PHA-Exchange> In preparation of PHA2 (39) Part 1 of 4

[Claudio]

Dear friends,
Here is part 1 of 4 of what I think is a very important document that just came out from WHO which, as I have commented in this server before, has set up the Commission on the Social Determinants of Health. This is an excerpt of the launching document (courtesy of Alec Irwin). It is longish, but well worth every minute of your reading!
Claudio

TAKING IT TO THE NEXT LEVEL: THE COMMISSION ON SOCIAL DETERMINANTS OF HEALTH



2.1 Aims of the CSDH

The CSDH has been constituted at a time when momentum for action on SDH is rising. A convergence of

factors related to the scientific evidence base, the mobilization of concerned constituencies and the

broader politics of development has created conditions in which unprecedented advances in health policy

to address SDH are within reach. But many countries and communities remain excluded -- particularly in

parts of the world where health needs and the negative impacts of SDH are greatest. A major push is

needed now to capture the existing momentum on SDH and take it to the next level: brokering a wider

understanding and acceptance of SDH strategies among decision-makers and stakeholders, particularly in

developing countries; translating scientific knowledge into pragmatic policy agendas adapted to countries'

levels of economic development; identifying successful interventions and showing how they can be

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scaled up; and ensuring that social determinants are lastingly anchored in health policy approaches at

WHO and among other global actors. These are the tasks the CSDH will take on.

During its three-year span of activity, the Commission aims for changes whereby the societal

relationships and factors that influence health and health systems will be visible, understood and

recognized as important. Based on this the opportunities for policy and action, and the costs of not acting,

will be widely known and debated. A growing number of institutions working in health at local, national

and global level will be using this knowledge and implementing relevant public policy affecting health.

Leadership, public interest and capable institutions within and beyond the health sector will sustain this

transformation. The social determinants of health will be incorporated into the planning, policy and

technical work of WHO.

The aims of the CSDH are ambitious. To achieve them, it will have to build on the work of predecessors,

understand their limitations and obstacles, and go farther. To do this will involve strategic decisions

guided by an understanding of history.



Key issues for the CSDH

The preceding historical overview brings into focus both some of the challenges the CSDH can expect to

face, and the reasons why this effort is so vital now. It offers lessons for the CSDH and raises questions

Commissioners may debate as they define their objectives and strategies more precisely. In the following

pages, we focus on four issues the historical survey has shown to be particularly crucial. In each of these

four areas, we identify a specific question or questions on which the Commission will need to achieve

clarity.

2.2.1 The scope of change: defining entry points

Efforts to promote change in health policy can be more or less ambitious in scope. This issue is illustrated

historically by the contrast between comprehensive and selective primary health care, i.e., between the

Health for All agenda as protagonized by Mahler at Alma-Ata and the Child Survival Revolution led by

Grant and UNICEF in the 1980s. The CSDH will face its own version of the challenge and the choice

embodied in these two figures and their respective strategies. On the one hand, the Commission could

understand itself as leading a "Copernican revolution" in thinking and action on health policy, with farreaching

implications for social structures and for how governments do business in exercising their

responsibility for the health of populations. On the other hand, the CSDH could set its sights more

modestly and aim simply to develop and promote a "toolkit" of interventions that states can implement

swiftly, without significant changes to their existing governance and budget structures or their

relationships with international financial institutions and donors (the SDH equivalent of the GOBI

strategy). And of course the choice need not be cast as a binary alternative. Various compromise

positions might be sought that could combine some of the strengths of both approaches. Yet the fact

remains that the CSDH will inevitably have to "come down somewhere" on what might be termed the

Mahler-Grant problem. This positioning should be the result of a conscious, reasoned and collective

choice, rather than simply emerge haphazardly from the Commission's day-by-day interactions with

partners and the media.

At the communications level, this decision is about a choice of vocabulary for the Commission (e.g.,

"social justice" vs. "efficiency" or "reducing disparities"). At the level of country operations and policy, it

is about entry points. Decisions about language are not "mere" linguistic subtleties, but have implications

for the way the CSDH will work with countries and the types of policies it will seek to promote. As

shown in the country examples above (section 1.8.3), policies and interventions to address SDH can


engage social structures at a variety of levels. The most ambitious policies may seek dramatically to

reduce gradients of wealth and power among different groups in society through redistributive processes.

At the other end of the spectrum, healthcare interventions targeted at disadvantaged groups seek to repair

or palliate the damage inflicted by social inequality, once such inequality has already translated itself into

physical illness affecting the bodies of disadvantaged individuals. Along this spectrum, it will be crucial

for the CSDH to identify the level(s) at which it will seek to promote change. A typology or mapping of

entry points for policy action on SDH and health inequities was sketched earlier. It presented the

following entry points for policies and interventions on SDH:

. Decreasing social stratification itself, by reducing "inequalities in power, prestige, income and

wealth linked to different socioeconomic positions";

. Decreasing the specific exposure to health-damaging factors suffered by people in disadvantaged

positions;

. Lessening the vulnerability of disadvantaged people to the health-damaging conditions they face;

. Intervening through healthcare to reduce the unequal consequences of ill-health and prevent

further socioeconomic degradation among disadvantaged people who become ill.

In essence, this framework asks at what point(s) along the chain of social production of health/illness it is

desirable (and feasible) to intervene in a given context: through broad redistributive policies that aim to

alter fundamental social inequalities; through less ambitious, intermediate policies that seek to shield

members of socially disadvantaged groups against the worst health consequences of their increased

exposure to health threats (examples would include anti-smoking programmes targeted at low-income

groups and occupational safety regulations that reduce health risks connected with specific forms of lowprestige

work); or by providing fairer medical care at the end of the "social production chain".

Linked to the question of entry points is the issue of universal versus targeted programmes. Graham and

Kelly recall that evidence on the links between people's socioeconomic circumstance and their health has

thus far generated two kinds of policy responsescxxv. The first focuses on those in the poorest

circumstances and the poorest health: on the most socially excluded, those with most risk factors and

those most difficult to reach. This focus has been important in linking health inequalities to the social

exclusion agenda, and in focusing policies at local and community level. In policy and intervention terms,

this leads to approaches that attempt to lift the worst off out of the extreme situation in which they find

themselves. In effect, such interventions help only a relatively small part of the population. The second

approach recognizes that, while those in the poorest circumstances are in the poorest health, this is part of

a broader social gradient in health. This means that it is not only the poorest groups and communities who

have poorer health than those in the most advantaged circumstances. In addition, there are large numbers

of people who, while they could not be described as socially excluded, are relatively disadvantaged in

health terms. Preventive and other interventions could produce major improvements in their health and

proportionate savings for the healthcare system. Because universal programmes may be seen as too

costly, there is a risk that strategies will focus primarily on targeted interventions addressing intermediary

determinants, which simply manage the consequences of poverty, while the processes that cause it remain

unchangedcxxvi. Indeed, some critics argue that an unintended effect of targeted interventions may be to

legitimize poverty, making it both more tolerable for individuals and less costly for societycxxvii.

Commissioners will want to reflect carefully about the level(s) at which they want to promote change; the

desirability/feasibility of selecting various policy entry points; the forces and capacities for action that

must be aligned at the various levels; and the appropriate political strategies for obtaining results.

Determinations about policy entry points and the content of recommended policies will vary with the

specificities of national contexts. Successful health policy to address SDH cannot adopt a "one-size-fitsall"

character. Different countries and jurisdictions find themselves at very different stages of readiness

for action on SDH and of openness to more fundamental redistributive approaches88. The particularities


of national and local contexts will show which social determinants need to be addressed most urgently to

improve population health, and which policy tools are most appropriate. National and local specificities,

in particular economic and political power relations, will define the opportunities and constraints for

action and indicate which constituencies may align themselves with an SDH agenda, and which may

offer resistance. Thus, the key question becomes not only "What entry point(s) will be chosen?" but also

and more fundamentally, "How will you decide?" That is, what criteria will be utilized to make decisions

about the level of policies/interventions to be recommended in particular cases?

Presumably, in addition to a framework of entry points for SDH interventions and policies, the CSDH

will need to develop a typology of countries and/or subnational jurisdictions with respect to their

capacities for action on SDH. Elaborating this typology will be an important task for the Commission's

scientific team and lies well beyond the scope of the present paper. Some key points can be noted,

however. National income will be an important differentiator, and wealthy countries will presumably in

most cases have considerably greater facility for implementing comprehensive SDH policies than will

poor countries. However, as Good health at low cost made clear in the 1980s, and as many subsequent

studies have confirmed, income is not the only relevant factor. Countries with roughly equivalent levels

of national income exhibit very different levels of performance in areas of social achievement with

relevance for health, such as access to adequate food for all members of the population; housing quality;

water and sanitation; and education. The CSDH typology will thus have to group countries not only by

income level, but with reference to the other, in some cases less easily quantifiable factors that will shape

opportunities for action. In exploring contextual influences on health systems, Roemer, Kleczkowski and

Van Der Werff cxxviii have proposed a typology of countries that points toward what may be relevant

variables. They classify countries based on three criteria:

. The extent to which health is a priority in the governmental /societal agenda, reflected in the level of

national resources allocated to health;

. The degree to which responsibility for financing and organizing the provision of health services to

individuals is assumed as (1) a collective social responsibility or (2) primarily the responsibility of the

individuals concerned;

. The extent to which society (through political authorities) assumes responsibility for an equitable

distribution of health resources.

As the GHLC analyses acknowledged, but as technical planners sometimes forget, a country's political,

economic and social history is deeply relevant to understanding what policies will be appropriate and

effective there. The WHO Health Equity Team has recently argued for a more historically and politically

contextualized understanding of health systemscxxix. This principle applies a fortiori to efforts to mobilize

constituencies, engage policymakers and implement interventions on SDH.

Down the line, the issue of national specificities and appropriate modes of engagement will raise a range

of important strategic questions for the Commission. These include how the CSDH will co-operate with

countries whose political structure is federal (see Canada example above), and what sorts of policy

recommendations and support the CSDH may seek to provide to constituencies in countries whose

economic and political situations (including conflict and/or highly authoritarian, unresponsive

governance) make major national health policy action on SDH extremely unlikely in the near and

medium term. Will such countries be (tacitly) "written off" by the CSDH as cases in which Commission

resources and energy cannot sensibly be invested, or will some effort be made to develop

recommendations and policy dialogue in these settings that could begin to lay foundations for long-term

change?




Main strategic questions:



. How will the CSDH position itself on the "Mahler-Grant problem": i.e.,

choosing (or compromising) between: (1) a far-reaching structural critique based

on a social justice vision and (2) promoting a number of tightly focused

interventions that may produce short-term results, but risk leaving the deeper

causes of avoidable suffering and health inequities untouched? If a more

comprehensive, values-oriented approach is taken, the CSDH may sacrifice

short-term efficacy and measurable results. If a more selective, interventionfocused,

pragmatic stance is adopted, critics may well wonder why a global

Commission was required for this job, rather than a much less costly technical

working group.

. What evaluation criteria will the CSDH put in place to identify appropriate

policy entry points for different countries/jurisdictions?

...to be continued.

  
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