PHA-Exchange> In preparation of PHA2 (39) Part 2 of 4

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2.2.2 Anticipating potential resistance to CSDH messages -- and preparing strategically

On the question of why policy action on SDH has lagged in most settings, the existing literature presents

two main explanatory strands. The first sees the blockage as a problem of knowledge, the second as a

question of powercxxx. According to the first account, action to address SDH has been weak because the

evidence base on which to build such action is inadequate, or existing evidence has not been effectively

communicated to those in a position to effect change. The second account emphasizes the politicaleconomic

dimension of power and profit, and suggests that the most important barriers to action on SDH

lie in this area. It sees policy failure on SDH not primarily as a symptom of ignorance, but as the logical

consequence of existing power relations. Notably the fact that certain influential constituencies derive

benefit from a status quo in which SDH are not addressed, and believe their interests would be

compromised if policies were enacted to tackle social determinants aggressively.

The key objectives of the CSDH clearly include filling gaps in the scientific evidence base relative to

social determinants and effective policies and interventions to address them. The very existence of the

Commission reflects the conviction that effective communication of SDH messages to policymakers,

health and development actors and the broader public can help catalyse action that will significantly

improve vulnerable people's chances for health. However, the CSDH must also take seriously the second

explanatory strand just evoked, centred on political-economic power relations. Our historical survey has

suggested that it is not primarily the lack of knowledge that has thus far hampered action on SDH. Over

the past quarter century, the evidence available has been sufficient for most countries to acknowledge in

principle (via numerous declarations and official statements) the urgent need for such action. However,

between that acknowledgement and the actual implementation of meaningful policies, political barriers

have often emerged.

It is particularly important that the CSDH focus on these issues at the very outset of its activities.

Designing and carrying through a process to collect scientific evidence will in a sense be obvious and

"natural" to many Commissioners and their support staff; addressing the political barriers may be less so.

Yet if the political strategy is not well developed, the evidence collection, however scientifically sound,

may fail to generate the concrete change the Commission seeks.

Scholars have begun to analyse the political/structural aspect of resistance to SDH approaches89,130, but

much work remains to be done. This paper cannot map the relevant power relationships in exhaustive

detail, since the particularities of national and local contexts will once again be crucial, and relevant

constituencies will vary across the range of thematic areas the Commission will address (e.g., food

security, housing, social exclusion, etc.). This detailed political mapping will be a primary responsibility

for the Commission's Knowledge Networks and for the co-ordinating groups in each partner country.

What the present paper can do is identify several broad constituencies likely to feel their interests are

threatened by SDH policy approaches. By focusing clearly on these constituencies and understanding

their respective stakes in processes related to SDH, the Commission can develop strategies to draw them

into the CSDH process through dialogue or, failing that, to minimize the damage caused by their

resistance.

 

The medical establishment

SDH agendas, including efforts to advance health promotion and intersectoral action, have in the past

encountered active or passive resistance on the part of many medical professionals and institutions14,16,89.

It is reasonable to suppose that this pattern will continue under the CSDH. A significant challenge for

SDH and health equity agendas will be bringing the medical establishment on board as a constructive

partner.

Health care providers, especially physicians, are generally part of the social elite, and share its values and

class interests. Like other members of privileged social categories, they will resent and often resist

government policies that redistribute resources from the more advantaged to the less well-off in society.

Furthermore, and more importantly, physicians have a strong group interest in maintaining their

monopoly over authoritative discourse and practice around health. Medical professionals are reluctant to

see control of health issues slip away from them to other sectors and professional constituencies, or to

cede to communities the power to set health agendas. The atrophy of intersectoral action and the

widespread discrediting of community participation under Health for All partly reflected this persistent

dynamic, although other causal factors were also relevant.

The reasons for this pattern have to do in part with doctors' desire to maintain their social prestige, but the

more fundamental issue is economic. Individual physicians and the medical establishment as a whole

make money by providing curative interventions. They will not make money from the introduction of a

school feeding programme or improvements to the housing stock in a slum neighbourhood. McGinnis et

al. have underscored the inherent structural asymmetry between public health and the provision of

curative medical care, when it comes to political clout and the competition for resources. This issue must

be of concern to the Commission as it develops its approach to policy dialogue. In many settings the

structural configuration of health governance institutions has combined with "interest group dynamics" to

result in a "vacuum of political accountability for maintaining population health". In contrast, "a welldefined

set of actors--physicians and other health care providers--has responsibility for medical care". In

addition to their ethical commitment to deliver medical services to those who need them, "providers have

a strong financial incentive to provide medical care, as well as an interest-group incentives to lobby for

increasingly more medical care resources"5. To the extent that SDH programmes are seen as competing

for these scarce resources that might otherwise be invested in medical care, health care providers and

other constituencies that derive profit from patient care and related services may resist them.

 

Within national governments

SDH interventions represent major opportunities to improve the health status of populations, particularly

vulnerable groups, at relatively low cost. National governments should be eager to pursue these policies.

However, the desire and/or the technical capacity of governments to implement such approaches can by

no means be taken for granted.

The Ministry of Health may be wary of social determinants approaches, because these may be seen both

as channelling health funds away from the MoH towards other government departments, and as loosening

the MoH's scientific and political authority over health. Making health "everybody's business" should

register as a highly constructive development, but it could also be seen as a diminishment of the power

and prerogatives of the MoH and health sector specialists. At the same time, earlier experiences in IAH

suggest that non-health ministries and government officials may (at least initially) also be reluctant to

commit time, energy and resources to work oriented towards health goals42.

In general, many elected officials must of course make their own tacit cost-benefit calculations in terms

of election cycles and the need to quickly deliver tangible benefits to electors. They operate on a

compressed time-frame and seek opportunities for "quick wins", with a preference moreover for policy

options where the causal link between intervention and outcome is obvious. In contrast, some SDH

programmes might require years or decades to really begin generating major measurable effects. Such

efforts will do little to advance decision-makers' immediate electoral interests. Furthermore, the lines of

causality in intersectoral action are notoriously complex, making it difficult in many instances to prove

that a particular programme was the source of a given health improvement. Added to this is the

consideration that the prime beneficiaries of many SDH interventions would be poor and marginalized

constituencies who are often less likely to participate in the political process and thus to "pay off" in

terms of votes for politicians.

As McGinnis et al. argue: "It takes more than just evidence that social change would improve health to

convince the general public [or a fortiori policymakers] that such redistributive investments should be

undertaken. These choices are very much about ideology and social values"5. Some government leaders

will be opposed to many aspects of an SDH programme on ideological grounds, because they will see

SDH interventions as largely constituting unnecessary government interference in processes better left to

market forces and individual choice/responsibility. The resistance to the introduction of new,

government-led redistributive policies will be encountered among leaders of some wealthy countries

eager to secure global dominance for the neoliberal "free market" model; it can also be expected among

officials in some developing countries who are strongly lobbied and influenced either by private sector

interests or by major global institutions closely aligned with the neoliberal agenda. Moreover, even in

countries interested in adopting redistributive mechanisms to address SDH, governments may be unable

to implement such programmes: because of lack of resources; as the result of social sector spending

ceilings and other constraints imposed by IFIs and donors; or because of the shortfalls they face in terms

of human and other resources for planning, implementing and managing complicated social programmes.

At the same time, many developing country policymakers and programme implementers exhibit an

(understandable) level of "initiative fatigue", scepticism and resistance to priorities seen as imposed from

outside. Such resistance is an inherent obstacle to the introduction of any major new programme initiative

in some developing countries. Thus it will be crucial for the CSDH to co-ordinate its policy

recommendations with the existing structures and policy frameworks through which countries operate,

and which govern relationships between developing countries and donors (e.g., PRSPs). The CSDH must

not be seen as piling on yet another set of "global priorities" and recommended actions with no clear

relationship to the structures and processes currently in use.

 

The corporate sector

Resistance to certain CSDH policy recommendations -- as to previous attempts to catalyse action on

health risk factors such as smoking and diet -- is likely to come from some corporate and commercial

interests. Homedes and Ugalde have shown that neoliberal health sector reforms in Latin America have

primarily benefited large corporations. They argue that under these reforms: "Excluded health policies are

those that have a negative impact on corporate profits such as safety programs in factories and

agriculture, accident reduction in vehicle transportation, tobacco reduction, the promotion of generic

drugs, and the promotion of essential drug lists"54. If the corporate sector and its allies have opposed such

components within health sector programming, it is reasonable to assume they will resist similar

strategies proposed under the banner of SDH.

 

The most obvious tensions for an SDH agenda may arise with those corporations that profit directly from

the marketing of potentially health-damaging products and lifestyles: e.g., manufacturers of tobacco

products; sugar; fast food and junk foods; alcohol; automobiles; and weapons. As McGinnis et al. note

for the US context: "The behavioural issues that together account for so many deaths -- tobacco, alcohol,

dietary excess and sedentary lifestyles -- are all products in part of strong commercial forces. Tobacco

and alcohol represent US industries with annual sales of well over $100 billion. The food industry spends

billions just on advertising and promotion"5.

In this sense, the sustained effort to confront the tobacco industry and to establish the Framework

Convention on Tobacco Control may provide lessons for the work of the CSDHcxxxi. Yet the situation of

an SDH agenda with respect to corporate interests is more complex that in the case of tobacco. Rather

than a single industry (and one moreover with a largely negative public profile), SDH interventions may

be seen as potentially threatening the interests of national and transnational companies in a variety of

different sectors, including some of the world's most powerful and beloved consumer product brands. The

recommendations that will emerge from the Commission's Knowledge Networks on

employment/working conditions and globalization/trade are particularly sensitive in this regard.

Numerous transnational corporations are strongly inclined to fight government regulation and controls

over questions such as labour practices, workplace safety and the impact of corporate activities on the

environment. Companies' profitability often depends on eluding such unwelcome constraints. This is in

addition to companies' perpetual motivation to minimize the sums they must pay in taxes. It is to be

anticipated that many transnational corporations may perceive policies addressing social and

environmental determinants of health as a threat, insofar as such policies might raise companies'

production costs and impose additional regulations on their behaviour with regard to production

processes, labour relations, environmental impacts and marketing practices.

Corporate interests likely to be made uncomfortable by an SDH agenda include powerful companies in

the for-profit medical sector and the pharmaceutical industry. The pharmaceutical industry may regard

the CSDH as threatening for two reasons: first, because an "upstream" preventive-promotive approach to

health will not generate profits for the industry (and might indeed in the long run actually reduce demand

for some of its products); second because of worries that the globalization and trade Knowledge Network

or other organs of the Commission might publicly criticize the industry and/or generate policy

recommendations seen as contrary to its interests.

 

Within international organizations and the development community

Institutions such as the World Bank and IMF have immense power to influence health and social policy

in developing countries. The struggles of the Alma-Ata agenda in the 1980s offer, among other things, a

lesson about what is likely to happen when health leaders recommend policies that are significantly out of

step with the frameworks being promoted by the international financial institutions. To avoid a repetition

of this scenario, the CSDH will need to manage its relationship with the IFIs and other major

development institutions strategically. This may be a difficult challenge. While the IFIs' policy

approaches have evolved since the 1980s, some analysts caution that the changes have been more on the

level of rhetoric than of substance. The World Bank's acknowledgement of the importance of a strong,

capable statecxxxii and the presence of new frameworks such as PRSPs do not necessarily signify changes

in the underlying assumptions and imperatives of the neoliberal model. Critics argue that the

asymmetrical power relationships between the IFIs and countries and the sorts of policy approaches

recommended by the World Bank and IMF remain as before in many instances 68,cxxxiii. The IFIs continue

to advocate market liberalization and privatization, a "leaner" state and strict ceilings on public spending,

including for health and social services. Their advice to countries may thus in many cases run counter to

the policy approaches the CSDH will promote.

38

Moreover, both the IFIs and the bilateral development agencies of powerful countries are strongly

influenced by corporate agendas. IFIs often act to advance the interests of corporations with close ties to

their major shareholder governments. Thus to the extent the Commission's messages and policy advice

are perceived as threatening to influential corporate constituencies, the IFIs and bilaterals may seek to

discredit the Commission and its recommendations, either through public critiques or behind the scenes

advice to national policymakers and other interlocutors. The CSDH may thus wish to consider advance

outreach to key constituencies within the IFIs, bilaterals and other donor agencies as a special priority,

developing and implementing targeted outreach strategies in the early phase of its operations.

 

Main strategic questions:

. To interest political leaders, a SDH policy agenda will have to offer

opportunities for some "quick wins". This principle applies to country-level

political processes and at the global level to the Commission itself. What

might "quick wins" look like, for countries tackling social determinants and for

the CSDH?

. How will the Commission develop its relationship with the major international

financial institutions, in particular the World Bank?
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