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

[Claudio]

2.2.4 Evidence, political processes and the CSDH "story line"

Scientific evidence is surely important to persuade constituencies sceptical about the value of health

policy oriented to SDH. But evidence by itself it is rarely if ever sufficient to catalyse political action. In

political terms, what may be at least as crucial as the evidence itself is the "story" in which it is

embedded.

This idea is of course not new. Indeed, it is as old as politics itself. However, the importance of this

theme has been strongly confirmed in recent public health history. The primary health care movement

that arose in the 1970s was able to draw on evidence from successful community-based health

programmes in the preceding decade. Yet what enabled PHC and Health for All to become the rallying

cries of a global movement was not the evidence presented (which in the 1970s was relatively scant).

What drove this change was the compelling narrative of justice, human flourishing and social

transformation told by PHC's proponents and embodied by the epic figure of Mahler. In the same way,

the subsequent victory of selective PHC was less a matter of evidence per se than of shifting political

interests coupled with the emergence of a new and in some ways even more compelling (because

simpler) "story line". This new story switched from a narrative about social justice to one focused on

dying children and how quick action could save their lives. The SPHC narrative was essentially reducible

to a set of "before and after" images often used in the promotion of the "child survival revolution". The

first showed a small child desperately ill with diarrhea, weak and dehydrated, the second the same child

restored to vibrant life by the administration of oral rehydration salts14. The SPHC/GOBI story elided or

glossed over many of the political and economic complexities with which the proponents of the Alma-

Ata vision had tried to grapple. But precisely this elemental, human simplicity made the force and

marketability of SPHC and the child survival agenda.

The importance of the story element to policy change in health has recently been confirmed by an

intriguing research exercise. A team of leading public health experts studied the way scientific

information is actually used (or ignored) in policymaking processes by exploring this issue in a

qualitative residential workshop with senior policy advisers. Their findings should push public health

scientists to renounce the belief that they can influence policy simply by providing government officials

with scientifically solid evidence. Policymakers interviewed for the study stressed the need for simple

messages unclouded by jargon and argued that researchers should be more attentive to the timeframes

within which governments operate. Sound evidence does not possess an inherent power to spur change, if

it is not presented compellingly and in a timely manner, and if its relevance to decision-makers' current

concerns is not made clear. Many policymakers emphasized the "value of a good story". As one UK

health policy adviser observed:

 

"[What is important is] how convincingly the evidence is presented, and how interesting you

make it. The face validity of a 'good story' is an example of how presentation style can influence

politics"138.

Participants argued that the importance of stories is not antithetical to the idea of evidence-based

policymaking. As one informant stressed, it is not a case of either/or. "Stories themselves can be used in a

credible way along with the evidence". Indeed, the story is the humanizing vehicle through which the

evidence takes on its full significance.

A social determinants "story line" must be able to capture the attention of political decision-makers and

other stakeholders, inspiring them with the sense that SDH are important and that action to address these

factors is feasible and timely. It must enable and encourage policymakers to "sell" the SDH agenda to

their colleagues and constituents. Creating and collectively "owning" this compelling, coherent story line

is arguably the most important challenge facing the CSDH.

 

Main strategic question:

. What story does the CSDH want to tell about social conditions and human

well-being? What narrative will capture the imaginations, feelings, intellect

and will of political decision-makers and the broader public and inspire them

to action?

 

CONCLUSION

Today an unprecedented opportunity exists to tackle the roots of suffering and unnecessary death in the

world's poor and vulnerable communities. The roots of most health inequalities and of the bulk of human

suffering are social: the social determinants of health. Over the past decade, scientific knowledge on SDH

has advanced dramatically, and today the political conditions for action are more favourable than ever

before. This opportunity is too important to let slip away. To seize it will require leadership based on a

mastery of the relevant science, but also moral vision and political wisdom. This is why the Commission

on Social Determinants of Health has been constituted now.

This exceptional opportunity has emerged through a long historical process. Strongly affirmed in the

1948 WHO Constitution, the social dimensions of health were eclipsed during the subsequent public

health era dominated by technology-based vertical programmes. The social determinants of health and

the need for intersectoral action to address them reemerged in the Alma-Ata period, and were central to

the model of comprehensive PHC proposed to drive the Health for All agenda. During this period, some

countries made important strides in addressing key social determinants such as nutrition and women's

education. However, like other aspects of comprehensive PHC, action on determinants was weakened by

the neoliberal economic and political consensus dominant in the 1980s and beyond, with its focus on

privatization, deregulation, shrinking states and freeing markets. Under the prolonged ascendancy of

variants of neoliberalism, state-led action to improve health by addressing underlying social inequities

appeared unfeasible in many contexts.

Recently, however, the tide has again begun to turn. The flaws of neoliberal policy prescriptions have

been exposed and the need for alternative development approaches widely recognized. Concern with

health inequalities between and within countries has increased, while progress in the scientific

understanding of the social determinants of health accelerated in the 1990s. In a growing number of

countries this scientific evidence is being applied to shape bold new public policy approaches. For the

moment, this trend remains largely concentrated in high-income countries, but several developing countries have begun to take innovative action on SDH, and more could be poised to do so. The

Millennium Development Goals adopted by 189 countries in 2000 set a new integrated framework for

global development that has once again focused attention on the interwovenness of development

challenges and the need for simultaneous, coordinated action across a range of sectors including

macroeconomic policy, food and agriculture, education, gender, and health. Without strong policy action

on SDH, the health-related MDGs will not be attained in most low- and middle-income countries. This

moment of "tidal shift" constitutes a historic opportunity for action on social determinants and a chance to

change theory and practice about what constitutes health policy -- as opposed to policies concerned with

the delivery of health care services.

As the CSDH embarks on its mission, a sense of history will be a valuable resource. To maximize its

chances of success, the Commission must craft its strategies with an awareness of past SDH efforts and

the lessons these experiences can teach. This paper has attempted to provide a selective historical

overview of major efforts to address SDH. It has traced in broad outlines the growth of knowledge on

SDH and, equally important, some of the political dynamics that shaped efforts to intervene on the social

dimensions of health and contributed to their success or frustration. The paper has not tried to offer

prescriptions. It will have fulfilled its function if it brings into clearer focus some of the urgent issues

with which the Commissioners must grapple, as the CSDH establishes its identity, fixes its objectives and

frames its strategies. 

 

In conclusion, we recall the key strategic questions identified:

1. How will the CSDH position itself on the "Mahler-Grant 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, intervention-focused, 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. This issue fundamentally concerns how Commissioners

understand their political role, and the place they assign to moral values in an undertaking that

aims to leverage policy action and bring concrete, measurable results rapidly.

2. What evaluation structure will the CSDH put in place to identify appropriate policy entry points

for different countries/jurisdictions?

3. 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?

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

institutions, in particular the World Bank?

5. How can the CSDH most effectively position itself within the global and national processes

connected to the Millennium Development Goals (MDGs)?

6. Is it scientifically credible, strategically desirable and/or ethically acceptable for the CSDH to

argue that health policies tackling social determinants are a wise investment that will "pay off" in

terms of enhanced economic performance and/or cost savings to health systems down the line?

7. Can the CSDH operate strategically to get "buy-in" from the business community, without losing

credibility with other key constituencies, including civil society organizations? How will potential

conflicts among these interests be mediated within the Commission as its work proceeds?

8. Drawing together all these and other issues is the question of "story". This is not a mere footnote

to the scientific and political problems the Commission must confront, but is at the heart of the

CSDH's effort to catalyse change. What story do the members of the CSDH collectively want to

tell about social conditions and human well-being? What narrative will capture the imaginations,

feelings, intellect and will of political decision-makers and the broader public and inspire them to

action?

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