The Lancet, Volume 372, Issue 9650, Pages 1684 - 1689, 8 November 2008
doi:10.1016/S0140-6736(08)61693-1
Cite or Link Using DOI
Cite or Link Using DOIAddressing social determinants of health inequities: what can the state and civil society do?
Prof Michael P Kelly PhD d 
,
, Summary
In
this Health Policy article, we selected and reviewed evidence
synthesised by nine knowledge networks established by WHO to support
the Commission on the Social Determinants of Health. We have indicated
the part that national governments and civil society can play in
reducing health inequity. Government action can take three forms: (1)
as provider or guarantor of human rights and essential services; (2) as
facilitator of policy frameworks that provide the basis for equitable
health improvement; and (3) as gatherer and monitor of data about their
populations in ways that generate health information about mortality
and morbidity and data about health equity. We use examples from the
knowledge networks to illustrate some of the options governments have
in fulfilling this role. Civil society takes many forms: here, we have
used examples of community groups and social movements. Governments and
civil society can have important positive roles in addressing health
inequity if political will exists.
Research
and action to promote greater health equity has a long tradition.
However, the launch of the report of the WHO Commission on the Social
Determinants of Health (CSDH)1 represents an important milestone, calling as it does for renewed and
sustained action to achieve greater health equity by focusing attention
on the central role of action to address the social determinants and by
collation of global evidence to support this action. Nine knowledge
networks, established to aid the CSDH, have been synthesising knowledge
on opportunities for improved action in key areas: early child
development,2 employment conditions,3 health systems,4 urban settings,5 globalisation,6 social exclusion,7 women and gender equity,8 priority public-health conditions,9 and measurement and evidence.10 More than 350 researchers, practitioners, policy makers, and
civil-society representatives, and 100 institutions across countries of
low, middle, and high incomes, had a role in these networks, which
appraised a rich diversity of actions by many actors, including United
Nations agencies, national governments, international and national
donor institutions, private-sector organisations, and civil society. In
this Health Policy article, our intention is not to summarise the work
of the knowledge networks as a whole. Rather, our aim is more modest:
to draw on selected evidence from across the knowledge networks to
highlight the pivotal role of national governments and civil society in
the pursuit of greater health equity.
Approach to evidence
The
conventional biomedical approach to determinants of health does not
generally embrace causal pathways to illness that originate in laws,
tax systems, the behaviour of multinational organisations, or global
financial systems. The implication of the social determinants approach,
however, is that causal chains run from macro social, political, and
economic factors to the pathogenesis of disease. These causal factors
produce disease not only in individuals but also in highly patterned
ways in populations. These patterns are shaped by distributions of
socioeconomic advantage and disadvantage and are observable across
entire societies, rich and poor alike, and between groups.10, 11
The
two causal chains—of individual disease and of population patterns of
disease—present challenges for research. Although much is already
known, evidence of relevant causal pathways must continue to be
refined, partly on the basis of enhanced disaggregation of
population-health data. Similarly, methodological developments are
needed in evaluative research to ensure that we are able adequately to
appraise the effect of the diverse actions described in the knowledge
networks' reports. In view of the limitations of the current evidence
base—both epidemiological and evaluative—on the social determinants of
health and health inequities, the networks had to be flexible,
multidisciplinary, and inclusive in the type of data they used. There
was also a concern to incorporate findings on the subjective
experiences of people most directly affected by health inequities, to
let their voices be heard. For these reasons, no single hierarchy of
evidence was adopted.
Notwithstanding
the difficulties and limitations of the knowledge available, the
political challenge is to ensure that action is taken on the basis of
the abundant information that is already available. The work of the
knowledge networks points to the potential for action by many actors at
many levels,12 but findings from all networks emphasised the pivotal part to be played
by national governments and civil society, whether as informal
groupings of communities of interest or place, formal organisations, or
wider social movements. In the following sections, we describe the
broad contours of these roles and present examples of this for
governments, drawing selected cases from across the knowledge networks.
Role of national governments and state action
Successful
governmental actions can reduce health inequity in at least three ways.
First, they can ensure provision of basic services and protect and
promote human rights (including entitlements to services such as health
care and education) and the right to a decent standard of living,13 thus making sure resources are distributed in more equitable ways.
Second, they can establish and maintain legislative and regulatory
frameworks to influence the action of others and their own. Third, they
can monitor the health status of different population groups, health
outcomes of social inequalities, and effects and progress of action to
reduce inequities and use this information to inform ongoing
interventions.
Human rights and essential services
Without
doubt, the universal welfare systems introduced after World War II in
most OECD (Organisation for Economic Cooperation and Development)
countries substantially reduced poverty, reversed exclusionary
processes, promoted social cohesion, and enhanced population health.7,14—16 For example, the early child development knowledge network has gathered
strong evidence from around the world that shows the best developmental
outcomes for children are achieved both by ensuring universal access to
quality child care, nutrition, health services, and education, and when
policies support families and communities. Comprehensive welfare
policies in France and Sweden have diminished child poverty to levels
that are some of the lowest in OECD nations. However, the potential is
not confined to high-income countries.4 Outside the OECD, evidence from Thailand, Sri Lanka, Cuba, South
Africa, and Brazil shows that good leadership, even under challenging
circumstances, can provide innovative interventions and benefits to
socially marginalised groups or other subpopulations.4 Irrespective of economic development, countries with a more generous
welfare state and regulated labour markets have reduced unhealthy
employment and working conditions to a greater extent than those that
do not. For example, data from wealthy countries such as Canada,
Australia, the USA, and the UK show that workplaces at which unions are
present are safer than those without unions and that union
representatives are well placed to record occupational risks and
advocate for change.3, 17
Since
the late 1970s, a widespread shift has taken place away from state
involvement in the provision of universal social protection, health
services, and education funded through taxation and social insurance,
towards more individualistic models of welfare—what Jacob Hacker,
writing in the US context, has called the privatisation of risk.17 This process of forming a market for public services in countries of
low and middle income is promoted by the problematic conditions
attaching to aid, loans, or debt relief from governments in high-income
nations and international financial institutions.6 Evidence collated by the knowledge networks suggests that these
approaches to the provision of basic services for poor populations
create many difficulties from the perspective of health equity.4, 17 In 2001, for example, Colombia introduced a dual system of health-care
insurance: a contributory scheme for those who can afford it; and a
subsidised scheme that covers 20·2 million people with low
incomes—47·7% of the population. This scheme left 5·6 million
individuals (13·3% of the population) ineligible for either scheme, so
a partial subsidy was initiated to allow these people to access free
emergency health care in certain public facilities.
But
counter forces have also operated. For example, in countries of low and
middle incomes, publicly funded and administered social protection
policies have reduced financial and other forms of labour market
insecurity. Across OECD countries, in particular the Nordic social
democracies, governments have maintained a commitment to spending on
social protection.16, 18 Governments such as those of South Africa, Venezuela, and Brazil, are
developing universal approaches that also aim for enhanced social
cohesion and solidarity: these warrant greater attention and evaluation
in the future. The international human rights framework was identified
in a background paper for the WHO commission as “the appropriate
conceptual structure within which to advance towards health equity
through action on [social determinants of health]”.19 Constitutional rights to health services are just one way in which
national governments can at least create a climate in which an
equitable distribution of resources to meet basic needs can be pursued.
Another, suggested by the United Nations' Special Rapporteur on the
right to health, entails development of a right-to-health impact
assessment framework that can be applied in an anticipatory way to the
provisions of trade agreements.
Legislative and regulatory frameworks
Policy
frameworks that regulate or enable actions towards the goal of health
equity are another means by which governments can exert leadership.
These frameworks might focus on a nation's relationship with external
agents—eg, with respect to regulation of global trade relations—or be
concerned with internal issues, such as achievement of greater gender
equity or support of cross-sector work. Typical characteristics of
successful frameworks are that they outline roles and responsibilities
(including legal responsibilities, such as those related to human
rights) of every sector, how collaboration will proceed, and what
resources will be available.
The need
for robust national policy frameworks to regulate the action of
international agencies with the aim of promotion of health equity is
nowhere more relevant than in relation to globalisation. Globalisation
brings indirect health benefits through increased economic growth and
poverty reduction.20 Yet, reality is not that simple. For example, lost revenues resulting
from rapid reduction of tariffs in many countries of low and middle
income have not always been replaced by growth or alternative tax
structures. Losses affect public financing of health services,
education, water and sanitation services, and other social protection
investments. A necessary, but not sufficient, condition for any further
liberalisation of trade is creation of regulatory frameworks that
ensure establishment of effective alternative means of public revenue
generation and greater equity in access to health services and other
schemes related to social determinants of health.6
National
policy frameworks are also needed to challenge the argument that
deregulated labour markets and low wages are inevitable. For example,
despite high wages and benefit levels, some countries with so-called
active labour market policies are amongst the most competitive in
global markets.3 In countries of low and middle income in particular, governments must
put in place the regulatory frameworks needed to ensure that protection
of labour legislation is extended to workers in informal labour
markets, who might represent most of the employed population.
National
policy frameworks also offer a mechanism for making sure of the success
of multisector action on social determinants. For example, in Eritrea,
a holistic approach to early child development—including families,
caregivers, community institutions, health and community centres,
schools, and development agencies—has resulted in better infrastructure
and increased preschool and primary school enrolment levels compared
with other countries in the region.2 Experiences from Mexico, Sri Lanka, Chile, Sweden, and the UK4 highlight that intersectoral action for health and improvements in
health equity are attributed not only to the performance of the health
sector but also to the coordinated action of all ministries to promote
socioeconomic development.4
Within
the health sector, governments can directly influence the degree to
which public-health programmes are mandated to act on broader
determinants of health and are accountable for improvements in health
equity. In nations of low and middle income, sizeable portions of
national budgets (government and donor funding) are directed to
strategies to prevent and treat specific conditions or diseases (eg,
tuberculosis, malaria, maternal and child health, and HIV/AIDS).
Analyses done by 14 priority public-health nodes (alcohol,
cardiovascular diseases, child health and nutrition, diabetes, food
safety, HIV/AIDS, making pregnancy safer, malaria, mental disorders,
neglected tropical diseases, oral health, sexual and reproductive
health, tuberculosis, and violence and injuries), which are all
existing WHO programmes, show that ample opportunities exist to adjust
the design and coordinated implementation of these initiatives to
enhance health equity when a social determinants approach is adopted.
This can include augmentation of access to poor and other marginalised
subpopulations and directly addressing the conditions that put these
people at high risk of disease.9
National
regulatory and legislative frameworks have also been shown to have
substantial positive effects on gender equity. For example, over the
past 40 years in Tunisia, changes in personal status laws have raised
women's legal and social status, thus outlawing repudiation and
polygamy, establishing a minimum age for marriage, and providing equal
wages for men and women.21 In Sweden, creation of a division of gender equality within the
national administration—coupled with enforcement of a gender equality
strategy that requires public and private organisations to undertake
systematic gender analysis of all policies and services—has resulted in
greater health equity.8
Monitoring of health status
Systems
to monitor health equity must involve analysis of age, sex,
socioeconomic group (eg, as an indication of education and wealth),
race, ethnic origin, and place of residence, and other key factors that
define socioeconomic (dis)advantage.10 Currently, analyses and interpretation of relations between health and
these variables are rarely undertaken outside of high-income countries.3 Some governments have successfully mandated that new policies and
interventions, irrespective of their primary intent, are evaluated from
a health-equity perspective.10 Support for nations of low and middle income as they augment their
capacity to implement these tasks is urgently needed. Similarly,
governments can demand increased coordination and integration of
international agencies, and likewise, international agencies—including
donors—can support civil society organisations specifically to advance
health equity irrespective of the state's role or position.
Role of civil society
Civil
society actors can be powerful drivers for positive social, political,
and economic changes that affect health equity. These actions include
those of informal community groups, formal civil society organisations
such as labour unions, and large-scale social movements such as the
anti-apartheid movement in South Africa.
People
who are the intended beneficiaries of government policies and actions
have a right to participate in their design, delivery, and assessment.
Evidence shows that successful engagement of target communities in
decisions about how to address social determinants of health will
increase the likelihood of policies and actions being appropriate,
acceptable, and effective7 and can have a direct effect on individual health by raising people's sense of control over their lives.9, 22 In Dhaka, Bangladesh, one of the most populated urban areas in the
world, integration of local communities in the design and delivery of
an overall waste collection system proved a highly successful way of
supplying a service that was previously non-existent for marginalised
populations. In Marikina City, Philippines, a comprehensive plan that
integrated health services, infrastructure development, and
environmental upgrading, with strong community involvement, led to a
sharp reduction in dengue.5
A large-scale example of participative democracy in action is the Barrio Adentro primary health-care programme in Venezuela, which enabled 17 million
people on low income to gain access to health services within 3 years,
and has now extended into other policy areas. Neighbourhood health
committees are a key element in this initiative. At first, these
committees—elected from local residents—were responsible for
identification of accommodation in the Barrio for new doctors and the
clinics they were to open. However, over time they are becoming a force
to promote local social cohesion. The committees retain oversight of
strategic development of health care in their neighbourhoods. By 2006,
almost 9000 elected neighbourhood health committees were registered
with the national health committee coordinating office set up by the
Ministry of Health. These committees are becoming involved in
implementation of other social missions in their neighbourhoods and are
seen as a key building block in the new participative democracy the
Venezuelan government is seeking to build.
Early
positive outcomes of the Venezuelan social experiments focusing on
health care, literacy, land reform, and other social determinants have
been described.23 However, in many countries, the knowledge and perspectives of lay
people, particularly indigenous populations, is frequently devalued and
ignored.24, 25 Policy changes can and have addressed this issue, but to be successful
they must acknowledge the change in power balance implied by community
engagement and address the resistance this shift might lead to within
professional groups and the organisations in which they work.7
Formal
civil society organisations have enabled improvements to social
determinants of health at all levels of society, through advocacy,
monitoring, mobilisation of communities, provision of technical support
and training, and giving a voice to the most disadvantaged sections of
society.4 Women's organisations have been at the forefront of this success, with
generation of new and compelling evidence of gender inequality and
inequities in health, experimentation with innovative programmes,
political mobilisation, and demands for accountability from governments
and the intergovernmental system.8 In doing so, they have had a catalytic role in changing the social and
political climate nationally, regionally, and globally and in pushing
governments to exercise their leadership roles.
An
example is the process that led to India's Protection of Women from
Domestic Violence Act 2005. An early draft in 2002 of the Domestic
Violence Bill left many loopholes, including no recourse for a woman
who might be thrown out onto the streets by a violent husband if she
dares to challenge him with the law. As a result of strong lobbying by
women's groups and effective redrafting by feminist lawyers the draft
was changed, and a considerably enhanced Act uses a broad definition of
violence to include beating, slapping, punching, forced sex, insults,
or name-calling. The Act allows abused women to complain directly to
judges instead of police, who usually side with men and rarely act on
complaints. Moreover, it covers not only wives and live-in partners but
also sisters, mothers, mothers-in-law, or any other female relation
living with a violent man. As such, it is one of the most progressive
pieces of legislation on this subject to date.8, 26
Many
contemporary social movements are working for greater social and health
equity at local, national, regional, and global levels. Some political
or religious aims are contested and do not always conform to national
policies. In the case of Latin American indigenous movements, the
central claim is for recognition of their culture, autonomy, and
collective ownership of their ancient lands. A well established
effective movement is the Zapatistas in Chiapas, Mexico. This
movement has established its own systems to provide food, housing,
education, and health services, with traditional health providers
complementing occidental medicine. The Zapatista health services have
delivered important health outcomes sometimes in very short timescales,
including a sharp decline in maternal mortality. The indigenous
communities in the north of Guatemala have been developing similar
services—including health-care provision that combines traditional and
occidental medicines—with very good results.27—30
Labour
associations have had, and continue to have, a role in augmentation of
employment conditions. In addition to trade unions, new social
movements—such as informal workers' alliances in countries of low and
middle income, fair-wear garment workers, fair-trade basic food
producers, and antichild labour campaigns—are now also developing and
affecting employment conditions. Social movements typically bring
together several civil society organisations and others towards a
common cause. In Norway, an extensive alliance of unions and community
groups has formed For velferdsstaten (For the Welfare State) to
campaign in favour of social welfare and public services. In South
Africa, broad-based post-apartheid social movements are diverse and
address land equity, gender, sexuality, racism, environment, education,
conditions of formal and informal labour, access to infrastructure,
housing, eviction, HIV/AIDS treatment, crime and safety, debt, and
geopolitics. These movements focus on material improvement of poor
people's lives, legal rights, social and environmental justice, and
stigma and discrimination.7
Finally,
civil society in all its forms usually supports generation of
information on population preferences and needs. In turn, these
organisations can be used to affect resource allocation and hold health
officials accountable at national and international levels, such as The
People's Health Movement.
The evidence
reviewed by the knowledge networks and described above suggests that if
national governments support civil society activity, this action can
have a positive effect on inequity of social determinants of health.
Such support can be entirely consistent with the normal role of
government in setting regulatory frameworks for civil society and
should include: (1) recognition of the political legitimacy of civil
society and a community's voice; (2) involvement of civil society in
all its forms in policy development, implementation, and monitoring;
(3) ratification and implementation of legal protection for civil
society organisations; (4) design of policies that transfer real power
to people; (5) resourcing of policy implementation to support community
empowerment; and (6) reform of professional education to give greater
status to lay and indigenous knowledge.
Properly
functioning civil society needs a free and responsible press that takes
up issues of inequity, encourages public debate, and challenges
government and other interest groups to be transparent and fair.
Powerful synergies have emerged when civil society, public-health
programmes, and the media have joined forces to stimulate and sustain
sound national and international public debates—for example, promotion
of exclusive breastfeeding, trade policy measures that restrict access
to essential medicines (notably in the case of HIV infection), and
restrictions on tobacco marketing.
In
their funding policies, multilateral agencies and international
development partners (or donors) have supported good practices by
provision both of incentives for national governments to work
effectively with communities and civil society organisations and of
resources for capacity building for civil society action and community
involvement. More broadly, the international community has a powerful
advocacy role to promote legal protections for civil society
organisations and community action within nation states.
Conclusions
We
have drawn on evidence from across the nine knowledge networks to show
the key parts to be played by national governments and civil society in
action to achieve greater health equity. The data suggest that health
equity is substantially enhanced when national governments accept
responsibility for protection and promotion of human rights, thus
guaranteeing universal provision to meet needs, including for example,
health care, sanitation and safe water, social protection, and
education. Establishment and maintenance of policy frameworks, such as
legislation and regulations, including financial regulation, has also
been shown to be an effective mechanism national governments can use to
shape the action of others—both external and internal to the state—to
promote greater equity in health and the social determinants of health.
A
diverse body of evidence also suggests that a dynamic and engaged civil
society—in all its forms—can enhance the relevance and acceptability of
actions addressing the social determinants of health equity, and by
increasing people's sense of control over their lives it can work
through psychosocial pathways to enhance health directly. Therefore, in
the pursuit of greater health equity, the state has an important role
in fostering democratic engagement, political freedoms, and free
speech, to actively promote development of a vibrant civil society.
However, civil society action in the form of community engagement
cannot be the 21st century's magic bullet: local community action is
inevitably constrained by the wider context in which it operates. Local
community action is fairly powerless in the face of global forces
driving powerful exclusionary processes, weak or corrupt governments
unable or unwilling to act for greater equity, or both of these
factors. By contrast, major social organisations—such as the
anti-apartheid movement—have shown the potential of large-scale civil
society action to affect the larger national and international stage.
These
lessons raise challenges that are both scientific and political.
Scientific challenges are to describe as precisely as possible the two
overlapping but analytically separate causal pathways that account for
both individual and population patterns of disease, drawing on
knowledge and best practice examples from around the world, and to
develop methods for robust assessment of action to enhance health
equity. Politically, the key players—namely states, governments,
corporations, and civil society—need to recognise and act on what is
already known about the social determinants of health. Political
actors, in particular, must change their behaviour substantially. Thus,
a key part of our collective future work is to ensure that reduction of
health inequity by addressing its social determinants remains high on
the political agenda.
Contributors
All
authors wrote the report. The following were co-authors of the nine
knowledge networks' reports, on which this article is based: Jens
Aagaard Hansen, Awa Aidara Kane, Daniel Albrecht, Francisco Armada,
Joan Benach, Chantal Blouin, Josiane Bonnefoy, Jennifer Butt,
Claire-Lise Chaignat, Haejoo Chung, Sarah Escorel, Francisco Espejo,
Mark Exworthy, Christopher Fitzpatrick, Michelle Funk, Gauden Galea,
Francis Grenier, Mario Hernandez Alvarez, Clyde Hertzman, Lori G Irwin,
Ernesto Jaramillo, Heidi Johnston, Stella Kwan, Kelley Lee, Knut
Lönnroth, Shawn Malarcher, Jose Miguel Martinez, Matthews Mathai, Jane
Mathieson, David Meddings, Shanthi Mendis, Antony Morgan, Landon Myer,
Thelma Narayan, Anne Marie Perucic, Poul Erik Petersen, Michael
Quinlan, Kumanan Rasanathan, Dag Rekve, Laetitia Rispel, Gojka Roglic,
Vivien Runnels, Vilma Santana, Robert Scherpbier, Arjumand Siddiqi,
Anand Sivasankara Kurup, Orielle Solar, Emma Stewart.
Conflict of interest statement
We
declare that we have no conflicts of interest. All authors, except
those identified as WHO staff, were members of the different knowledge
networks. The views expressed within this paper are those of the
authors and not necessarily those of WHO.
Acknowledgments
We thank Ross Gribbin for technical support in preparing the article.
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conflictos. In: Seoane J, ed. Movimientos sociales y conflicto en
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a World Health Organization, Geneva, Switzerland
b WHO Centre for Health Development, Kobe, Japan
c School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
d National Institute for Health and Clinical Excellence, London, UK
e Institute of Population Health, University of Ottawa, Ottawa, ON, Canada
f University of Toronto, Toronto, ON, Canada
g Karolinska Institutet, Department of Public Health Sciences, Division of International Health, Stockholm, Sweden
h Division of Health Research, Lancaster University, Lancaster, UK
i Centre for Public Health Policy, Indian Institute of Management, Bangalore, India
j International Research Initiatives Program, Human Early Learning
Partnership, University of British Columbia, Vancouver, BC, Canada
Correspondence to: Prof Michael P Kelly, National Institute for Health
and Clinical Excellence (NICE), Mid City Place, 71 High Holborn, London
WC1V 6NA, UKArticle Options
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