PHA-Exch> The social determinants of health: Developing an evidence base for political action

[Claudio Schuftan]

From: Ruggiero, Mrs. Ana Lucia (WDC) ruglucia at paho.org

 *The social determinants of health: Developing an evidence base for
political action*

*Final Report from Measurement and Evidence Knowledge Network*

Michael P. Kelly (Co-chair) - Josiane Bonnefoy (Co-chair)

*World Health Organization - Commission on the Social Determinants of
Health, 2007*

* *Available online as PDf file [165p.] at:
http://www.who.int/social_determinants/resources/mekn_report_10oct07.pdf

 "……This report begins by identifying six problems which make developing the
evidence base on the social determinants of health potentially difficult.
These are:
- lack of precision in specifying causal pathways;
- merging the causes of health improvement with the causes of health
inequities;
- lack of clarity about health gradients and health gaps;
- inadequacies in the descriptions of the axes of social differentiation in
populations;
- the impact of context on interpreting evidence and on the concepts used to
gather evidence; and
- the problems of getting knowledge into action.

 In order to overcome these difficulties a number of principles are
described which help move the measurement of the social determinants
forward. These relate to defining equity as a value; taking an evidence
based approach; being methodologically diverse; differentiating between
health differences, health gaps and health gradients; clarifying the causal
pathways; taking both a structural and a dynamic approach to understanding
social systems; and explicating potential bias.

 The report proceeds by describing in detail what the evidence based
approach entails including reference to equity proofing. The implications of
methodological diversity are also explored. A framework for developing,
implementing, monitoring and evaluating policy is outlined.

 At the centre of the framework is the policy-making process which is
described beginning with a consideration of the challenges of policies
relating to the social determinants. These include the multi-causal nature
of the social determinants themselves, the fact that social determinants
operate over the whole of the life course which is a considerably longer
time frame than most political initiatives, the need to work
intersectorally, and the removal of the nation state as the major locus of
policy-making in many parts of the world.

 The ways to make the case for policies are described and appropriate entry
points and communications strategies are identified.

The next four elements of the framework are outlined in turn:
(a) evidence generation,
(b) evidence synthesis and guidance development,
(c) implementation and evaluation, and
(d) learning from practice. Finally the report describes the principal ways
in which policies relating to the social determinants may be monitored…."

 *Contents*

*1 The challenge of measurement and evidence about the social determinants
of health*

*1.1 Conceptual and theoretical issues *

1.1.1 Causal pathways

1.1.2 The difference between the causes of health and the causes of health
inequities

1.1.3 Accuracy of descriptions of the social structure

1.1.4 Context

1.1.5 Nature of health inequity gradients

1.1.6 Translation of knowledge into action

*1.2 Eight principles for developing the evidence base*

*2 Taking an evidence based approach *

*2.1 The evidence based approach *

*2.2 'Equity proofing'*

*3 Gaps and gradients *

*3.1 Health gaps*

*3.2 Health gradients*

*3.3 Shape of health gradients...25*

*4 Framework for policy development, implementation, monitoring and
evaluation *

*5 Getting social determinants on the policy agenda – making the case *

*5.1 SDH and the policy-making process*

*5.2 Conceptual models to inform policy-making*

5.2.1 'Policy streams' model

5.2.2 Network models

5.2.3 Policy failure model

5.2.4 Stages of policy development

*5.3 Making the case*

*6 Generating evidence for policy and practice*

*7 Evidence synthesis and action*

*7.1 Synthesizing complex and diverse data*

7.1.1 Systematic reviews of effectiveness

7.1.2 Evidence synthesis

7.1.3 Quantitative approaches to evidence synthesis

7.1.4 Qualitative approaches to evidence synthesis

7.1.5 Mixed approaches to evidence synthesis

7.1.6 Combining separate syntheses: the EPPI approach

*7.2 Producing guidance for action *

*8 Effective implementation and evaluation *

*8.1 Health equity auditing, needs assessment and impact assessment *

8.1.1 Health equity auditing

8.1.2 Health impact assessment

*8.2 Organizational development and change management *

*8.3 Readiness for intersectoral action*

*8.4 Effective ways of involving local communities *

*8.5 Evaluation *

*9 Learning from practice *

*9.1 Why do we need to collect knowledge from practice? *

*9.2 What do we know about the features of an effective system for learning
from practice? *

*9.3 What sorts of information should be collected? *

*10 Monitoring*

*10.1 Use of data to monitor health inequities*

10.1.1 Measuring the magnitude of health inequities

*10.2 Sources of health data *

10.2.1 Vital statistics

10.2.2 Censuses

10.2.3 Population-based surveys

10.2.4 Health records

*10.3 Issues in interpreting key equity stratifiers *

10.3.1 Education

10.3.2 Occupation

10.3.3 Income

10.3.4 Gender

10.3.5 Ethnicity/ race/ caste/ tribe/ religion

10.3.6 Place of residence

*10.4 Special issues in low and middle income countries*

10.4.1 Measuring socioeconomic position and other social constructs

10.4.2 Sources of data on social inequalities in health

10.4.3 Interpreting data on social inequalities in health

*10.5 Improvements in monitoring systems *

*11 Further issues for consideration *

*11.1 Attribution of effects and outcomes*

11.1.1 General theories

11.1.2 Theories of change

11.1.3 Micro theories or programme theories

11.1.4 Tacit knowledge theories

11.1.5 Priorities for action

*11.2 The challenge of policy *

*11.3 Hierarchies of evidence *

*11.4 Equity: relative or absolute?*

*11.5 Where further research and development is required*

*12 Conclusion*

*13 Recommendations for policy makers and practitioners*

*14 References*

*APPENDICES*

*I Measurement and Evidence Knowledge Network (MEKN) and its methods 113*

*                II Illustrative case studies*
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