capacity-building, and monitoring and evaluation) to support countries in their endeavours to build
their own social protection floor. requests for technical assistance can be directed to any of the participating un agencies.

several international and national organizations have endorsed the sPF-i. This initiative provides a model for intersectoral action on
social determinants, transcending the mandate of any individual un agency. The sPF-i is being implemented through a coherent,
system-wide approach involving joint un country responses, with each un agency offering cutting-edge advice in its respective areas
of expertise to ensure the optimal use of experts, resources, and logistical support.

More information on the un social Protection Floor initiative can be found at http://biturl.net/bhtc.

33 | World Conference on Social

Determinants of Health (WCSDH)
 “Addressing the social determinants of health is key for progress towards achieving
universal health coverage. Most promising are coordinated policy approaches such as
the ILO/WHO-led Social Protection Floor initiative.”
Mr Assane Diop, Executive Director, Social Protection Sector,
International Labour Organization

health inequities, and vice versa. Furthermore, not all partners will useful resources (available on accompanying DVD)
necessarily accept health equity as a shared measure of progress
on global priorities. regardless, the actions necessary to reduce • Committee for Development Policy. implementing the Millennium
Development Goals: Health inequality and the role of global health
carbon emissions to a level consistent with limiting global warming partnerships. New York, United Nations, 2009.
to 2°c must be undertaken in a way that also ensures the prospects
• Friel S et al. Climate change, noncommunicable diseases, and
for sustainable human development and for the economic capacity development: the relationships and common policy opportunities.
to address the social determinants in low- and middle-income annual review of Public Health, 2011, 32:133–147.
countries. • Koller T et al. Global health inequalities and social determinants of
health: opportunities for the EU to contribute to monitoring and action.
in short, the issues that global governance needs to consider in In: Moving forward equity in health: monitoring social determinants of
managing these conflicts are similar to those discussed above for health and the reduction of health inequalities. Spain, Ministry of Health
national governance. The upcoming un conference on sustainable and Social Policy, 2010:50–59.
Development (rio+20) presents an excellent opportunity to deepen • Global health and foreign policy: strategic opportunities and challenges.
these discussions and to find ways to strengthen coordinated Note by the Secretary-General. A/64/365. New York, UN General
actions in the fields of health and environment. The expiry of the Assembly, 2009.
MDG targets in 2015 also provides a stimulus for global actors • WHO. Global status report on noncommunicable diseases 2010. Geneva,
to consider how to proceed with the reforms necessary for policy WHO, 2011.
coherence, with implementation of a social determinants approach
to harmonize action on key priorities.

4.

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| Discussion PaPer | | 34
5. MoniTorinG ProGress:
MeasureMenT anD anaLYsis
To inForM PoLicies anD BuiLD
accounTaBiLiTY on sociaL
DeTerMinanTs

35 | World Conference on Social

Determinants of Health (WCSDH)
e
ffective governance for social determinants requires providers; thus it is important to focus collection and analysis on
monitoring and measurement to inform policy-making, what is required to inform and monitor policies rather than to gather
evaluate implementation, and build accountability. inequities data just for the sake of doing so.
in health outcomes, social determinants, and the implementation
and impact of policies must be monitored.55 This information needs identifying sources and collecting data
to be institutionalized as part of accountability mechanisms to guide
policy-making in all sectors. Policy-making requires information on both social determinants
and health outcomes. Monitoring social determinants requires
inadequate information on health inequities in many countries information from beyond the health sector. routine data collection
offers one explanation for a lack of action to combat these problems. systems in other sectors (for example, education and housing) can
Without efforts to compare the health status of different population be rich sources of information on key social determinants as well
groups, health inequities remain invisible, and progress in average as measures of development. as policies on social determinants
health indicators often masks persisting or worsening differences need to act across sectors, monitoring requires a systems approach,
between groups. improvements in data collection and analysis of with identification of necessary information through the pathways
disparities have helped put health inequities on policy agendas, of social determinants required for reduction of health inequities.
particularly in some high-income countries. While necessary, The reliable availability of the data needed to make the link
however, measurement of differences in health outcomes is not between these social determinants and health inequities is crucial
sufficient to support governance of action on social determinants. for progress.
The availability of data varies greatly between countries, yet in all
countries there is an urgent need for better measurement of social ideally, monitoring systems need to be sensitive in order to capture
determinants and their impact on health and for analysis of the inequities across the entire social gradient rather than focusing only
impact of all policies on health inequities. on population averages or known marginalized groups. Data on
inequities in health outcomes and on health system performance
Monitoring of social determinants requires the collection of data can be derived from a number of sources commonly used by health
and the dissemination and application of these data in the policy information systems. However, these systems are not usually
process. Measurement of inequities in health outcomes is generally designed for routine generation, synthesis, or dissemination of data
more developed than measurement of the social production of and information on social determinants, health inequities, or the
health and disease. Moreover, less information is routinely collected
associations between the two. Health measures are not well linked
about the distribution of social and environmental risks for ill health
to policy-monitoring systems in other sectors.
than about biological risk factors. This dearth of information is a
barrier to monitoring the effects of policy and to developing and Vital statistics, including birth and death registries, provide a sound
evaluating evidence-based interventions on social determinants basis for analysing disparities in health outcomes. cause-of-death
to reduce inequities. There is a need to move beyond traditional registries allow monitoring of death rates according to social factors
epidemiology to consider other methods that are linked to people’s such as education, occupation, sex, ethnicity, and place of residence.
cultural context, value systems, goals, and expectations.10 a narrow censuses provide highly useful information on population groups
focus on health and disease outcomes obscures the relationship of and can also yield information on social determinants, especially
social determinants to broader development goals. if linked to mortality data. Population-based surveys can provide
Monitoring of health inequities and social determinants needs to be essential data in the absence of systematic health information
fully integrated into policy-making, particularly into accountability systems or for investigating specific concerns. Health records can
mechanisms. This integration requires sensitivity to the vast provide information on health outcomes and the performance of
differences between country contexts in terms of data availability, the health sector; however, they are often incomplete and exclude
political setting, and the nature of the health inequities themselves. individuals who do not use health services.
Most importantly, it requires the provision of usable information
efforts to expand coverage of civil registration, which currently
that informs the design of effective policies to address social
excludes more than half of the world’s population, represent a
determinants, permits monitoring of changes in inequities, and
significant step in reducing inequities. information is often especially
explains the impact of specific strategies and choices.
sparse for marginalized groups (for example, rural communities,
it is critical to understand which data are most important for a given undocumented migrants or the urban poor) who are critical to an
setting and to know how to turn data into information that can understanding of health inequities. issues of quality and timeliness
be used by the different audiences (including communities and civil of data are also important. collection of information on social
society) who contribute to policy-making. as much attention needs factors associated with disadvantage and an ability to analyse
to be given to the dissemination and availability of usable data on data by geographical location can greatly assist policy efforts, but
social determinants and related policies as to the generation of ensuring quality and timeliness is often disproportionately difficult
data. in all cases, data collection has costs and places a burden on in poorer and marginalized groups.
5.

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| Discussion PaPer | | 36
Disaggregating data Table 5. Potential basket of indicators for monitoring of
social determinants and health inequities
To monitor health inequities and social determinants, data must
be separated, analysed, and compared — or “disaggregated” —
Social determinant indicator Data source
according to the main factors known to be associated with health
inequities. These social “stratifiers” include age, income, education, 1. Total debt service as percentage of gross World Bank
national income
class, occupation, sex, ethnicity (or “race” in some jurisdictions),
disability, and place of residence (to the smallest administrative 2. Extent to which a country’s citizens are able to World Bank
unit possible). Disaggregation is essential for implementing policies participate in selecting their government; extent
of freedoms of expression, association, and the
that address inequities, but it also allows better decision-making media
and accountability at the local level. advances in geographical
information systems can facilitate the collection of disaggregated 3. Total government expenditure on health and WHO; UNESCO
education as percentage of total government
geographical data and the dissemination of these data in a usable expenditure
form.
4. Ratio of wages to corporate profits World Bank
The selection of stratifiers depends on the context, as it is not 5. Proportion of young people not in school or OECD
feasible or even desirable to disaggregate by all possible factors, employment, by age and sex
given limited resources for data collection. For example, in settings
6. Informal sector employment (%) ILO
where levels of employment and education are universally high,
employment status and level of education may be poor proxies for 7. Gini coefficient (income distribution) World Bank
socioeconomic position. in low-income settings and in communities 8. Adult literacy rate (%) for the population over 15 UNDP; UNESCO
that are not entirely cash based, income may not be an accurate years of age *
marker of socioeconomic position, and alternative measures may 9. Ratio of highest-paid to lowest-paid workers * ILO
need to be identified. other context-specific ways to examine
individual and household wealth include ownership of material 10 . Net primary school enrolment ratio of females UNDP; UNESCO
to males *
goods (for example, a refrigerator, radio, or bicycle), agricultural
wealth (for example, livestock or land ownership), and access to key 11. Completion of primary/secondary education by UNESCO
services (for example, running water, toilets, bank accounts, and ethnic/ "race" group in a country *

health care facilities). 12. Access to improved water (%) * WHO

Health outcome
selecting indicators and targets 1. Healthy life expectancy (male, female) * WHO
To inform policy change, monitoring systems require the establishment
2. Deliveries attended by skilled birth attendant WHO
of agreed-upon goals for reduction of health inequities, with clear (% by wealth quintiles) *
indicators and targets, across different sectors. Monitoring systems
should include indicators that measure social determinants and 3. Under-5 mortality ratio (rural, urban) * WHO
methods for linking data from different sectors to elucidate their 4. Infant mortality ratio (by wealth quintiles) * WHO
impact in reducing or exacerbating health inequities. in selecting 5. Newborns with low birth weight WHO
indicators, issues of timeliness, comparability, harmonization, and (% by mother’s education) *
accessibility need to be considered.
6. Children aged <5 years with moderately or WHO
extremely low values for weight and height
These indicators should also include a balance between measures
(rural, urban) *
reflecting factors that increase the risk of ill health and measures
promoting the well-being of populations. indicators and targets 7. Prevalence of obesity among adults (15 years and WHO
older) (by wealth quintiles) *
are needed in terms of health gaps, access to services, and
social determinants. indicators already developed for monitoring 8. HIV prevalence among adults aged 15-49 (male, WHO
the implementation of human rights–based approaches or for female) *
considering specific aspects of inequity (for example, gender Indicators reflect a spectrum across types of determinants (root causes to
risk conditions). All reflect existing indicators with data available for multiple
inequities) can also be used. setting targets and indicators must not countries, with the source noted. Indicators marked with an asterisk (*) should
be a merely technical endeavour; as with indicators used for other be stratified by one or more dimensions — for example, socioeconomic status,
purposes, it needs to be part of the policy-making process to reduce education, occupation, sex, and/or ethnicity (religion, “race”, tribal affiliation).
health inequities. Types of within-country potential differentials are provided in parentheses
for health outcome indicators. For a number of indicators included in the
proposed list, sufficiently stratified data are available to make monitoring
possible. For others, data collection efforts at the national level need to be
strengthened.

37 | World Conference on Social

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indicators selected for monitoring policies aimed at reducing health that need to be involved in the action. Disadvantaged social groups
inequities need to be clearly understood by policy-makers across the and key social problems are likely to be well known. rich sources of
different sectors that influence the social determinants as well as by additional data can be found by tapping into the knowledge base of
communities. Thus simpler measures may be more transparent and those working most closely with communities and of the communities
easier to interpret than complex summary measures. Health inequities themselves. civil society groups, including trade unions and community
can be assessed through relative and absolute measures; since the organizations, often have in-depth information and data on problems
two types of measure illustrate different aspects, both are needed and on the processes that are necessary to implement action on social
over time for comprehensive analysis and as inputs to policy-making. determinants. in addition, community leaders, health practitioners,
Table 5 presents a potential list of indicators to monitor social programme implementers, and political leaders are all sources of
determinants and health equity that derives from a draft list existing knowledge about problems influencing social determinants
developed during the commission process56 and since refined. chile and health inequities as well as their potential solutions. countries with
and england have already used a similar approach in recent work on poor data can make use of evidence from other settings, considering
social determinants, selecting specific indicators and then publishing how their own contexts differ from those in the countries from which
data by each territorial jurisdiction. The World conference provides the information is drawn.
an opportunity for discussion of these indicators and generation
effective action on health inequities generally does require some
of momentum towards an internationally agreed-upon list. The
investment in expanding monitoring systems, particularly to obtain
intention is for a small number of indicators to be selected for
international comparison and for the chosen indicators to reflect both more information on social determinants. even with well-developed
inequities in health outcomes and key stages in the accumulation of monitoring systems, most of the available information relates
social disadvantage across the life course. a wider set of indicators to health outcomes, with much less focus on measuring social
would be needed to monitor key policies appropriate to the local determinants (and inequities in their distribution). To address this
or national context. These indicators need to be identified at the issue, two key strategies are required: (1) collection of new data on
relevant operational level in order to accurately reflect the local some factors and (2) better linkage, harmonization, and sharing of
situation, but at the same time they must be consistent with an existing data by different sectors. countries can aspire to systems
understanding of the framework of pathways that lead to health that routinely collect information on social determinants, health
inequities. outcomes, and relevant health determinants in a coherent fashion.
The challenges in choosing to collect new data are to identify the
Moving forward despite unavailability key factors that need to be studied, in light of the context (for
example, which communities are most disadvantaged), and to
of systematic data ensure that new data can be rapidly used to inform policies and
Globally, monitoring of health inequities ranges from countries with monitor planned interventions.
little routinely collected health data to countries that measure health
inequities routinely but may still lack data on social determinants.
strengthening data collection systems to remedy these gaps is often
a slow process. in this situation, lack of data should not preclude
action to reduce health inequities. after all, policy-makers frequently
must make decisions without systematic information or evidence.

several options can help overcome a lack of routine population-based

data. Population-based surveys conducted at regular intervals can be
used to provide some information. For example, the Demographic and
Health surveys (DHs), which are conducted in many countries at 5-year
intervals, collect data on the education and employment status of
individuals within participating households and are a valuable resource
in describing between-group health differences related to social
factors. other useful surveys include the Multiple indicator cluster
surveys (Mics) and the World Health survey. Health facility reporting
data can also be used in some instances to compare communities in
terms of geographical patterns in illness and service use.

Better use can be made of qualitative methodologies such as

observational evidence, evaluations, and natural policy experiments.
Generation of the evidence required for action on health inequities
requires a multidisciplinary approach reflecting the range of sectors 5.

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| Discussion PaPer | | 38
 “We must not ignore ethnic health inequities when they arise. We must be purposeful
and bold in the response we make to ensure we achieve the change we need. In
New Zealand, some important gains have been made in beginning to assess the
prevalence and impact of racism on Mãori health and inequalities, such as measures
included in the New Zealand Health Survey.”
Hon Tariana Turia, Associate Minister of Health, New Zealand

Disseminating information on health process by which data and information are translated into the
implementation of policies is complex. The system for collecting
inequities and social determinants to data on health inequities and social determinants must be aligned
inform action with policy-making processes so that data are communicated to
policy-makers in a meaningful and timely manner and government
The availability of evidence highlighting health inequities or the objectives and accountabilities are taken into consideration.
effectiveness of particular policy or programme options does not information on health inequities and social determinants needs to
automatically result in the implementation of systematic policies on inform problem identification and the development of policy options.
social determinants. Translating evidence into useful information Data for problem identification can come from routine collection and
for action on social determinants and health equity requires reporting as well as from specific initiatives. a range of tools can
mechanisms for assessing the information and communicating it to be helpful in considering the impact of different policies on health
policy-makers and other stakeholders. Data on social determinants inequities. Tools such as scorecards and benchmarks can simplify
must be made more broadly available to all sectors to allow analysis, and summarize health equity issues for input into policy-making.
interpretation, and advocacy by a wide range of actors, including However, the key is not to choose exactly the right tool but rather
civil society and communities. in particular, information needs to to integrate awareness of social determinants and health inequities
be fed back and integrated into accountability mechanisms for the into the overall process.
implementation of policies.

improved dissemination of information needs to be accompanied assessing the health and equity impacts of
by efforts to present information in a way that is meaningful to the different policy options
audience and to build the community’s capacity to interpret and
use such information. For example, public websites and simple once reducing health equities is identified as a high priority across
mechanisms such as traffic-light coding can be used to compare the policy-making, it is important to use a range of tools to consider the
progress of different geographical areas or social groups in terms impact of various sectors’ policies on equity. Two key approaches
of key social determinants. synthesis of evidence through the use are health impact assessment and health equity assessment tools.
of reviews, policy briefs, or guidelines for action can make this Gender mainstreaming and human rights tools can also be of value.
evidence available in a form that is digestible for policy-makers.
Health impact assessment (Hia) is an important tool in facilitating
setting up systems for feedback and sharing of knowledge, such as
integrated action on social determinants by helping policy-makers
communities of practice, can provide opportunities for comparisons
systematically assess how different policy options will affect health
and for peer learning among practitioners and policy-makers.
and thus enabling them to take health consequences into account
“observatories” have proved useful institutions in many countries to
when choosing between options. Hia draws on the methodologies
analyse and disseminate health-related data and synthesize these
developed for environmental impact assessment and shares similar
data into a useful form for policy-makers, but there is a need for a
steps and procedures with other impact assessments, including
greater focus in their work on social determinants.
poverty, social, and strategic impact assessments. Four key values
underpin Hia in informing decision-making: democracy, equity,
integrating data into policy processes sustainable development, and ethical use of evidence. Hia provides
Political processes within society do not operate solely on the basis recommendations on how a proposed policy, plan, or strategy can
of rationality and evidence but rather rely on negotiation among be modified or adapted to avoid health risks, to promote health
various — and often contradictory — interests. Moreover, the gain, and to reduce health inequities.

39 | World Conference on Social

Determinants of Health (WCSDH)
Likewise, health equity assessment tools aim to orient policy-making useful resources (available on accompanying DVD)
with regard to effects on health inequities. For example, the urban
Health equity assessment and response Tool (urban HearT, see • Marmot M et al. Fair society, healthy lives: strategic review of health
inequalities in england, post-2010, the Marmot review. London, UCL, 2010.
http://www.who.or.jp/urbanheart.html) is a tested tool developed
• Sadana R et al. Overview: Monitoring of social determinants of health
by WHo to systematically incorporate health equity considerations
and the reduction of health inequalities in the EU. In: Moving forward
into the planning cycle, specifically in urban settings. Health equity equity in health: monitoring social determinants of health and the reduction
audits can be used to judge the fairness of the distribution of of health inequalities. Madrid, Spain, Ministry of Health and Social Policy,
services or resources, given the health needs of different groups and 2010:23–31.
areas, and to identify priority actions. • Stiglitz J et al. report by the commission on the Measurement of economic
Performance and social Progress. Available from: http://www.stiglitz-sen-
fitoussi.fr/en/index.htm.
• WHO. urban Health equity assessment and response Tool (urban HearT).
Available from http://www.who.or.jp/urbanheart.html.

THE EQUITY WATCH IN EAST AND SOUTHERN AFRICA

almost all countries in east and southern africa have policy commitments to promote health equity. in 2007, eQuineT, a network of
professionals, civil society, state, parliament, and academics within the region that promotes health equity, analysed and reported
on regional health equity. This report contributed to a 2010 east, central, and southern africa regional Health Ministers Meeting
resolution to track and report on progress in addressing health inequities. in addition, the report was used in 2009, in consultation
with institutions in the region, to develop a framework for gathering and analysing evidence on health equity at the national and
regional levels. in an endeavour termed the “equity Watch”, national teams — involving state and nonstate actors and working with
eQuineT — organize, analyse, and accessibly present a range of existing quantitative and qualitative evidence to assess progress
in addressing health inequities, to evaluate social determinants and health care, and to inform social dialogue on proposals for
strengthening health equity. in addition to areas of importance for specific countries, 25 progress markers are included in all equity
Watch reports:

• five markers of advancing equity in health;

• seven markers of access to national resources and social determinants;
• eight markers of resourcing redistributive health systems;
• five markers of a more just return from the global economy.

The regional Health community Monitoring and evaluation expert Group provided input into the progress markers. at a national
level, the pilot equity Watch in Zimbabwe and the dialogue it prompted led to strengthened civil-society and parliamentary advocacy
for primary health care. The Mozambique equity Watch was discussed in 2010 to identify follow-up work that is now being pursued,
including improvement of equity in resource allocation and follow-up research on social determinants and health inequities within
districts. at a review meeting on the recently completed report from the Zambia equity Watch in June 2011, stakeholders proposed
that it be repeated annually in conjunction with monitoring of the implementation of the national Health strategic Plan and proposed
to use it to inform action across key sectors involved in social determinants. The Kenya and uganda equity Watch reports are being
finalized (with evidence from the Kenya report feeding into the new national Health Policy), and a second regional equity Watch
is being compiled to share evidence on progress, gaps, and promising practice, including for report-back on the Health Ministers
resolution.

More information is available at http://www.equinetafrica.org.

5.

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| Discussion PaPer | | 40
 MONITORING HEALTH INEQUITIES AND SOCIAL INDICATORS IN NEW ZEALAND AND ENGLAND
in new Zealand, the reduction of health inequities has become a priority in the past two decades. The new Zealand Public Health and
Disability act 2000 explicitly identified the need for the health sector to reduce inequities. Developments in policy and practice have
been assisted and even driven by substantial expansion of the evidence for health inequities. This progress has resulted in reductions
in ethnic health inequities between indigenous Mãori and non-indigenous new Zealanders over the past decade. Key advances have
included:

• the development of the new Zealand Deprivation index (nZDep), a small-area, census-based summary index of deprivation that is
based on several socioeconomic factors and provides a measure of socioeconomic status according to place of residence;
• the development and enforcement of data protocols for the recording of ethnicity in the health sector;
• the new Zealand census-Mortality study, an ongoing project that links mortality data to census records, providing more and better-
quality data for monitoring of health inequities;
• the expansion of the new Zealand Health survey, with the inclusion of questions on experience of racial discrimination to enhance
understanding of the impact of interpersonal racism on ethnic health inequities;
• the establishment of a series of new Zealand social reports that measure social well-being over time in terms of ten social outcome
domains (including but not limited to health).

More information on the new Zealand experience can be found in the following publications:

crampton P et al. Degrees of deprivation in new Zealand. Wellington, Bateman, 2002.

Ministry of Health. ethnicity data protocols for the health and disability sector. Wellington, Ministry of Health, 2004. available from http://biturl.net/bhue.
Harris r et al. racism and health: the relationship between experience of racial discrimination and health in new Zealand. social science and
Medicine, 2006, 63:1428–1441.
Blakely T et al. Tracking disparity: trends in ethnic and socioeconomic inequalities in mortality, 1981–2004. Wellington, Ministry of Health, 2007.
available from http://biturl.net/bhuf.
Pega F et al. Monitoring social well-being: the case of new Zealand’s social reports / Te P rongo oranga Tangata. social Determinants of Health
Discussion Paper 3 (case studies). Geneva, WHo, 2010. available from http://biturl.net/bhuc.

in england, following the review of heath inequities chaired by sir Michael Marmot, national targets in three areas were proposed:
health outcomes across the social gradient (life expectancy, health expectancy, and well-being); child development across the social
gradient (readiness for school and young people not in education, employment, or training); and income sufficient for healthy living.
not all of the targets could be directly measured immediately, especially in terms of their social or geographical distribution. in the
short term, the best available proxy indicators for most of these targets were identified and used to monitor across the life course. in
addition to life expectancy and disability-free life expectancy, the indicators included:

• early childhood development;

• the proportion of 16- to 18-year-olds not in education, employment, or training (a measure related to the transition between school
and work);
• the proportion of people on means-tested benefits (a measure of adult poverty).

The analysis was conducted and published for every local authority in the country on the one-year anniversary of the Marmot
review. The slope index of inequality was also produced for the two health measures to quantify the social gradient within each local
authority. The analysis was simple, generated great interest, and permitted the monitoring of progress. More information can be found
at http://www.marmotreview.org and at http://biturL.net/bwu6.

41 | World Conference on Social

Determinants of Health (WCSDH)
concLusion: urGenT sTePs

a
cting on social determinants to build inclusive societies, second, the inequitable distribution of power among different
improve health, and achieve broader development can be classes and groups within society must be ameliorated by promoting
a difficult task. action is possible, however, in all countries, the participation of previously excluded groups in decision-making.
at all income levels. every country can begin to implement a social Promoting the political participation of communities is essential
determinants approach in order to improve the functioning of its to creating a broad social base of support for innovative policies
society and to set out on the path towards reducing health inequities. on social determinants. community participation can significantly
Moreover, with the necessary political will, considerable progress enhance the quality and responsiveness of health and other social
can be made in increasing the attention paid to social determinants services, improving management, monitoring, accountability,
of health and to crafting policies that are more coherent with this and evaluation. in facilitating and strengthening participation,
objective at the global level. governments need to recognize the leadership of social movements
in highlighting key processes for implementation, this discussion and civil society organizations. The current gap between the rhetoric
paper is far from exhaustive. However, while the execution of national of participation and the reality must be closed by addressing
strategies will need to be adapted according to realities in each country, the obstacles to full participation, many of which may lie within
priority themes can be identified for action at the outset. governments and international agencies themselves. These entities
need to invest in community participation, creating favourable
First, there is a need to build governance for action on social conditions and facilitating the empowerment of all stakeholders.
determinants at every level, from the local to the global. This effort must
integrate work across the whole of a country’s government, across the Third, monitoring of health inequities cannot be limited to the health
whole international system, and — at both levels — within the health sector and the measurement of health outcomes. Measurement of
sector and between sectors. Holistic action on social determinants inequities in health outcomes alone defines the problem but supplies
requires the consideration of all interests and the inclusion of all parties little ammunition for its solution. Monitoring of inequities in key
affected in the decision-making process, especially those that are most social determinants and linking of data from different sectors can
disadvantaged. it also requires agreement on shared higher goals across help optimize policy design through a social determinants approach,
sectors; health inequities must be recognized as a common measure of with changes implemented when adverse outcomes are identified.
policy failure, and conflicts among different interests must be resolved in
terms of these shared goals. in the context of increasing global concern Fourth, implementing the range of processes highlighted in
about the social impacts of growing disparities in life opportunities, it is this paper requires urgent and sustained political and technical
an excellent time to institutionalize a greater concern for equity across capacity-building at all levels — among policy-makers, among
decision-making processes in the whole of government and the whole government workers involved in service delivery, within civil society,
system of global governance. in cooperating with individual countries and in the private sector. in building the capacity for work on
and developing rules, norms, and policies at the international level, the social determinants, the global community can play a vital role by
global community has a particular responsibility to consider how its facilitating further exchange of expertise and knowledge, creating
actions support or detract from a concern for equity. Potential priority and disseminating tools, and providing training. These activities
actions for further consideration and discussion at the World conference may prove most useful when they involve countries whose contexts
are presented in the box below. are similar.

“There is enough evidence associating health indicators to social issues. We already

know, for instance, that public policies are fundamental to address the social
determinants of health. We have to admit there is also enough evidence to prove
that it is possible to do things differently. Political will and cooperation between
countries are fundamental.”
Dr Alexandre Padilha, Minister of Health, Brazil

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| Discussion PaPer | | 42
Fifth, despite the overarching need for work across all sectors, action
within the health sector remains crucial. institutionalizing equity in the
health sector not only makes it possible for this sector to contribute
significantly to reducing health inequities but also provides a clear
signal to other sectors. unless the health sector “puts its own house
in order”57 and provides effective measures reflecting the scale of the
problem, the motivation to act and subsequent progress on health
inequities will be undermined. in all of the areas discussed in this paper,
the health sector has an important role to play, both nationally and
globally, in generating and promoting increased attention to social
determinants. While it cannot expect to play a dominant role in this
process, the health sector should exercise leadership in building strategic
alliances with other sectors that have broadly overlapping agendas (for
example, social protection, education, employment, and environmental
protection). Moreover, the health sector can influence debates and
guide the formulation of policies that affect social determinants.

Finally, countries that have made progress on health inequities have not
necessarily employed all of the strategies covered in this paper. These
countries have identified desired outcomes — not always related to
health — and proceeded to act. in an era of overwhelmingly complex
problems, action on social determinants is urgently needed to make the
final push towards fulfilment of the MDGs; to address environmental
challenges, including climate change; to tackle ncDs; to protect conference provides an opportunity for countries, the global community,
economic and social development; to build social protection systems; civil society, and the private sector to resolve to act together on social
and to ensure the inclusion of every societal group through exercising determinants in order to achieve these shared goals and prevent the
of the freedom that exists in fair opportunities for all. The World needless loss of millions of lives to social injustice each year.

POTENTIAL PRIORITY ACTIONS FOR CONSIDERATION

DURING THE WORLD CONFERENCE

• Agreement on a global monitoring framework through - Food security

which countries can measure social determinants - UN Social Protection Floor
- Integration of a social determinants approach into new - Women’s and children’s health
measures of societal goals - Noncommunicable diseases
- Revision, validation, and implementation of the - HIV/AIDS, tuberculosis, and malaria
indicators presented in this paper
• Common UN platform for work on social
• Integration of a social determinants approach and determinants of health
harmonized targets in addressing key global priorities in - Advocacy
the post–MDG period - Research agenda
- Climate change - Capacity-building and toolkit
- Joint technical assistance

43 | World Conference on Social

Determinants of Health (WCSDH)
GLossarY
Accra Agenda for Action (AAA): an international agreement, adopted in Health Disparity: Differences in health status between population groups.
2008, that highlights the need for specific reforms in the aid sector to achieve This term is used to describe both health inequities and health inequalities,
improved aid effectiveness.58 particularly in the united states of america.
Capacity-Building: The process by which individuals, organizations, Health Equity: The absence of differences in health that are not only
institutions, and societies develop abilities to perform functions, solve unnecessary and avoidable but are also considered unfair and unjust. Health
problems, and set and achieve objectives. Developing capacity requires action equity does not imply that everyone should have identical health outcomes,
at three interrelated levels: individual, institutional, and societal.59 but it does imply that all population groups should have equal opportunities for
health and therefore that there should not be systematic differences in health
Civil Society: The space for collective action around shared interests,
status between groups.
purposes, and values. civil society is generally distinct from government
and commercial for-profit actors, although these boundaries can be blurred. Health Equity Assessment Tool: a tool designed to facilitate the
civil society is not homogeneous, encompassing charities, development consideration of health equity and inequities in the policy development process.
nongovernmental organizations, community groups, men’s and women’s (see urban HearT below for an example of a health equity assessment tool.)
organizations, faith-based organizations, professional associations, trade
Health Equity Audit: a specialized audit used to judge the fairness of the
unions, social movements, coalitions, and advocacy groups. There is certainly
distribution of services or resources, given the health needs of different groups
no one ‘civil society’ view, and civil society actors contend with issues of
and areas, and to identify priority actions.
representativeness and legitimacy similar to those encountered by other
representatives and advocates. The inclusion of civil society, despite its Health Impact Assessment (HIA): a combination of procedures,
complexity and heterogeneity, is essential to build public support and to give methodologies, and tools by which a policy, programme, product, or service
expression to marginalized individuals and groups and to others who often are may be assessed in terms of its effects on the health of populations.63
not heard. civil society actors can enhance the participation of communities in
the provision of services and in policy decision-making. Health in All Policies Approach: a policy strategy that establishes health as
a shared goal across the whole of government and as a common indicator of
Commission on Social Determinants of Health (CSDH): a global network development. This strategy highlights the important links between health and
of policy makers, researchers, and civil society leaders brought together by broader economic and social goals in modern societies. in addition, it positions
WHo to provide support in tackling the social causes of poor health and improvements in population health and reductions in health inequities as complex
health inequities. The csDH had a three-year mandate (2005–2008) to gather high-priority problems that demand an integrated policy response across sectors.
and review evidence on what was needed to reduce health inequities within This response needs to consider the impacts of policies on social determinants as
and between countries and to report its recommendations for action to the well as the benefits of improvements in health for the goals of other sectors.26
Director-General of WHo.
Health Inequality: a difference in health between groups of people. in some
Demographic and Health Surveys (DHS): nationally representative jurisdictions health inequality is used to denote the same meaning as health
household surveys with large sample sizes (usually between 5,000 and 30,000 inequity.
households). These surveys provide data on a wide range of monitoring and
Health Inequity: unfair and avoidable or remediable inequalities in health
impact evaluation indicators in the areas of population, health, and nutrition.
between populations within countries and between countries. These
Typically, the surveys are conducted every five years to allow comparisons over
differences arise from social processes and are not natural or inevitable.
time.60
Health Lens: an important component of a Health in all Policies approach,
Environmental Impact Assessment: a process to predict the environmental
used to identify key relationships between population health and well-being
effects of proposed initiatives before they are implemented. More specifically,
and other societal goals and deliver mutually beneficial outcomes. Five key
an environmental assessment may identify possible environmental effects;
steps in using a health lens include fostering strong relationships with other
propose measures to mitigate adverse effects; or predict whether there will be
sectors and agreeing upon a focus of policy; elucidating impacts between
significant adverse environmental effects.61
health and the policy area under focus and identifying evidenced-based policy
Epidemic: The occurrence of cases of disease in excess of what would normally options; producing final policy recommendations jointly owned by all partner
be expected in a defined community, geographical area, or season. agencies; steering recommendations through the decision-making process;
and evaluating the effectiveness of the health lens.29
Equity Assessment: a structured process for assessing the potential impact
of a programme or policy on inequities and/or on disadvantaged populations. Health System: The structured and interrelated set of all actors and institutions
whose primary intent is to improve or maintain health.
Governance: The process by which governments (including their different
constituent sectors) and other social organizations interact, relate to citizens, Intersectoral Action (ISA): integrated work between different sectors
and take decisions in a complex and globalized world. in this process, societies towards a collective goal. in the context of health, isa refers to actions affecting
or organizations make decisions, determine whom they involve in doing so, and health outcomes undertaken by sectors outside the health sector, possibly —
identify ways to ensure accountability for actions.28 but not necessarily — in collaboration with the health sector.
Health: a state of complete physical, mental, and social well-being, as Millennium Development Goals (MDGs): The un MDGs are eight goals
opposed to the mere absence of disease or infirmity.62 that all 191 un Member states have agreed to try to achieve by the year

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| Discussion PaPer | | 44
2015. The un Millennium Declaration, signed in september 2000, commits economic, environmental, and cultural forces that determine people’s living
world leaders to combat poverty, hunger, disease, illiteracy, environmental conditions.
degradation, and discrimination against women. The MDGs are derived from
Social Gradient: Health differentials affecting the entire global population
this Declaration, and all have specific targets and indicators.
that are often tied to socioeconomic status but are seen in all countries,
Multiple Indicator Cluster Surveys (MICS): a survey programme developed regardless of income level. The poorest of the poor, around the world, have the
by uniceF to provide internationally comparable, statistically rigorous data on worst health. Within countries, the evidence shows that, in general, the lower
the situation of children and women.64 an individual’s socioeconomic position, the worse his or her health.
Needs Assessment: a systematic procedure for determining the nature and Social Impact Assessments: The processes of analysing, monitoring, and
extent of health needs in a population, the causes and contributing factors managing the intended and unintended social consequences, both positive and
to those needs, and the human, organizational, and community resources negative, of planned policies and programmes as well as any social change
available to respond to those needs.63 processes invoked by those interventions. The primary purpose of social impact
assessment is to bring about a more sustainable and equitable biophysical and
Noncommunicable Diseases (NCDs): also referred to as chronic diseases,
human environment.66
ncDs are diseases of long duration and generally slow progression. The four
main types of ncDs are cardiovascular diseases (for example, heart attacks and Social Justice: The organization of society towards an available common
stroke), cancer, chronic respiratory diseases (for example, chronic obstructed good for all, to which all are expected to contribute. To promote and respect
pulmonary disease and asthma), and diabetes. social justice means to be part of a society where all members, regardless
of their background, have basic human rights and equitable access to their
Paris Declaration on Aid Effectiveness: The Paris Declaration on aid
community’s wealth and resources.
effectiveness expresses the international community’s consensus on the
direction for reforming aid delivery and management to improve effectiveness Social Protection: The set of policies and programmes designed to reduce
and achieve results.58 poverty and vulnerability by promoting efficient labour markets, diminishing
people’s exposure to risks, and enhancing people’s capacity to protect
Participatory Budgeting: a participatory approach to national budgeting
themselves against hazards and interruption/loss of income. The policies and
designed to strengthen collaboration between the government, the private
procedures included in social protection involve five major kinds of activities:
sector, and civil society. Participatory budgeting processes can facilitate more
labour market policies and programmes, social insurance programs, social
effective and equitable use of public resources, deter corrupt practices, and
assistance, micro- and area-based schemes, and child protection.67
achieve more sustainable outcomes.
United Nations Framework Convention on Climate Change: an
Prepayment Pooling Mechanisms: The funding of health services from
international treaty, established in 1992, dedicated to exploring opportunities
taxation, social insurance schemes, or a mix of the two, reducing the need for
to reduce and address global warming. More recently, a number of nations have
out-of-pocket payment at point of service.
approved the Kyoto Protocol, which is a legally binding addition to the treaty.68
Primary Health Care: an approach to health equity and health systems
United Nations Social Protection Floor Initiative (SPF-I): a joint
emphasizing the importance of primary care (that is, the provision of
un effort to build a global coalition of un agencies, international
integrated, accessible health care services by clinicians who are accountable
nongovernmental organizations, development banks, bilateral organizations,
for addressing a large majority of personal health care needs, developing a
and other development partners that are committed to collaborating at the
sustained partnership with patients, and practising in the context of family and
national, regional, and global levels to support countries in building national
community) as well as the need to work across different sectors, address the
social protection floors for their populations. The sPF-i corresponds to a set of
social and economic factors that determine health, mobilize the participation
essential transfers, services, and facilities that all citizens everywhere should
of communities in health systems, and ensure the use and development of
enjoy to ensure the realization of the rights embodied in human rights treaties.69
technology that is appropriate in terms of setting and cost. Primary health care
efforts aim to move care closer to where people live, to ensure the involvement Universal Health Coverage: access to and use of quality services through
of people in decisions about their own health care, and to address key aspects the continuum of care for all people in a society. universal health coverage
of the physical and social environment essential to health, such as water, ensures that disadvantaged groups with greater health needs receive the
sanitation, and education. This approach was codified in the Declaration of resources necessary for the provision of appropriate health services to meet
alma ata in 1978.65 their needs.
Social Determinants of Health: The conditions in which people are born, Urban Health Equity Assessment and Response Tool (Urban HEART):
grow, live, work, and age, including the health system. These circumstances a tested tool developed by WHo to systematically incorporate health equity
are shaped by the distribution of money, power, and resources at global, considerations into the planning cycle, specifically in urban settings. urban
national, and local levels, which are themselves influenced by policy HearT is a tool intended to give policy-makers and key stakeholders at the
choices. The social determinants of health are mostly responsible for national and local levels a user-friendly guide to assess and respond to urban
health inequities. This term is also shorthand for the wider social, political, health inequities.70

45 | World Conference on Social

Determinants of Health (WCSDH)
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1. commission on social Determinants of Health. closing the gap in a 20. 2010-2015 five-year plan of action. Quito, unasur south american
generation: health equity through action on the social determinants Health council, 2010.
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21. World health report 2008: Primary health care: now more than ever.
Geneva, WHo, 2008.
Geneva, WHo, 2008.
2. resolution WHa62.14. reducing health inequities through action on the
22. The global social crisis: report on the world social situation 2011. new
social determinants of health. Geneva, 2009. available from: http://apps.
York, un, 2011.
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47 | World Conference on Social

Determinants of Health (WCSDH)
 T
he World conference on social Determinants of Health represents
a tremendous opportunity to reduce the toll of thousands of lives
lost, each day, due to social injustice. This discussion paper aims to
inform the proceedings and help fulfil the purpose of the World conference:
to share experiences on how to reduce health inequities and to mobilize
commitment to urgently implement action on social determinants. The paper
does not provide a blueprint, but instead lays out the key components (which
form the World conference themes) that all countries need to integrate in
implementing a social determinants approach. The paper aims to show that,
in all countries, it is possible to put policy into practice on social determinants
of health to improve health and well-being, reduce health inequities, and
promote development.

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