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SOCIAL DETERMINANTS OF HEALTH

ACCESS TO POWER, MONEY AND RESOURCES AND THE CONDITIONS OF DAILY LIFE —
THE CIRCUMSTANCES IN WHICH PEOPLE ARE BORN, GROW, LIVE, WORK, AND AGE

[energy] [investment] [community/gov.] [water] [justice] [food]


[providers of services, education, etc.] [accessible & safe] [supply & safety]

ACTION ON THE SOCIAL DETERMINANTS


OF HEALTH: LEARNING FROM PREVIOUS
EXPERIENCES
Social Determinants of Health Discussion Paper 1
ISBN 978 92 4 150087 6

WORLD HEALTH ORGANIZATION


AVENUE APPIA
1211 GENEVA 27
SWITZERLAND
DEBATES, POLICY & PRACTICE, CASE STUDIES
WWW.WHO.INT/SOCIAL_DETERMINANTS
ACTION ON THE SOCIAL
DETERMINANTS OF
HEALTH:
LEARNING FROM
PREVIOUS EXPERIENCES

World Health Organization


Geneva
2010
The Series:
The Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the social
determinants of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, and
capacity building. They aim to review country experiences with an eye to understanding practice, innovations, and encouraging
frank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed.

Background:
This paper was prepared for the launch of the Commission on Social Determinants of Health (CSDH) by its secretariat based at
WHO in Geneva. It was discussed by the Commissioners and then revised considering their input. It was written by Alec Irwin
and Elena Scali.

Acknowledgments:
The authors want to thank Dr Jeannette Vega and Dr Orielle Solar and the 18 commissioners that participated in the launch of
the Commission on Social Determinants of Health for the valuable comments and peer review in the preparation of the different
drafts of this paper. Thanks to Nicole Valentine, who coordinated production.

Suggested Citation:
Irwin A, Scali E. Action on the Social Determinants of Health: learning from previous experiences. Social Determinants of Health
Discussion Paper 1 (Debates). Geneva, World Health Organization, 2010.

WHO Library Cataloguing-in- Publication Data

Action on the social determinants of health: learning from previous experiences.

(Discussion Paper Series on Social Determinants of Health, 1)

1.Socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. I.World Health Organization.

ISBN 978 92 4 150087 6 (NLM classification: WA 525)

© World Health Organization 2010


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Action on the social determinants of health: learning from previous experiences

Contents

EXECUTIVE SUMMARY 2

1. INTRODUCTION 4

2. HISTORICAL OVERVIEW 5
2.1 Roots of a social approach to health 5
2.2 The 1950s: emphasis on technology and disease-specific campaigns 5
2.3 The 1960s and early 70s: the rise of community-based approaches 6
2.4 The crystallization of a movement: Alma-Ata and primary health care 8
2.5 In the wake of Alma-Ata: “Good health at low cost” 9
2.6 The rise of selective primary health care 12
2.7 The political-economic context of the 1980s: neoliberalism 14
2.8 The 1990s and beyond: contested paradigms and shifting power relations 16
2.8.1 Debates on development and globalization 16
2.8.2 Mixed signals from WHO 17
2.8.3 SDH approaches at country level 18
2.9 The 2000s: growing momentum and new opportunities 25

3. TAKING IT TO THE NEXT LEVEL: THE COMMISSION ON SOCIAL


DETERMINANTS OF HEALTH 27
3.1 Aims of the CSDH 27
3.2 Key issues for the CSDH 27
3.2.1 The scope of change: defining entry points 27
3.2.2 Anticipating potential resistance to CSDH messages – and preparing strategically 30
3.2.3 Identifying allies and political opportunities 34
3.2.4 Evidence, political processes and the CSDH “story line” 37

4. CONCLUSION 39

LIST OF ABBREVIATIONS 41

REFERENCES 42

1
Executive summary

T
oday an unprecedented opportunity exists to improve health in some of the world’s poorest and
most vulnerable communities by tackling the root causes of disease and health inequalities. The
most powerful of these causes are the social conditions in which people live and work, referred
to as the social determinants of health (SDH). The Millennium Development Goals (MDGs)
shape the current global development agenda. The MDGs recognize the interdependence of health and
social conditions and present an opportunity to promote health policies that tackle the social roots of
unfair and avoidable human suffering.

The Commission on Social Determinants of Health (CSDH) is poised for leadership in this process.
To reach its objectives, however, the CSDH must learn from the history of previous attempts to spur
action on SDH. This paper pursues three questions: (1) Why didn’t previous efforts to promote health
policies on social determinants succeed? (2) Why do we think the CSDH can do better? (3) What can
the Commission learn from previous experiences – negative and positive – that can increase its chances
for success?

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 re-emerged strongly in
the Health for All movement under the leadership of Halfdan Mahler. Intersectoral action on SDH
was central to the model of comprehensive primary health care proposed to drive the Health for All
agenda following the 1978 Alma-Ata conference. During this period, some low-income countries
made important strides in improving population health statistics through approaches involving action
on key social determinants. Rapidly, however, a scaled-back version of primary health care, “selective
primary health care”, gained influence. Selective primary health care focused on a small number of cost-
effective interventions and downplayed the social dimension. The most important example of selective
primary health care was the GOBI strategy (growth monitoring, oral rehydration, breastfeeding and
immunization) promoted by UNICEF in its “child survival revolution”. The contrast in approaches
between comprehensive and selective PHC raises strategic questions for the CSDH.

Like other aspects of comprehensive primary health care, 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. The 1990s saw an increasing influence of the World Bank in
global health policy, with mixed messages from WHO. During this period, however, important scientific
advances emerged in the understanding of SDH, and in the late 1990s several countries, particularly in
Europe, began to design and implement innovative health policies to improve health and reduce health
inequalities through action on SDH. These policies targeted different entry points. The more ambitious
aimed to alter patterns of inequality in society through far-reaching redistributive mechanisms. Less
radical, palliative programmes sought to protect disadvantaged populations against specific forms of
exposure and vulnerability linked to their lower socioeconomic status.

2
Action on the social determinants of health: learning from previous experiences

The 2000s have seen a pendulum swing in global health politics. Health stands higher than ever on
the international development agenda, and stakeholders increasingly acknowledge the inadequacy of
health strategies that fail to address the social roots of illness and well-being. Momentum for action on
the social dimensions of health is building. The Millennium Development Goals were adopted by 189
countries at the United Nations Millennium Summit in 2000. They set ambitious targets in poverty and
hunger reduction; education; women’s empowerment; child health; maternal health; control of epidemic
diseases; environmental protection; and the development of a fair global trading system, to be reached by
2015. The MDGs have created a favourable climate for multisectoral action and underscored connections
between health and social factors. An increasing number of countries are implementing SDH policies,
but there is an urgent need to expand this momentum to developing countries where the effects of
SDH are most damaging for human welfare. This is the context in which the CSDH will begin its work.

Based on the historical survey, four key issue areas are highlighted, in which the members of the CSDH
must take strategic decisions early in their process.

1 The first concerns the scope of change the Commission will seek to promote and appropriate policy
entry points. Here the CSDH will face its own version of the choice between comprehensive and
selective primary health care that confronted public health leaders in the 1980s. The CSDH will
need evaluation criteria for identifying appropriate policy entry points for different countries/
jurisdictions.

2 Potential resistance to CSDH messages can be anticipated from several constituencies, which the
Commission should seek to engage proactively. The Commission will want to identify a set of
potential “quick wins” for itself and for national political leaders taking up an SDH agenda.
Commissioners will want to develop a strategy for dialogue with the international financial
institutions, in particular the World Bank.

3 The CSDH will also benefit from exceptional political opportunities. It will effectively position itself
within the global and national processes connected to the MDGs. Alliances with both the business
community and civil society are possible, but competing interests will need to be managed. The
opportunity and limits of economic arguments for SDH policies remain to be clarified, and such
arguments raise deeper ethical questions.

4 In addition to robust evidence, the Commission needs a compelling, collectively owned “story line”
about the social determinants of health, in which the evidence can be embedded and communicated.
What story does the CSDH want to tell about social conditions and human well-being?

With answer to these questions in place, the Commission will lead a global effort to protect vulnerable
families and secure the health of future generations by tackling disease and suffering at their roots.

3
1 Introduction

T
oday health stands higher than ever on these recommendations were rarely translated
the international development agenda, into effective policies. Strong messages on SDH
and health inequalities between and emerged again in the mid-1990s, but once more
within countries have emerged as a policy implementation made little headway in the
central concern for the global community1,2,3,4. developing countries where needs are greatest.
An unprecedented opportunity exists to improve Understanding the reasons for these frustrations
health in some of the world’s poorest and is fundamental to planning an effective strategy
most vulnerable communities – if approaches for the CSDH.
are chosen that tackle the real causes of health
problems. The most powerful of these causes are As an input to the strategy process, this paper seeks
the social conditions in which people live and to shed light on three related questions:
work, referred to as the social determinants of 1 Why didn’t previous efforts to promote health
health (SDH). Social determinants reflect people’s policies on social determinants succeed?
different positions in the social “ladder” of status, 2 Why do we think the CSDH can do better?
power and resources. Evidence shows that most of 3 What can the Commission learn from previous
the global burden of disease and the bulk of health experiences – negative and positive – that can
inequalities are caused by social determinants5,6. increase its chances for success?

The Millennium Development Goals (MDGs) The first part of this study reviews previous
recognize this interdependence between health major efforts to address social determinants with
and social conditions. The MDG framework shows attention to these efforts’ political contexts. The
that without significant gains in poverty reduction, second part identifies a series of key strategic
food security, education, women’s empowerment issues based on the historical record and outlines
and improved living conditions in slums, many factors that should enable the CSDH to catalyse
countries will not attain health targets7,8. And effective action.
without progress in health, other MDG objectives
will also remain beyond reach. Today, an An issue of vocabulary requires preliminary
international development agenda shaped by the clarification. One of the Commission’s main
MDGs provides a crucial opportunity to promote messages is that policies and interventions well
health policies that tackle the social roots of unfair beyond the traditional health sector should be
and avoidable human suffering. understood as part of a robust health policy.
“Health policy” is not equal to “health care
The Commission on Social Determinants of policy”. In the following pages, terms such as
Health (CSDH) is poised for leadership in this “SDH policies” and “SDH approaches” are used
process. To reach its objectives, however, the as a time-saving shorthand. These terms refer to
CSDH must learn from history. In the 1970s and health policies that address the social determinants
80s, the global Health for All strategy emphasized of health.
the need to address social determinants, yet

4
Action on the social determinants of health: learning from previous experiences

2 Historical overview

2.1 Roots of a social approach (emphasis added), identifying the Organization’s


to health goal as “the attainment by all peoples of the highest
possible level” of this state11. The Organization’s
The recognition that social and environmental core functions include working with Member
factors decisively influence people’s health is States and appropriate specialized agencies “to
ancient. The sanitary campaigns of the 19th promote … the improvement of nutrition, housing,
century and much of the work of the founding sanitation, recreation, economic or working
fathers of modern public health reflected conditions and other aspects of environmental
awareness of the powerful relationship between hygiene,” as required to achieve health progress.
people’s social position, their living conditions WHO’s Constitution thus foresees a supportive
and their health outcomes. Recent epidemiological integration of biomedical/technological and
research has confirmed the centrality of social and social approaches to health, though this unity has
environmental factors in the major population often come unravelled during the Organization’s
health improvements registered in industrialized subsequent history12.
countries beginning in the early 19th century.
McKeown’s analyses revealed that most of the
substantial modern reduction in mortality from 2.2 The 1950s: emphasis
infectious diseases such as tuberculosis took place on technology and disease-
prior to the development of effective medical specific campaigns
therapies. Instead, the main driving forces behind
mortality reduction were changes in food supplies The WHO Constitution provided space for a social
and living conditions10. model of health linked to broad human rights
commitments. However, the post-World War II
The Constitution of the World Health Organization, context of Cold War politics and decolonization
drafted in 1946, shows that the Organization’s hampered the implementation of this vision
founders intended for WHO to address the social and favoured an approach based more on health
roots of health problems, as well as the challenges technologies delivered through campaigns bearing
of delivering effective curative medical care. The a “militaristic” imprint 13. Several historical
Constitution famously defines health as “a state of factors promoted this pattern. One was the
complete physical, mental and social well-being” series of major drug research breakthroughs that
produced an array of new antibiotics, vaccines
and other medicines in this period, inspiring
health professionals and the general public with
the sense that technology held the answer to the
world’s health problems. This boom also propelled
“Do we not always find the the rise of the modern pharmaceutical industry,
destined to become not only a source of scientific
diseases of the populace traceable benefits but also a political force whose lobbying
to defects in society?”9 power would increasingly influence national and
international health policy. Another key change in
Rudolf Virchow (1821-1902) the political context was the temporary withdrawal
of the Soviet Union and other communist countries
5
from the United Nations and UN agencies in begun in the mid-1950s, relied once again on
1949. Following the Soviet pullout, UN agencies, technology – in this case the wide spraying of
including WHO, came more strongly under the the insecticide DDT to kill mosquito vectors. The
influence of the United States. Despite the key US massive programme proved to be a costly failure15.
role in shaping the WHO Constitution, US officials
were at that time reluctant to emphasize a social
model of health whose ideological overtones were 2.3 The 1960s and early 70s:
unwelcome in the Cold War setting. the rise of community-based
approaches
During this period and subsequently, health care
models in the developing world were influenced By the mid-1960s, it was clear in many parts of
by the dynamics of colonialism. The health systems the world that the dominant medical and public
established in areas of Africa and Asia colonized health models were not meeting the most urgent
by European powers catered almost exclusively needs of poor and disadvantaged populations
to colonizing elites and focused on high- (the majority of people in developing countries).
technology curative care in a handful of urban Out of necessity, local communities and health
hospitals. There was little concern for broader care workers searched for alternatives to vertical
public health and few services for people living disease campaigns and the emphasis on urban-
in slums or rural areas. Many former colonies based curative care. A renewed concern with
gained independence in the 1950s and 60s and the social, economic and political dimensions of
established their own national health systems. health emerged.
Unfortunately these were often patterned on the
models that had existed under colonial rule. On During the 1960s and early 70s, health workers
paper, post-independence health strategies often and community organizers in a number of
acknowledged the need to extend services to rural countries joined forces to pioneer what became
and disadvantaged populations, but in practice known as community-based health programmes
the bulk of government and international donor (CBHP)14. Such initiatives emphasized grassroots
funding for health continued to flow to urban- participation and community empowerment
based curative care. During this period, some in health decision-making and often situated
newly independent low-income countries spent their efforts within a human rights framework
over half their national health budgets maintaining that related health to broader economic, social,
one or two gleaming “disease palaces” – high-tech political and environmental demands. The
hospitals stocked with the latest equipment, staffed importance of high-end medical technology
by western-trained doctors and catering to the was downplayed, and reliance on highly trained
health needs of the urban elite14. medical professionals was minimized. Instead,
it was thought that locally recruited community
International public health during this period was health workers could, with limited training, assist
characterized by the proliferation of “vertical” their neighbours in confronting the majority
programmes – narrowly focused, technology- of common health problems. Health education
driven campaigns targeting specific diseases and disease prevention were at the heart of these
such as malaria, smallpox, TB and yaws. Such strategies.
programmes were seen as highly efficient and
in some cases offered the advantage of easily China’s rural health workers (figuratively referred
measurable targets (number of vaccinations to as “barefoot doctors”) were the most famous
delivered, etc.). Yet by their nature they tended to example. These were “a diverse array of village
ignore the social context and its role in producing health workers who lived in the communities
well-being or disease. Like hospital-centred they served, stressed rural rather than urban
health care, they tended to leave the most serious health care, preventive rather than curative
health challenges of the bulk of the population services, and combined western and traditional
(particularly the rural poor) unaddressed. The medicines”16. Community-based initiatives also
vertical campaigns begun in this period generated flourished in Bangladesh, Costa Rica, Guatemala,
a few notable successes, most famously the India, Mexico, Nicaragua, the Philippines, South
eradication of smallpox. However, the limitations Africa and other countries. In some instances,
of this approach were revealed by failures like such initiatives engaged directly not only with
the WHO-UNICEF campaign for the global social and environmental determinants of health,
elimination of malaria. The malaria campaign, but with underlying issues of political-economic
6
Action on the social determinants of health: learning from previous experiences

structures and power relations. In some parts of in Africa, Asia and Latin America. The book
Latin America, Brazilian educator Paulo Freire’s advocated a robust engagement with the social
awareness-raising methods were adapted to health dimensions of health, arguing that:
education and promotion. In the Philippines,
some groups practiced community-based
“structural analysis” through which community
members traced the social and political roots of
their health problems. “These methodologies for
empowerment became tools in helping groups “We have studies demonstrating
of disadvantaged people conduct a ‘community that many of the ‘causes’ of
diagnosis’ of their health problems, analyze the common health problems derive
multiplicity of causes and plan strategic remedial
from parts of society itself and that
actions” in innovative ways14. In Central America,
South Africa and the Philippines, loose alliances a strict health sectoral approach is
of community-based health programmes gradually ineffective, other actions outside
grew into social movements linking health, social the field of health perhaps having
justice and human rights agendas. Werner and greater health effects than strictly
Sanders argue that in several cases (the overthrow health interventions”18.
of the Somoza dictatorship in Nicaragua, resistance
to the South African apartheid regime and the Newell (1975)
weakening and eventual toppling of Ferdinand
Marcos’ authoritarian government in the
Philippines), community-based health movements In the same year, WHO and UNICEF published a
helped lay the groundwork for political change joint report examining Alternative approaches to
and the eventual reversal of despotic regimes14. meeting basic health needs in developing countries.
Reciprocally, Cueto argues, anti-imperialist The report underscored the shortcomings
movements in many developing countries and a of vertical disease programmes that relied on
weakening of US prestige as a result of setbacks technological fixes and ignored community
in Viet Nam helped create favourable conditions ownership. It emphasized that social factors such as
for the global uptake of these alternative health poverty, inadequate housing and lack of education
models during the late 1960s16. were the real roots underlying the proximal causes
of morbidity in developing countries19.
What had begun as independent, local or
national CBHP experiments acquired a growing This emerging model of health work found a
international profile and a cumulative authority powerful champion in Halfdan Mahler, a Danish
in the early 1970s. Some NGOs and international physician and public health veteran who became
missionary organizations, in particular the Director-General of WHO in 1973. Mahler was a
Christian Medical Commission, played an charismatic leader with deep moral convictions,
important role in promoting community- for whom “social justice was a holy word”20. He was
based models on the ground and disseminating angered at global inequities in health and at the
information on their success17. By the early 1970s, avoidable suffering undergone by millions of poor
awareness was growing that technologically and marginalized people. Having participated in
driven approaches to health care had failed to vertical disease campaigns in Latin America and
significantly improve population health in many Asia, Mahler was convinced that such approaches
developing countries, while results were being were incapable of resolving the most important
obtained in some very poor settings through health problems, and that an excessive focus on
community-based programs. Some leading advanced curative technologies was distorting
scholars, international public health planners and many developing countries’ health systems.
development experts began to advocate broad Hand in hand with the expansion of basic health
adoption of an approach to health informed by care services to disadvantaged communities,
the practices and priorities of CBHP. This included action to address non-medical determinants
leaders at WHO. In 1975, WHO’s Kenneth was necessary to overcome health inequalities
Newell, Director of the Organization’s Division of and achieve “Health for All by the year 2000”,
Strengthening Health Services, published Health as Mahler proposed at the 1976 World Health
by the People, which presented success stories from Assembly. “Health for all,” he argued, “implies
a series of community-based health initiatives the removal of the obstacles to health – that is to
7
say, the elimination of malnutrition, ignorance, improvement of living conditions”16. Logically,
contaminated drinking water and unhygienic PHC included among its pillars intersectoral
housing – quite as much as it does the solution of action to address social and environmental health
purely medical problems”21. determinants. The Alma-Ata declaration specified
that PHC “involves, in addition to the health
sector, all related sectors and aspects of national
2.4 The crystallization of a and community development, in particular
movement: Alma-Ata and agriculture, animal husbandry, food, industry,
primary health care education, housing, public works, communication,
and other sectors; and demands the coordinated
This new agenda took centre stage at the efforts of all these sectors”.
International Conference on Primary Health Care,
sponsored by WHO and UNICEF at Alma-Ata, Under Mahler’s leadership, WHO reconfigured
Kazakhstan, in September 1978. 3,000 delegates its organizational profile and a significant part of
from 134 governments and 67 international its programming around Health for All through
organizations participated in the Alma-Ata PHC. Accordingly, health work under the
conference, destined to become a milestone in HFA banner regularly incorporated, at least on
modern public health. The conference declaration paper, intersectoral action to address social and
embraced Mahler’s goal of “Health for All by environmental determinants. During the 1980s,
the Year 2000”, with primary health care (PHC) as the drive towards HFA unfolded, the concept
as the means. The adoption of the HFA/PHC of intersectoral action for health (IAH) took on
strategy marked a forceful re-emergence of social increasing prominence, and a special unit was
determinants as a major public health concern. created within WHO to address this theme. In
The PHC model as articulated at Alma-Ata 1986, WHO and the Rockefeller Foundation co-
“explicitly stated the need for a comprehensive sponsored a major consultation on IAH at the
health strategy that not only provided health latter’s Bellagio conference facility23, and technical
services but also addressed the underlying social, discussions on IAH were held at the 39th World
economic and political causes of poor health” Health Assembly. The WHA discussions included
(original emphasis)14. working groups on health inequalities; agriculture,
food and nutrition; education, culture, information
Many elements of the PHC approach were shaped and lifestyles; and the environment, including
by the Chinese “barefoot doctors” model and water and sanitation, habitat and industry24.
other community-based health experiences
accumulated over the previous decade. The From the mid-1980s, SDH were also given
Alma-Ata declaration presented PHC in a double prominence in the emerging health promotion
light. On the one hand, as the fundamental level movement. The First International Conference on
of care within a health system reconfigured to Health Promotion – cosponsored by the Canadian
emphasize the basic health needs of the majority, Public Health Association, Canada’s Health and
PHC was “the first level of contact of individuals, Welfare department and WHO – was held in
the family and community with the national health Ottawa in November 1986. The conference adopted
system”22. But PHC was also a philosophy of health the Ottawa Charter on Health Promotion, which
work as part of the “overall social and economic identified eight key determinants (“prerequisites”)
development of the community”22. Cueto identifies of health: peace, shelter, education, food, income,
three salient principles of the PHC philosophy. a stable eco-system, sustainable resources, social
The first was “appropriate technology”: i.e., the justice, and equity. It was understood that this
commitment to shift health resources from urban broad range of fundamental enabling factors could
hospitals to meeting the basic needs of rural and not be addressed by the health sector alone, but
disadvantaged populations. The second was a would require coordinated action among different
“critique of medical elitism,” implying reduced government departments, as well as among
reliance on highly specialized doctors and nurses nongovernmental and voluntary organizations,
and greater mobilization of community members the private sector and the media25. Following
to take responsibilities in health work. The third Ottawa, a series of international health promotion
core component of PHC was an explicit linkage conferences developed the messages contained
between health and social development. “Health in the charter and sought to build a sustained
work was perceived not as an isolated and short- movement26.
lived intervention but as part of a process of
8
Action on the social determinants of health: learning from previous experiences

2.5 In the wake of Alma-Ata: “Good health at low cost” (GHLC) was the title
“Good health at low cost” of a conference sponsored by the Rockefeller
Foundation in April-May 1985. The published
The years following the Alma-Ata conference proceedings became an important reference in
were not generally favourable for health progress debates about how to foster sustainable health
among poor and marginalized communities, improvements in the developing world27. The
for reasons to be examined shortly. However, conference closely examined the cases of three
a number of developing countries emerged as countries (China, Costa Rica and Sri Lanka) and
models of good practice during this period. They one Indian state (Kerala) that had succeeded
were able to improve their health indicators and in obtaining unusually good health results (as
strengthen equity, through programmes in which measured by life expectancy and child mortality
intersectoral action on health determinants played figures), despite low GDP and modest per capita
an important role. health expenditures, relative to high-income
countries.

Costa Rica

In 1988 the Pan-American Health Organization characterized Costa Rica as a “developing non-industrial nation with health indicators comparable to
those registered a few years ago by some advanced industrial nations”28. Between 1970 and 1983, the country cut general mortality by 40 percent, and
infant mortality was reduced by 70 percent29.

Commitment to nationwide coverage in health care and key basic social services contributed crucially to this pattern. A 1971 law guaranteed medical
care and hospitalization coverage under social security for the entire population. Regardless of salary level, all workers became affiliated with social
security benefits provided through the Caja Costarricense del Seguro Social (Costa Rican Social Security Fund, or CCSS), funded through state resources
and compulsory contributions from workers. The CCSS was one of a range of policy instruments based on principles of national solidarity and coverage
for the very poor. The CCSS drove several broad public health interventions: immunization campaigns were intensified against diseases such as measles
and diphtheria; the provision of potable water and sewage disposal were expanded, especially in rural areas. The two-thirds decline in infant mortality
in the 1970s appears to have been due to Costa Rica’s multi-pronged strategy simultaneously tackling a range of medical, infrastructural and social
factors30.

The Rural Health Program (RHP), launched in 1973, and the urban Community Health Program of 1976 delivered robust, multifaceted primary health care.
Taken together, these programs expanded access to medical services to approximately 60 percent of the population – both urban and rural – by 198030.
At the outset of the CCSS, less than 20 percent of the rural population had access to minimal health services31. The RHP identified areas of greatest
need and trained community health workers to visit homes in their respective areas in order to improve health practices, sanitation and vaccination
of children. At its core was a primary health care approach which provided a broad range of services to individuals (e.g., vaccination, nutrition,
family planning, and dental care); environmental health activities (e.g., potable drinking water, improvement of rural housing, excreta elimination); and
complementary supporting services (e.g., health education, data collection and promoting community organization)29. The RHP significantly expanded
services so that by the end of the 1970s, health services covered more than 60 percent of the rural population while all health indicators improved
significantly nationwide29,31. The urban Community Health Program, patterned after the RHP, aimed to improve the living conditions of slum dwellers.
Within three years of its creation in 1976, the program reached 57 percent of the urban population. By the end of the decade, this initiative has
succeeded in expanding vaccination to 85-90 percent of urban population, feces disposal in urban areas had increased from 60 to 96 percent and 100
percent of the urban population had access to potable water29.

Analysts of the country’s success have underscored Costa Rica’s strong policy link between health and education. Knowledge about health is regarded
as an essential part of education at all levels, and the education system has consciously been used as a venue through which to promote good health.
The free and compulsory grammar school system, operational since 1869, was expanded to include free middle school and a strengthening of the
university system in 1949. Due to the expansion of children’s school during the 1940s and 1950s, the proportion of women who completed primary
school increased from 17 percent in 1960 to 65 percent in 1980. This trend appears to have been a driver of the substantial decline in infant mortality
during the 1970s30.

9
The GHLC cases are still frequently cited when some of the strategies pursued by GHLC countries
analysts wish to give examples of health progress which contributed to their status as good practice
in developing countries, and in particular to show models. In what follows, we look at two GHLC
how policy in non-health sectors can improve jurisdictions and a third country, Cuba, which
health status. The question of which factors was not included in the study, but had pursued
contributed most to these jurisdictions’ success similar public health policies. Our particular aim
has continued to concern analysts – along with the is to see how these countries used intersectoral
corollary problem of why it has been so difficult for policies addressing health determinants as key
other countries at similar income levels to replicate tools for improving population health indicators
their achievements. A generation later, the issues and in particular meeting the needs of vulnerable
raised in Good health at low cost remain relevant, population groups.
and it is well worth looking in greater depth at

Sri Lanka

Sir Lanka achieved strong improvements in health indicators following independence in 1948, despite the country’s failure to generate sustained
economic growth32. An expansive primary health care system provided free to the entire population contributed significantly to population health gains33.
At the same time, pro-equity strategies across several social sectors played a major role in improving health outcomes32.

In agriculture, self-sufficiency in rice production and other essential food stuffs was a priority for the newly independent nation. “The agricultural
strategy of succeeding governments … diversified peasant agriculture with high-yielding crops, increased overall production and boosted the incomes
of farmers”. By the early 1980s, this program had reduced regional and class disparities, providing relief for some of the poorest groups, such as the
rice-growing peasantry, as part of a national effort to meet “basic needs” across the whole population. Over several decades, a food rationing scheme
ensured the supply of rice and several other essential food items at subsidized or stable prices to all households through a network of cooperatives. As
a result, between 1956 and 1963, the average caloric intake of the population as a whole increased by 40 percent32. Simultaneous efforts to increase
and improve the rural housing stock led to better structure, design and quality of rural housing34. Meanwhile, the health and well-being of workers,
particularly women and youth, were addressed through a series of labour laws in the 1950s. These included provisions to limit the work week to 45
hours and to provide annual compulsory vacation and sick leave with pay. The extension of an affordable public transportation network of rail and road
services increased the rural population’s access to basic health care services. In 1978, 70 percent of births in Sri Lanka took place to hospitals, clinics
and maternity homes32.

Universal free education has been provided since independence through a network of primary, secondary and tertiary educational institutions. By 1980,
health education and physical activity were included in the school curriculum. From 1945 onward, all students were provided with a free mid-day meal.
A large expansion in female education in the 1950s and 1960s virtually eradicated literacy differences between males and females and led to a wide
acceptance of family planning and a decline in the birth rate from the early 1960s32.

Analysts found that this whole range of intersectoral actions was facilitated by the country’s political system and culture of civil society participation.
The competitive political environment in Sri Lanka enabled the poor rural majority to secure a considerable degree of redistribution and social welfare
benefits. Women became active in the political process even before national independence, forcing the political elite to respond to their concerns.
The high priority accorded to maternal and child health in the 1930s and 1940s was a result. The popularity of political leaders, particularly in the two
decades prior to independence, was based upon their capacity to secure a wide range of state services for the electorate, among which health and
education assumed a high priority. A large and active non-governmental sector pressed political, economic and health concerns effectively. Groups
including village-level rural development societies and women’s associations were active in initiating public health campaigns, such as the anti-TB
campaign34.

10
Action on the social determinants of health: learning from previous experiences

Cuba

Post-revolutionary Cuba constituted an important example of “good health at low cost” that did not make it onto the agenda of the 1985 conference.
Cuba’s population health profile more closely resembles wealthy countries like the US and Canada than most other Latin American countries35. While
Cuba had likely attained one of the most favourable mortality levels in the developing world by the end of the 1950s, further significant declines in
mortality took place following the socialist revolution of 1959. The revolution brought medical and public-health resources within the reach of formerly
marginalized sectors of society. By redirecting national wealth towards the fulfilment of basic needs, the standard of living for the more disadvantaged
social groups was improved despite the country’s faltering economic performance in the 1960s and 1970s. Rural-urban differences in health and its
social determinants were reduced as the state invested more national resources in rural areas36. In 1959 the country’s infant mortality rate was 60/1000
live births and life expectancy was 65.1 years. By the mid-1980s Cuba had attained an infant mortality rate of 15/1000 and female life expectancy of
76 years37.

The principles of universality, equitable access and governmental control guided post-revolutionary Cuban health policies, which focussed on achieving
social equity through free provision of needed services, including medical care, diagnostic tests and vaccines for 13 preventable diseases. Cuba’s
public health policy prioritizes health promotion and disease prevention activities, decentralization, intersectoral action and community participation;
it features a local primary care approach which exists within an organized system of consultation and referral for more specialized care. At local level,
physicians and nurses live within the community they serve and provide not only clinical diagnosis and treatment, but also community education about
general health issues and non-medical health determinants35.

Cuba has made progress in addressing the social determinants of health, applying the same basic principles of universality, equitable access and
government control. Education has been a national priority. The government launched massive literacy campaigns shortly after the revolution,
nationalizing all private schools and making education free and universal. Subsequently, programmes to ensure that every adult obtained at least a
sixth grade education were put in place36. Cuba’s literacy rate is 96.7 percent, remarkable considering that before the revolution, one quarter of Cubans
were illiterate and another tenth were semiliterate35. The post-revolutionary period also saw campaigns to improve standards of hygiene and sanitation
in urban areas by increasing access to potable water through expansion of the network of aqueducts35,36. From early on, discussion of post-revolutionary
Cuba’s health and social policies bore an ideological and polemical stamp. Critics of the Cuban system pointed to restrictions on individual rights and
a generalized economic stagnation under the socialist regime. Defenders argued that Cuba’s commitment to social equity and universal primary health
care enabled the country to limit the health damage associated with prolonged economic embargo38.

While the GHLC jurisdictions and countries In the area of IAH, the most crucial areas appeared
like Cuba exhibited a range of different political to be: (1) guaranteeing an adequate food intake
frameworks and public health strategies, Good for all, including the most socially vulnerable
health at low cost argued that it was possible to groups, and (2) women’s education. The theme of
discern elements of a common pattern among women’s education/literacy as a health determinant
developing countries that had made exceptional subsequently provided the rationale for health
health progress. promotion campaigns in several developing
countries40.
Five shared social and political
Ironically, by the time Good health at low cost was
factors making “good health at low
published, several of the jurisdictions studied
cost” possible39
– including Costa Rica and Sri Lanka – were
being affected by global economic and political
p Historical commitment to health changes that would threaten the population health
as a social goal achievements praised in the volume (see below).
Subsequent decades revealed the vulnerability to
p Social welfare orientation to external shocks and domestic political vicissitudes
development of some of the policies that had enabled these
countries to become models for improving
p Community participation in population health and health equity.
decision-making processes
relative to health The message of GHLC was both encouraging
and deeply challenging for health policy makers
p Universal coverage of health in developing countries41. On the one hand, the
services for all social groups study confirmed that impressive health gains were
(equity) possible in countries with relatively low GDP
per capita. But on the other hand, the enabling
p Intersectoral linkages for health. 11
social and political conditions that appeared to a deeper level, beyond the inability to furnish
have made GHLC countries’ success possible were data in specific cases, profound methodological
precisely, as the above list suggests, conditions that uncertainty persisted about how to measure
the majority of developing countries did not and social conditions and processes and accurately
perhaps could not fulfil. Many of these countries evaluate their health effects. The problem was
lacked a historical commitment to health as a complicated both by the inherent complexity
social goal; a tradition of democratic community of such processes and by the frequent time-lag
participation; and equity in health services between the introduction of social policies and
coverage (or even the serious political will to the observation of effects in population health.
strive for it). Few countries’ development policies Measurement experts reached no clear resolution
could realistically be described as oriented towards on the methodological challenges of evaluation
broadly shared social welfare. and attribution in social contexts where by
definition the conditions of controlled clinical
Thus, of the five social and political factors found trials could not be approximated.
by Rosenfield to be common to GHLC countries
and to explain their success, the one seemingly During the 1980s, IAH also ran up against
most easily within reach for developing country government structures and budgeting processes
policymakers was the last: intersectoral linkages poorly adapted to intersectoral approaches. One
for action on health determinants. Accordingly, review identified the following difficulties:
a formal commitment to IAH became part of ∏ Vertical boundaries between sections in

many countries’ official health policy frameworks government


in the 1980s. However, the track record of ∏ Integrated programmes often seen as

actual results from national implementation of threatening to sector-specific budgets, to


IAH was feeble. Indeed, despite the high profile the direct access of sectors to donors, and
accorded to intersectoral action in the Alma-Ata to sectors’ functional autonomy
Declaration, WHA technical discussions, the health ∏ Weak position of health and environment

promotion movement and Good health at low cost, sectors within many governments
IAH to address social and environmental health ∏ Few economic incentives to support

determinants generally proved, in practice, to be intersectorality and integrated initiatives


the weakest component of the strategies associated ∏ Government priorities often defined by

with Health for All42. political expediency, rather than rational


analysis43.
Why? In part, precisely because many countries
attempted to implement IAH in isolation from Uncertainties about evidence and intra-
the other relevant social and political factors governmental dynamics were only part of the
pointed out in the above list. These contributing problem, however. Wider trends in the global
factors are to an important degree interdependent health and development policy environment
and mutually reinforcing. Thus, the chances of contributed to derailing efforts to implement
success in IAH vary with the strength of the other intersectoral health policies. A decisive factor was
pillars: broad commitment to health as a collective the rapid shift on the part of many donor agencies,
social and political goal; the crafting of economic international health authorities and countries from
development policies to promote social welfare; the ambitious Alma-Ata vision of primary health
community empowerment and participation; and care, which had included intersectoral action on
equity in health services coverage. Where these SDH as a core focus, to a narrower model of
objectives were not seriously pursued, IAH also “selective primary health care”.
faltered.

Later analysts identified further reasons why IAH 2.6 The rise of selective
failed to “take off ” in many countries in the wake primary health care
of Alma-Ata and GHLC. One problem concerned
evidence and measurement. Decision-makers in From early on, both the potential costs and the
other sectors complained that health experts were political implications of a full-blown version
often unable to provide quantitative evidence on of PHC were alarming to some constituencies.
the specific health impacts attributable to activities Selective PHC was rapidly proposed in the wake
in non-health sectors such as housing, transport, of the Alma-Ata conference as a more pragmatic,
education, food policy or industrial policy42. At financially palatable and politically unthreatening
12
Action on the social determinants of health: learning from previous experiences

alternative14,44. Rather than trying to strengthen was convinced international organizations had
all aspects of health systems simultaneously or a mission of moral leadership for social justice,
to transform social and political power relations Grant believed international agencies “had to do
(a possibly laudable but necessarily long-term their best with finite resources and short-lived
objective), advocates of selective PHC maintained political opportunities”, working within existing
that, at least in the short term, efforts should political constraints, rather than succumbing to
concentrate on a small number of cost-effective utopian visions. This meant renouncing ambitions
interventions aimed to attack a country’s or of broad social transformation to concentrate on
region’s major sources of mortality and morbidity. narrow but feasible interventions16. This tightly
Selective PHC in effect eliminated the social and focused, pragmatic approach was embodied in
political dimensions of the original PHC vision. the GOBI strategy.
The theorists of selective PHC presented it as an
“interim” strategy to be implemented urgently GOBI proved effective in many settings in
while countries worked to marshal the more cutting child mortality. However, it constituted
considerable resources and political commitment a dramatic retreat from the original Alma-Ata
needed for comprehensive PHC 44. In many vision, particularly regarding intersectoral action
settings, however, the interim model effectively on social and environmental health determinants.
suppressed comprehensive PHC as a long-term Additional components with a more multisectoral
objective. character (family planning, female education
and food supplementation) were added later,
Selective PHC focused particularly on maternal on paper, to the original GOBI interventions,
health and child health, seen as areas where a few but these additional ideas were ignored in many
simple interventions could dramatically reduce places. Indeed, in actual practice the GOBI
illness and premature death. The most famous strategy was even narrower than the acronym
example of selective PHC was the strategy for implied, since many countries restricted their
reduction of child mortality known as “GOBI” child survival campaigns to oral rehydration
– short for growth monitoring, oral rehydration therapy and immunization 14 . The narrow
therapy, breastfeeding and immunization. By selection of interventions targeted primarily at
concentrating on wide implementation of these women of childbearing age and children under 5
interventions in developing countries, proponents “was designed to improve health statistics, but it
argued, rapid progress could be made in reducing abandoned Alma-Ata’s focus on social equity and
child mortality, without waiting for the completion health systems development”38.
of necessarily lengthy processes of health systems
strengthening (or a fortiori for structural social The fate of the Health for All effort and the
change). The four GOBI interventions “appeared implications of the shift from comprehensive to
easy to monitor and evaluate. Moreover, they were selective PHC have generated a substantial and
measurable and had clear targets”. It was foreseen often polemical literature14,46,47,48,49. For critics of
that this model would appeal to potential funders, selective PHC, including recently Magnussen et
as well as to political leaders eager for quick al.: “the selective approach ignores the broader
results, since “indicators of success and accounts context of development and the values that are
could be produced more rapidly” than with the imbued in the equitable development of countries.
sorts of complex social processes associated with It does not address health as more than the absence
comprehensive PHC16. of disease; as a state of well-being, including
dignity; and as embodying the ability to be a
The GOBI strategy became the centrepiece functioning member of society. In conjunction
of the “child survival revolution” promoted with the lack of a development context, the
by UNICEF in the 1980s45. Under its earlier selective model does not acknowledge the role of
Executive Director Henry Labouisse, UNICEF social equity and social justice for the recipients
had cosponsored the Alma-Ata conference and of technologically driven medical interventions”38.
supported much of the early groundwork for Cueto summarizes that, for its critics, SPHC was
the original PHC strategy. The arrival of Jim a “narrowly technocentric” strategy that turned
Grant at the head of the agency in 1979 (the year away from the underlying social determinants
after Alma-Ata) signalled a fundamental shift of health, ignored the development context and
in UNICEF’s philosophy. Like Halfdan Mahler, its political complexities, and resembled vertical
Grant was a charismatic leader. But where Mahler programmes16.

13
On the other hand, defenders of the selective economic doctrines occurring at global level. This
approach object that comprehensive PHC and the shift had significant consequences for health, and in
Alma-Ata vision as a whole, while draped in moral particular for the capacity of governments to craft
language to which no one can object, were from the health policies addressing social determinants. To
start technically vague and financially unrealistic, fully understand the failures of intersectoral action
hence impossible to implement. The multiple on SDH (and the Alma-Ata strategy as a whole),
meanings of the term “primary health care” we must situate the “PHC vs. SPHC” problem
undermined its power. As Cueto observes: “In its within this broader context.
more radical version, PHC was adjunct to a social
revolution. For some this was negative and Mahler
was to be blamed for transforming WHO from a 2.7 The political-economic
technical into a politicized organization”. Others context of the 1980s:
believed Mahler was “naïve to expect changes neoliberalism
from the conservative bureaucracies of developing
countries”, and that he far overestimated the The 1980s saw the rise to dominance of the economic
capacity of a small number of enlightened experts and political model known as “neoliberalism” (for
and bottom-up community health projects to its emphasis on “liberalizing” or freeing markets)
effect lasting social change. Meanwhile the deep or the “Washington consensus” (since its main
political marginalization and impotence of the proponents – the US government, the World
rural poor were not sufficiently understood by Bank and the International Monetary Fund – are
PHC advocates. Likewise, defenders of the Alma- based in Washington, DC). The historical origins
Ata vision tended to romanticize and idealize and evolution of the neoliberal model have been
“communities” in the abstract, with too little discussed in detail elsewhere50,51. The core of the
attention to their actual functioning16. neoliberal vision was (and is) the conviction that
markets freed from government interference “are
These debates have implications that reach far the best and most efficient allocators of resources
beyond the specific historical context of the 1980s in production and distribution” and thus the most
to raise questions of relevance today – including effective mechanisms for promoting the common
for the Commission on Social Determinants good, including health50. Government involvement
of Health. Arguably, both the great strength in the economy and in social processes should be
and the fatal weakness of comprehensive minimized, since state-led processes are inherently
PHC stemmed from the fact that it was much wasteful, cumbersome and averse to innovation.
more than a model for delivering health care “The welfare state, in the neoliberal view, interferes
services. PHC and Health for All as presented with the ‘normal’ functioning of the market” and
at Alma-Ata constituted a far reaching project thus inevitably wastes resources and delivers
of social transformation, guided by an ideal of unsatisfactory results50. Logically, an overarching
the empowerment of disadvantaged people and goal of policy must be to reduce the role of the
communities, under a model of “development state in key areas (including health) where its
in the spirit of social justice”22. With such values presence leads to inefficiencies. Instead, maximum
at stake, it is hardly surprising that impassioned freedom must be accorded to market actors whose
debates on the meaning and legacy of Health for pursuit of their own interests will most rapidly
All continue today. A question with which the generate economic growth and create wealth –
CSDH must grapple is a version of the problem the key preconditions for improved well-being
embodied in the emblematic figures of Mahler for all. Better than any form of state-managed
and Grant. Whether to focus on highly charged redistribution, market processes themselves can
concepts like social justice or less strong (but also be trusted to distribute the benefits of economic
less threatening) ones like equity or efficiency. growth through all levels of society. A key postulate
The choice is not only about language but implies of the neoliberal economic orthodoxy of the 1980s
different levels of engagement with political and 90s was that, since economic growth was the
processes and quite different proposals for action. key to rapid development and ultimately to a better
life for all, countries should rapidly and rigorously
The emergence of selective PHC as an alternative implement policies to stimulate growth, with little
to the Alma-Ata vision in the early 1980s was not concern for the social consequences in the near
accidental. Rather, it was the logical reflection of term. While growth-enhancing policies such as
a broader shift in political power relations and cuts to government social spending might involve

14
Action on the social determinants of health: learning from previous experiences

“short-term pain” for disadvantaged communities, should be “context sensitive”, in practice HSR tended
this would be more than compensated by the to adopt a limited menu of measures assumed to be
“long-term gain” such policies would produce valid everywhere53. Features of the HSR agenda
by creating a favourable investment climate and included:
accelerating economic development. ∏ Increasing the private sector presence

in the health sector, through strategies


During the 1980s, the neoliberal view was such as encouraging private options for
successfully promoted domestically in wealthy financing and delivery of health services
countries by such leaders as Ronald Reagan in and contracting out
the USA, Margaret Thatcher in Great Britain and ∏ Separation of financing, purchasing and

Germany’s Helmut Kohl. In the international service provision functions


development field, neoliberalism was imposed ∏ Decentralization (often without adequate
by donor governments via bilateral programmes, regulatory and stewardship mechanisms
but most importantly through the activities of at the sub-national levels to which
the World Bank and International Monetary responsibility was devolved)
Fund. The prolonged global economic recession ∏ Focusing on efficiency (and not equity)
of the 1980s and the associated debt crisis in the as the primary performance criterion for
developing world pushed many low and middle- national health authorities, while at the
income countries to the brink of economic same time cutting human and financial
collapse. These events provided the context in resources to the health sector, so that the
which powerful northern governments and the exercise of efficient stewardship became
international financial institutions (IFIs) could increasingly difficult in practice
intervene directly in the economies of numerous
developing countries, requiring that such The effectiveness of HDR measures has been
countries reshape their economies according to widely debated, but evidence of negative impacts
neoliberal prescriptions in order to qualify for debt has emerged from many settings. In many
rescheduling and continued aid51. countries, government stewardship capacities
in health were weakened as a result of reform. A
Neoliberal doctrines affected health through recent review of HSR in Latin America concludes
two main mechanisms: (1) the health sector that the reforms failed to achieve their officially
reforms undertaken by many low and middle- stated objectives of improving health care and
income countries beginning in the 1980s; and reducing health inequity; indeed many HSR
(2) the broader economic structural adjustment processes “caused the opposite results: increased
programmes imposed on a large number of inequity, less efficiency and higher dissatisfaction,
countries as a condition for debt restructuring, without improving quality of care” 54. On the
access to new development loans and other forms other hand, the reforms attained unofficial
of international support. To these instruments for objectives that may have been more important.
the propagation of the neoliberal paradigm was Decentralization enabled central governments
added a third device, of particular importance to “offload” health sector costs to regional, state
from the mid-1990s onward: international trade and local authorities and to use the resulting
agreements and the rules established by bodies savings at national level to continue repaying
such as the World Trade Organization (WTO), foreign debts. Privatization created lucrative
formed in 1995. opportunities for US-based HMOs and private
health insurance companies anxious to penetrate
The neoliberal health sector reforms (HSR) of Latin American markets.
the 1980s and 90s aimed to address structural
problems in health systems, including: the need Processes in Africa and Asia encountered
to place limits on health sector expenditures and different obstacles, but generally brought similarly
to use resources more efficiently; poor systems unsatisfactory results. A detailed comparative
management; inadequate access to services for study of HSR processes in Ghana, India, Sri Lanka
poor people, despite the rhetoric of PHC; and poor and Zimbabwe concluded that reform packages
quality of services in many countries and regions52,53. were “inappropriately designed for developing
Unfortunately, in many instances the reforms country contexts” and “quite out of touch with
undertaken failed to remedy these problems and the reality of [countries’] health systems and the
in some cases actually made them worse. While broader socio-political environment”; meanwhile,
proponents of the reforms acknowledged that they “the political feasibility of the reforms was highly
15
questionable, especially in Asian countries”55. The sector payrolls. The sudden layoffs propelled huge
faith in the inherently beneficial effects of market numbers of people into unemployment, with no
dynamics which underlay reform proposals was safety nets and little chance of finding formal
misplaced in developing countries with relatively work in the private sector in many cases. The
weak regulatory and administrative capacities. negative health effects for individuals, families
and whole communities have been documented.
In some countries, particularly in southern Africa,
the resulting social destabilization and insecurity
contributed to hunger, the propagation of armed
conflict and the rapid spread of HIV/AIDS – with
In reality “the current state the poor, women and other socially disadvantaged
must have even more strengths groups bearing the brunt of the damage57.
and abilities than its archaic
As a result of SAPs and the global economic
predecessors, if it is going
malaise, social sector spending in many countries
to capitalize on the virtuous plummeted during the 1980s, with negative effects
efficiencies of the marketplace on the health status of vulnerable communities.
without suffering the latter’s side In the poorest 37 countries in the world, public
effects”, including negative impacts spending on education dropped by 25% in the
on equity56. 1980s, while public spending on health fell 50%58.
Since SAPs were implemented at the cost of great
human suffering, one would assume that their track
The same assumptions shaping HSR processes record in delivering enhanced economic growth,
were “writ large” in the macroeconomic structural their official raison d’être, must be impressive.
adjustment programmes (SAPs) implemented by Unfortunately this is not the case. Many of the
many countries in Africa, Asia and Latin America low-income countries that implemented SAPs,
under the guidance of the IFIs. SAPs typically particularly in Africa, saw little if any improvement
included the following components: liberalization in their GDP growth rate or other core economic
of trade policies (through elimination of tariffs indicators following adjustment. Thus the “short-
and other restrictions on imports); privatization of term pain” the programmes brought was much
public services and state enterprises; devaluation worse than the international financial institutions
of the national currency; and a shift from had predicted, while the promised “long-term
production of food and commodities for domestic gain” failed to materialize in many cases14,51.
consumption to production of goods for export14,51.

To understand the implications of neoliberal


economic models for efforts to address SDH, it 2.8 The 1990s and beyond:
is important to recall the impact of structural contested paradigms and
adjustment packages on many countries’ social shifting power relations
sector spending. A central principle of SAPs was
sharp reduction in government expenditures, 2.8.1 Debates on development and
in many cases meaning drastic cuts in social globalization
sector budgets. These cuts affected areas of key
importance as determinants of health, including Neoliberal economic prescriptions continued to
education, nutrition programmes, water and be widely applied through the 1990s. However,
sanitation, transport, housing and various forms as the decade advanced, these models were called
of social protection and safety nets, in addition to increasingly into question, in developing countries
direct spending in the health sector. With sharply and by a growing number of international agencies
falling public sector budgets, not only could new and constituencies in the global north. The
investment not be seriously envisaged to address successes and failures of the economic orthodoxy
social and environmental factors influencing embodied in SAPs were intensely debated;
health, but already existing supports were indictments of the IFIs multiplied through the
shorn away. Food subsidies, for example, were decade59,60,61. Fuel was added to the critiques as
slashed in many countries, while price controls countries of the former Soviet bloc began to
on staple goods were lifted. In addition, many register the social and health effects of economic
SAPs demanded large and abrupt cuts in public “shock therapy” programmes designed to move
16
Action on the social determinants of health: learning from previous experiences

these societies rapidly from planned economies on country-owned poverty reduction strategies
to the market system62,63. A series of local and that would serve as a framework for development
regional economic crises in the course of the assistance” 67. The value of the PRSP model
decade underscored the volatility of the new continues to be debated. The evidence available so
economic order and the vulnerability of poor and far suggests, however, that PRSPs tend to neglect
marginalized people to the economic fluctuations key issues related to health68, while a WHO report
that global actors seemed unable or unwilling in 2002 found no evidence that the PRSP process
to prevent. The resultant critiques fed a growing was leading to significantly increased spending
movement of social and political protest that commitments in health and education69. A 2003
surged into international headlines when tens of review of 23 highly-indebted poor countries’
thousands of demonstrators disrupted the meeting interim PRSPs (iPRSPs) concluded that much
of the World Trade Organization in Seattle, USA, remains to be done to integrate appropriate health
in 1999, opening a period in which massive street policies in poverty reduction strategies70. A lack
protests accompanied most major meetings of of country-specific data on the distribution of
international financial and trade bodies, as well disease, the composition of the burden of disease,
as fora like the G-8. the prevailing health system constraints and the
impact of health services were found in most
The concept of “globalization” was central to these of the iPRSPs reviewed. Moreover, only a small
contestations. Protesters and critics denounced group of iPRSPs documented efforts to explicitly
the perceived threat of a global economic order include the interests of the poor in the design of
dominated by transnational corporations and health policy; in fact, the majority did not take
volatile flows of “hot money”, whose fickle an explicitly pro-poor approach. The attention
movements could have devastating effects on given to making the distribution of public health
national economies and the well-being of poor expenditures more responsive to the needs of the
and vulnerable communities. Other commentators poor was even more limited.
emphasized the benefits of progressive economic
and technological integration and argued that the 2.8.2 Mixed signals from WHO
dynamism of the liberalized global economy was
the key to lifting hundreds of millions of people The late 1980s and early 1990s witnessed a waning
out of poverty, hunger and despair. Rival visions of WHO’s authority, with de facto leadership in
of what globalization is or should be clashed in the global health seen to shift from WHO to the World
media, scholarly publications, international fora Bank. In part this was a result of the Bank’s vastly
and policymakers’ debates64,65,66. greater financial resources; by 1990, Bank lending
in the population and health sector had surpassed
The international institutions which were prime WHO’s total budget71. In part the shift also reflected
objects of many of the debates were themselves the Bank’s elaboration of a comprehensive health
undergoing changes. Shaken by an unprecedented policy framework that increasingly set the terms of
wave of intellectual criticism and popular anger, the international debate, even for its opponents. While
Bretton Woods institutions and entities such as the open to criticism in many respects, the Bank’s
G-8 began to rethink their respective missions – or health policy model as presented in the 1993
at the very least to alter their rhetoric. To grapple World Development Report Investing in Health
more effectively with the debt problems plaguing showed intellectual strength and was coherent
numerous developing countries, the World Bank with regnant economic and political orthodoxy72.
and IMF launched the Heavily Indebted Poor
Countries (HIPC) initiative in 1996, and followed Despite the erosion of WHO’s influence during
it with an “enhanced” HIPC programme. The this period, however, the Organization’s activities
HIPC programmes offered carefully structured present a complex picture; important and
forms of debt relief to more than 40 of the poorest forward-looking work was undertaken by many
countries (the majority in Africa), the gains from groups within or connected with WHO. Some
which could be largely invested in core social efforts gave an important place to social and
expenditures such as health and education. To environmental determinants. For example, in
further galvanize poverty reduction efforts, certain regions, most clearly Europe, action to
the World Bank and IMF introduced Poverty address health equity challenges and the social
Reduction Strategy Papers (PRSPs) in December underpinnings of health continued as part of
1999 as a “new approach to the challenge of an unbroken commitment to the Health for All
reducing poverty in low-income countries, based ideal. A dedicated WHO Equity Initiative (1995-
17
98) based at Geneva Headquarters clarified the initiative on IAH was launched. The initiative
understanding of health equity as primarily related produced a set of substantial scholarly papers and
to people’s positions within social hierarchies, and reviews of IAH experience at national and global
thus to gradients of social, economic and political levels and culminated in a major international
power73,74. Despite intellectual products of high conference in Halifax, Nova Scotia, in 1997. The
quality, the momentum of the initiative was broken existence of the IAH initiative attested both to
by personality conflicts and political struggles. The continued recognition of the importance of the
initiative was suspended in 1998. social and environmental determinants of health
and the ongoing difficulties countries experienced
From 1994 to 1997, WHO sponsored the Task in addressing them77.
Force on Health in Development, chaired by
Brandford Taitt and including other prominent The arrival of Gro Harlem Brundtland as Director-
policy-makers as well as public health leaders. The General in 1998 brought significant changes
Task Force reviewed global development policies in WHO’s institutional agenda. Brundtland’s
and their health implications, highlighting the priorities included a new initiative on malaria (Roll
effect of social conditions on health and arguing Back Malaria), a global campaign against tobacco
that health impact among vulnerable populations and a rethinking of health systems. Brundtland
should be a central criterion in shaping policy is credited with having restored much of WHO’s
choices for economic development. Among a range tarnished credibility in international development
of other documents, the Task Force on Health in debates. However, this renewal came at a price, and
Development produced a WHO Position Paper for the sacrifices affected areas of importance for the
the 1995 World Summit for Social Development in Organization’s capacity to promote action on SDH.
Copenhagen. The paper interrogated the “trends For example, the ambitions of Health for All in the
towards privatization and market economies” that 21st Century were sharply scaled back. In the area
characterized the “globalization of the economic of health and development, Brundtland’s signature
system.” It argued that efforts to promote economic was the Commission on Macroeconomics and
growth should be “accompanied by more equitable Health (CMH), chaired by Jeffrey Sachs. The
access to the benefits of development, as inequities CMH’s basic argument was not novel. But by
have severe health consequences.” And it stressed putting numbers on the idea that ill-health among
that health issues could be “most effectively the poor costs the global economy vast sums
addressed through intersectoral collaboration” of money, the CMH captured the attention of
to tackle factors such as poverty, unemployment, policy-makers. Quantifying in dollar terms the
gender discrimination and social exclusion75. potential economic payoff of health improvements
Unfortunately, the Task Force’s practical impact in low and middle income countries, the CMH
was not proportional to the moral strength of its helped secure fresh prominence for health as
arguments. The group proposed a valuable set of a development issue. Because it embraced the
broad recommendations, but was not provided language of cost-effectiveness and looked at health
with mechanisms for implementation and follow- in terms of returns on investment, the CMH may
up. There was no systematic effort to recruit pilot have been perceived as more realistic, pragmatic
or partner countries to apply the Task Force’s and in touch with the real world than earlier WHO
advice in national policymaking and to measure initiatives such as the Task Force on Health in
outcomes. Within WHO itself, no structures had Development, which had discussed ethical values
been foreseen to operationalize the Task Force’s and invoked “the courage to care”78.
findings, and these lessons had little measurable
influence on the Organization’s country-level work 2.8.3 SDH approaches at country
and policy dialogue with Member States. level
A major WHO effort in the mid-1990s was Several countries made notable strides in the effort
the attempt to reinterpret and reinvigorate the to address social dimensions of health through the
Health For All strategy under the banner of Health 1990s and early 2000s.
For All in the 21st Century76. The revitalization
of HFA included a renewed effort to promote The direct roots of contemporary efforts to
intersectoral action as a key component of identify and address socially-determined health
public health strategies. Thus, ten years after the inequalities reach back to the Canadian Lalonde
landmark 1986 WHA technical consultations Report79 (1974) and the Black Report in the
on intersectoral action for health, a new WHO United Kingdom80 (1980). The Black study had
18
Action on the social determinants of health: learning from previous experiences

little immediate policy impact in the UK, then potentially far-reaching implications for public
governed by Prime Minister Margaret Thatcher’s policy led to efforts to translate relevant scientific
Conservative Party, whose leadership dismissed findings into language accessible to policy-makers
Black’s recommendations as utopian. However, and the general public87.
the document generated strong interest in portions
of the scientific community. It inspired a number The most rapid advances were made in a number
of comparable national enquiries into health of Western European countries, where in the late
inequalities in countries such as the Netherlands, 1990s and early 2000s momentum gathered for
Spain and Sweden. Public health specialists and systematic policy action to tackle health inequalities
political leaders in several countries began to and address SDH88. In some cases, notably Sweden,
explore policy options to address the troubling the result has been a dramatic reorientation of
patterns the studies revealed – though action public health towards a social approach. In the UK,
remained vulnerable to political power shifts the arrival in power in 1997 of a Labour government
(e.g., in Spain). Meanwhile the pervasive effects responsive to health equity concerns sparked a
of social gradients on health were progressively wave of fresh research and policy innovation that
clarified, in particular by data emerging from put the country at the forefront of efforts to tackle
the Whitehall studies of comparative health SDH and reduce health inequalities. Outside of
outcomes among British civil servants, led by Sir Europe, Australia, Canada and New Zealand have
Michael Marmot81,82. In Canada during the early been leaders in research and policy action on the
90s, a remarkable interdisciplinary research effort social dimensions of health, though tensions have
sponsored by the Canadian Institute for Advanced surfaced between an SDH approach and strategies
Research (CIAR) brought together experts from rooted in more market-based and individualized
public health and other natural and social science models of health and health care89,90. Meanwhile,
fields to explore together “the determinants of the successful efforts to address SDH through public
health of populations”. The objective was not only policy have not been limited to high-income
to bolster scientific knowledge, but to identify countries. In the 1990s, a number of developing
effective policy options in answer to the question: countries have also begun to implement promising
“What can be done to improve a democratic policies and interventions to tackle the social roots
nation’s health status?” The group’s key findings of ill health. To provide a sense of the range of
and recommendations, published in 1994 as Why approaches being implemented; of obstacles and
are some people healthy and others not?, influenced proposed solutions; and of the momentum that has
debates in Canada and beyond83. begun to build around social determinants, we will
next explore developments in a number of countries
The specific vocabulary of “social determinants of since the 1990s.
health” came into increasingly wide use beginning
in the mid-1990s. Tarlov (1996) was one of the first To survey and compare national SDH programmes
to employ the term systematically. Tarlov identified and policies requires a typology that can enable
four categories of health determinants: genetic and them to be grouped coherently, so that their
biological factors; medical care; individual health- similarities and differences emerge. The following
related behaviours; and the “social characteristics framework has been developed for that purpose.
within which living takes place”. Among these Building on Diderichsen, Evans and Whitehead
categories, he argued, “the social characteristics (2001)91, Mackenbach et al (2002)92 and others,
predominate”6. A series of important publications this framework classifies SDH policies according
generalized the use of this vocabulary 84 . to their entry points: i.e., the stage of the social
Researchers explored the questions of how social production of disease/well-being at which they
conditions and processes might translate into seek to intervene. To visualize the relationships
individual experiences of disease, as well as the among these strategies, it is useful to adopt the
contentious issue of whether social and economic image of a “social production chain” of linked
inequality per se could be seen as comprising mechanisms that lead from underlying social
health status for all members of a society, such stratification to an inequitable distribution of
that at any given level of national income more health outcomes, and then back from poor
egalitarian societies could be expected to exhibit health to people’s socioeconomic position and
better health than less egalitarian ones across the opportunities.
full range of socioeconomic positions85,86. The
growing sense that emerging evidence on SDH had The first entry point concerns programmes that

19
There are four key points along this chain where policies can intervene:

p By trying to decrease social stratification itself, i.e., to “reduce inequalities


in power, prestige, income and wealth linked to different socioeconomic
positions”92;

p By trying to decrease the specific exposure to health-damaging factors suffered


by people in disadvantaged positions;

p By seeking to lessen the vulnerability of disadvantaged people to the health-


damaging conditions they face;

p By intervening through healthcare to reduce the unequal consequences of ill-


health and prevent further socioeconomic degradation among disadvantaged
people who become ill.

seek to alter the socioeconomic hierarchy itself crossed with a classification according to whether
via redistributive measures. The second and programmes aim for universal coverage or instead
third reflect more modest intermediate strategies target specific groups within the population.
that aim to shield disadvantaged groups against
the negative health consequences of their social Based on the typology just sketched, several
position, for example by improving working national programmes which took shape in the
conditions or reducing smoking rates among late 1990s are particularly illustrative. Among
low-income groups. The fourth points to targeted many cases that merit discussion, we have chosen
medical care delivery strategies that seek to repair four for the purposes of present analysis. They have
the damage social forces inflict on vulnerable been selected: (1) to illustrate the range of entry
people’s health once that damage is already done, points identified above; (2) because lessons may
and to prevent the effects of illness from lowering be drawn not only from the actual content of the
people’s socioeconomic status even further. A policies, but from the political processes through
categorization of policies and interventions which they arose. The existence and accessibility of
according to these four entry points should also be ample documentation on this political background

20
Action on the social determinants of health: learning from previous experiences

A comprehensive national public health strategy: Sweden

In the late 1990s, Sweden launched a new and innovative public health strategy based on a social determinants model. Tellingly, the strategy does
not define its objectives in terms of morbidity or mortality figures. Rather, national health objectives are set by targeting the social and environmental
determinants of disease. The overall goal of the strategy is “the creation of societal conditions that ensure good health, on equal terms, for the entire
population”93. Equity in health is thus a central and explicit aim of Sweden’s public health policy. The strategy aims to alter the pattern of social
stratification that produces health inequities, while at the same time working at the intermediate level to address factors of specific exposures and
vulnerability among disadvantaged groups.

The policy is based on 11 objectives reflecting the most important determinants of health:
1 Participation and influence in society
2 Economic and social security
3 Secure and favourable conditions during childhood and adolescence
4 Healthier working life
5 Healthy and safe environments and products
6 Health and medical care that more actively promotes good health
7 Effective protection against communicable diseases
8 Safe sexuality and good reproductive health
9 Increased physical activity
0 Good eating habits and safe food
Reduced use of tobacco and alcohol, a society free from illicit drugs and a reduction in the harmful effects of excessive gambling

The first six objectives relate to structural factors while the remaining five “are about lifestyle choices which an individual can influence, but where
the social environment plays an important part. Responsibility for meeting these objectives is divided among various sectors and different levels in
society”, including municipalities, county councils and voluntary organizations, in addition to national government90. The program includes strategies to
reduce housing segregation and social isolation, to increase participation in healthy leisure activities, to channel extra resources to needy schools, and
to reduce unemployment and eliminate employment discrimination against immigrants. In essence, this approach seeks to strengthen conditions that
improve health in society that will in turn improve the health of individuals, particularly among the most vulnerable groups.

The strategy builds both on a Swedish cultural tradition of solidarity and on a governmental model of evidence-based decision-making94. Sweden has
a longstanding interest in the vital statistics of its population. Since the 18th century the government has kept records of births, deaths and causes of
mortality. This has afforded Sweden a strong statistical evidence base with which to pinpoint trends and causal patterns in health.

The new public health policy came to fruition through a consultative political process in which representatives of all Sweden’s major political parties
and of civil society were engaged. Demand for action on the social causes of health outcomes was expressed by researchers, politicians, county
councils, municipalities and health care providers, who called for guidelines and national objectives. Support also came from trade unions and non-
governmental organizations. The availability of reliable data to show the existence and patterns of health disparities was a major factor in galvanizing
pressure for action.

A member of the secretariat supporting development of the policy reported that, in the policy design process, surveys were sent to different government
sectors to explore how their sectoral activities influenced public health; taking a social determinants perspective - as opposed to a disease perspective
- it became relatively easy for non-health sectors to think through the health consequences of their activities. In this way other sectors were closely
involved in the policy design process from early on. Through the preparation, circulation and iteration of “green papers”, they were able to give
their feedback to the commission. Participation from civil society groups was also encouraged. Civil society organizations received green papers for
comment, and many provided substantive input94.

21
Coordinating national and local policy to tackle health inequalities: United Kingdom

The recommendations of the 1980 Black Report had little impact in Britain during the years of Conservative government (1979-1997). Over this period
the social health divide documented by Black widened considerably. By the late 1990s, English men born to professional parents could expect to live
on average almost 10 years longer than those whose fathers have unskilled jobs. Small steps to tackle “variations in health” during the last years of
Conservative government did little to alter the trend. The years of Conservative rule saw a substantial widening of income inequality in the UK and an
explosion of the number of families living on low incomes. By 1998-99, 14.3 million people (about one-quarter of the population) and 4.4 million children
(about one in three) were living in households receiving less than half the average national income95.

Assuming power in 1997, Labour Prime Minister Tony Blair made action on health inequalities a major national policy focus. Within a month of taking
office, Blair publicly acknowledged the link between poverty and health (a connection leaders of the previous government had been unwilling to draw).
The Labour government appointed Sir Donald Acheson to chair an Independent Inquiry into Inequalities in Health, charged with “identify[ing] priority
areas for future policy development … to reduce health inequalities”96. Released in 1998, the Acheson Report furnished a comprehensive synthesis
of scientific evidence on a range of topics linking social conditions and health and presented 39 recommendations. Of these, the Inquiry Committee
highlighted three as especially crucial:
1 All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities
2 A high priority should be given to the health of families with children
3 Further steps should be taken to reduce income inequalities and improve the living standards of poor households.

The Independent Inquiry thus strongly emphasized the importance of policy action to reduce inequalities of wealth and resources within society, in order
to address health inequalities at the root (entry point one, above). The government moved to align its policies with key recommendations of the Acheson
report. Reducing health inequalities: an agenda for action, published in 1999, summarized the government’s efforts across a range of areas, including:
∏ Raising living standards and tackling low income through increasing social benefit levels and introducing a minimum wage
∏ Focusing on education and early child development, for example through the creation of “Sure Start” preschool services in disadvantaged areas
∏ Strengthening employment by creating a range of welfare to work schemes for priority groups
∏ Building healthy communities through regeneration initiatives in disadvantaged areas, including the creation of Health Action Zones95,97

In 2001, the Secretary of State for Health announced two major national targets for the reduction of health inequalities by 2010, one defined in terms of
a target population defined by occupation/social class, the other defined geographically in terms of disadvantaged areas. The goals are: (1) to reduce by
at least 10 percent the gap in mortality between manual groups and the population as a whole; and (2) to reduce by at least 10 percent the gap between
the fifth of areas with the lowest life expectancy at birth and the population as a whole98. It was recognized that to meet these targets will require action
across all levels and departments of government, bridging traditional boundaries of responsibility. Accordingly, a Treasury-led Cross Cutting Review
on Health Inequalities took place between mid-2001 and mid-2002 to examine how the work of government departments and programmes could be
coordinated towards achieving the targets and how government spending could most effectively reduce health inequalities99.

The government’s overall strategy to narrow health gaps through action on social determinants is distinctive for its simultaneous emphasis on broad
redistributive efforts coordinated at national level and on locally managed area-based initiatives. Among the major national redistributive programmes,
one of the most ambitious was the introduction of the UK’s first-ever national minimum wage in April 1999. Over 1.5 million low-wage workers were
entitled to higher pay as a result of this measure. This and other national measures over the New Labour government’s first four budget cycles had a
positive impact on income inequality nationally. Families at the bottom end of the income distribution saw their incomes rise between 1997 and 2000
(by roughly 9 percent for those in the lowest decile), while those in the highest income deciles experienced a modest fall in incomes95.

At the same time, local area-based initiatives have also been promoted as a key mechanism to strengthen health in disadvantaged communities by
improving living conditions and tackling social exclusion. Among the most widely discussed of the area-based initiatives are the Health Action Zones
(HAZ) established in 1997 in 26 disadvantaged neighbourhoods across the country. HAZs involve partnerships between local statutory agencies, health
authorities and voluntary and community groups who work together to develop innovative ways to reduce health inequalities. Originally designed as
7-year pilot projects, HAZs were intended “to explore mechanisms for breaking through current organizational boundaries to tackle inequalities and to
deliver better services”100. Activities undertaken covered a broad range of social determinants. They included expanding training and job opportunities
for local people; promoting educational attainment among the disadvantaged; building social cohesion through a variety of community support
strategies; and improving access to health care. Initial progress on HAZ was uneven, and some local actors resented a belated decision by national
officials to require all HAZs to demonstrate their contributions towards national priorities in cardiovascular disease, cancer and mental illness – a move
that seemed to compromise local autonomy. Despite these difficulties, however, HAZ and other local initiatives have contributed promising innovations
in addressing some key SDH. In some cases, health awareness and understanding of the impact of SDH have been raised at community level, and local
stakeholders have been energetically engaged100.

22
Action on the social determinants of health: learning from previous experiences

SDH entry points and the future of the welfare state: Canada

Canada has long been regarded as a leader in international public health, particularly in addressing the broad determinants of health and strengthening
community involvement in public health processes101. The 1974 Lalonde report was among the first studies to propose a comprehensive framework
for understanding health determinants - including lifestyles, social and physical environment - and to acknowledge the limited role of health care in
improving health. Other noteworthy Canadian public health initiatives include the 1980s healthy communities movement and the 1986 Ottawa Charter
for Health Promotion. The country’s research tradition in medicine, public health and the social sciences has enabled Canada to contribute significantly
to the global scientific knowledge base on SDH, and has also fuelled vigorous domestic policy debates.

Canada’s federalist political system assigns primary responsibility for health and social policy to the provinces and territories, rather than centralizing
decision-making at national level. The 1990s saw important progress in building policy environments receptive to SDH approaches across federal,
provincial and territorial governments. In 1994 the country’s Ministers of Health adopted intersectoral action for health as one of the key directions for
improving the health of Canadians102. A 1998 Health Canada position paper identified an array of health determinants as potential targets for policy
action, including: “income and social status, social support networks, education, employment and working conditions, … healthy child development,
health services, gender and culture”103. In 1999, all levels of government endorsed a population health approach, which focuses on the upstream
causes of health outcomes. The population health model aims to address the interrelated conditions and factors that influence people’s health over the
life course. It identifies systematic variations in the social distribution of such factors and applies the resulting knowledge to develop and implement
policies and actions. Reducing inequities between population groups is an overarching goal, and intersectoral action for health a prominent strategy104.

Canada’s federal structure has both an enabling and a complicating influence on public health, and in particular on efforts to address SDH. Many
successful examples of intersectoral action for health at local level have emerged, and some provinces have made impressive progress with policies on
selected social determinants. However, overall national coordination is difficult, and some critics have charged that broad commitments in principle to
an upstream focus in public health policy have been slow to translate into concrete action101,105. A 1997 article by Sutcliffe and colleagues reported that
“many provinces had no evidence of mandated programs … that addressed the broader determinants of health or that used multiple strategies”101. In
the early 2000s, the medical care system continued to absorb the majority of health sector resources, with less than 3% of health spending allocated
towards health promotion and prevention105,106.

National debates on health and health care policy intensified in the late 1990s, entwined with wider discussions about the future of the welfare state
and the growing influence of neoliberalism on Canada’s economy and public life. The 90s were perceived as an era of broad prosperity, yet economic
gaps between the country’s haves and have-nots had widened substantially during the decade107. Teeple (2000) described the political and economic
conditions that had enabled the creation of the Canadian welfare state after World War II, including strong national identity and a perceived need to
mitigate class conflict108. He showed how those conditions had changed since the 1970s, with economic globalization and a shift towards neoliberal
models affecting policy environments. Drawing on such analyses, some Canadian public health experts critiqued the trend towards liberalization and
privatization, which they saw coupled with a growing public health focus on individual risk factors at the expense of underlying social and economic
inequities. Discussion of public health and SDH policy in Canada continues to contrast advocates of strong redistributive measures aimed to reduce
social stratification (entry point 1) with defenders of a less ambitious approach based on reducing exposures and risks among disadvantaged groups
(entry points 2-3)109.

23
A multi-pronged programme for disadvantaged families: Mexico’s Oportunidades

Mexico’s successful Oportunidades programme shows that innovative policy action on SDH can be achieved in developing countries. Oportunidades
(until 2002 PROGRESA) is an anti-poverty program in which conditional cash transfers are used to induce poor parents in rural areas to send their
children to school, improve the use of preventative and other medical services and adopt better nutrition. First launched nationally in 1997, the program
has produced such positive results in improving health and education outcomes that the government has expanded it to poor families in urban settings,
as well. Oportunidades is underpinned by the idea that there is a synergistic, mutually reinforcing effect of improvements in education, health and
nutrition; it has succeeded in beginning to transcend the “silo” mentality of social sector ministries110. The programme is by definition targeted rather
than universal in coverage. It seeks to shield poor families against certain forms of differential exposure and vulnerability, while also facilitating
improved access to healthcare services (our entry points 2-4).

The central goal of Oportunidades is to increase the capacities of the extremely poor in Mexico, who were identified on the basis of a multilevel
targeting strategy111. The program’s design is unconventional in that it provides monetary incentives – equivalent to a 25 percent increase in family
income – to families to increase their use of health services and schooling, with the ultimate goal of inducing parents to make decisions that will provide
their children with better health and education. The cash transfers are given to the mother of the family, an intentional strategy which is designed to
target funds within the household to improving the children’s education and nutrition112. Importantly, plans for rigorous, independent monitoring and
evaluation were built into Progresa from its inception, strengthening the programme’s scientific and political credibility by documenting quantifiable
outcomes in each of the programme’s three target areas.

In health, Progresa (and subsequently Oportunidades) disbursed cash transfers only if all family members accepted preventative health services delivered
by a branch of the Mexican Social Security Institute113. The health package is aimed at the most common health problems as well as the most significant
opportunities for prevention such as sanitation, family planning, care before and after childbirth, prevention and treatment of respiratory infections,
accident prevention and first aid, among others114. At the same time, the program seeks to improve the quality of services available through public
providers, particularly through ensuring a steady supply of medicines, more doctors and nurses and higher wages for healthcare providers110. Results
from a 2001 World Bank sponsored study showed increased utilization of public health clinics for preventative care, fewer inpatient hospitalizations
and a significant improvement in the health of both children and adults who took part in the programme; Progresa children experienced a 23 percent
reduction in illness, a 1 - 4 percent greater increase in height and an 18 percent reduction in anemia, relative to children not in the programme112. Adults
reported a reduction in the number of days of difficulty with daily activities due to illness and in the number of days in bed due to illness, as well as a
significant increase in the number of kilometres they were able to walk without being tired.

In education, grants are provided for each child under age 18 who are enrolled in school during the period when the risk of dropout is the greatest (the
third grade of primary school and the third level of secondary school). Since children are often relied upon to supplement the family’s income in times
of economic hardship, the size of the grant was calibrated to partially compensate for the lost wages, which increases as the child progresses through
school. Moreover, a slightly larger grant was given for girl children, out of recognition of the fact that they are more likely to drop out of school than
boys. As a result of the program, there were increases in secondary school enrolment which ranged from 11 to 14 points of girls and 5 to 8 percentage
points for boys. Transitions to secondary school increased by nearly 20 percent and child labour declined115.

To strengthen nutrition, cash transfers are disbursed only if children aged 5 and under and breastfeeding mothers attend nutrition monitoring clinics
where growth was measured, and if pregnant women visited clinics for prenatal care, nutritional supplements and health education. In addition, a
fixed transfer of $11 per month is provided for improved food consumption. Nutritional supplements at a level of 20 percent of caloric intake and 100
percent of the micronutrient requirements of children and lactating women are also provided. A 2000 evaluation found that children under 5 who were
required to seek well-child care and who received nutritional support had a 12 percent lower incidence of illness than children who were not in the
program116. Nutritional status was better for programme children, resulting in a reduced probability of stunting among children 12 to 36 months of age117.
In addition, beneficiaries reported both higher caloric consumption and a more diverse diet, including more fruits, vegetables and meat. Iron deficiency
also decreased by 18 percent118.

The Mexican government was committed to scaling up the program from its launch in 1997. By 2000, it covered approximately 2.6 million families,
about one-third of Mexico’s rural families, and operated in 50,000 rural villages119. The Inter-American Development Bank in 2002 approved a grant of
US$1 billion - its largest ever loan to Mexico - for the consolidation and expansion of Progresa to urban areas, and to ensure medium- and long-term
sustainability. The success of the Progresa/Oportunidades program has led to an expansion of this kind of multisectoral approach to other parts of Latin
America including Argentina, Brazil, Columbia, Honduras and Nicaragua.

Rigorous external evaluation of the project has been a key part of maintaining political legitimacy. As a result, the program has enjoyed
strong political support at the presidential level and within the federal Secretariats of Education, Health and Social Development. During
the political transition of 2000, the robust evaluation results and ongoing political commitment to fight poverty made it possible for the programme not
only to survive, but to expand120.

24
Action on the social determinants of health: learning from previous experiences

was an influencing factor in the choice of examples. that, overall, health in the 2000s stands higher
The preceding examples describe only a few of on the international development agenda than
the national-level policy responses to SDH that ever before1,121. This new prominence has been
began to emerge in the 1990s and have continued nourished both through high-level exercises such
and expanded in many settings. These examples as WHO’s Commission on Macroeconomics and
highlight both the momentum building around Health and by the ongoing efforts of communities
SDH and some of the major scientific and political and civil society groups mobilized to press
issues that continue to spark debate. their demands for health as a human right. The
increasing importance of health as a development
issue has intertwined with a growing awareness
2.9 The 2000s: growing and concern about health inequalities between
momentum and new and within countries. The concern with health
opportunities inequalities creates additional opportunities to
leverage action on SDH – since social factors are
In the 2000s, policy action on SDH has continued at the root of most health disparities.
to advance in several countries88,90. Meanwhile, the
broader global health and development context Meanwhile, the wide support garnered by the
has evolved in ways that provide strategic openings MDGs signals the emergence of a new, relatively
to further expand these achievements. more consensual climate in international health
and development, moving beyond some of the
Today, the global development agenda is polarizations of the 1990s and creating a foundation
increasingly shaped by the Millennium for more collaborative partnership work among
Development Goals (MDGs), adopted by diverse actors. The 1990s were characterized
189 countries following the United Nations by ideologically charged confrontations on
Millennium Summit in September 2000. The globalization, often cast as either “all good” or “all
8 MDGs are linked to quantitative targets and bad”. This climate of binary opposition has given
indicators in poverty and hunger reduction; way to more nuanced analyses in many circles.
education; women’s empowerment; child health; Recognizing the complexity and ambiguity of
maternal health; control of epidemic diseases; unfolding global political-economic processes,
environmental protection; and the development many actors have committed to a more pragmatic
of a fair global trading system. Crucially, the cooperative stance.
MDGs have refocused attention on the need
for coordinated multisectoral action. The MDG
framework overcomes the idea that developing
countries’ urgent social and development problems
can be addressed in isolation from each other,
through “silo”-style policy approaches in specific A shared interest has emerged
sectors. Without progress in fighting poverty, in maximizing the real benefits of
strengthening food security, improving access to global processes while at the same
education, supporting women’s empowerment and
time acknowledging the harm
improving living conditions in slums, for example,
the health-specific MDGs will not be attained in they can cause, in particular to
many low- and middle-income countries. At the vulnerable groups, and instituting
same time, without progress in health, countries policies to limit these negative
will fail to reach their MDG targets in other areas. effects and achieve a more
equitable distribution of costs and
Three of the eight MDGs are directly focused
benefits122,123.
on health, and several of the other goals have
important health components, confirming

25
platform of renewed connection to Health for All
Armed conflict, environmental degradation and values, mediated through Lee’s personal style as a
concerns about global security continue to pose pragmatic consensus-builder. In a December 2003
major threats and to provoke polarization. However, article in the Lancet, Lee wrote:
overall, a clearer sense of global interdependence
has emerged, and stakeholders in different A crucial part of justice in human relations is
countries and sectors are increasingly conscious promotion of equitable access to health-enabling
that they must work together. The awareness of conditions….The Alma-Ata goal of Health for
interdependence underpins the MDGs as an All was right. So were the basic principles of
unprecedented global compact between developed primary health care: equitable access, community
and developing nations7. Similar ideas informed participation, and intersectoral approaches to
the March 2002 International Conference on health improvement. These principles must be
Financing for Development in Monterrey, Mexico. adapted to today’s context121.
While progress remains uneven towards the long-
standing development assistance target of 0.7 In his address to the 57th World Health Assembly
percent of donor GNP, the cumulative force of in May 2004, Lee announced WHO’s intention to
the Millennium and Monterrey pledges marks create a global commission on health determinants
a shift of mindset in development cooperation. to advance a pro-equity agenda and strengthen
Under the MDGs and Monterrey commitments, the Organization’s support to Member States in
“countries have agreed to hold each other to implementing comprehensive approaches to health
account, and citizens of both high-income and problems, including their social and environmental
low-income countries are empowered to hold their roots. Lee stated that the commission would be
own governments to clear standards”8. oriented towards practical action. “The aim is to
bring together the knowledge of experts, especially
The 2000s have also seen an evolution in WHO’s those with practical experience of tackling these
role in promoting action on health equity and the problems. This can provide guidance for all our
social dimensions of health. In 2003 Lee Jong- programmes”124.
wook was elected WHO Director-General on a

26
Action on the social determinants of health: learning from previous experiences

3 Taking it to the next level:


the Commission on Social
Determinants of Health

3.1 Aims of the CSDH social determinants of health will be incorporated


into the planning, policy and technical work of
The CSDH has been constituted at a time when WHO.
momentum for action on SDH is rising. A
convergence of factors related to the scientific The aims of the CSDH are ambitious. To achieve
evidence base, the mobilization of concerned them, it will have to build on the work of
constituencies and the broader politics of predecessors, understand their limitations and
development has created conditions in which obstacles, and go farther. To do this will involve
unprecedented advances in health policy to strategic decisions guided by an understanding
address SDH are within reach. But many countries of history.
and communities remain excluded – particularly
in parts of the world where health needs and
the negative impacts of SDH are greatest. A 3.2 Key issues for the CSDH
major push is needed now to capture the existing
momentum on SDH and take it to the next level: The preceding historical overview brings into
brokering a wider understanding and acceptance focus both some of the challenges the CSDH can
of SDH strategies among decision-makers and expect to face, and the reasons why this effort is
stakeholders, particularly in developing countries; so vital now. It offers lessons for the CSDH and
translating scientific knowledge into pragmatic raises questions Commissioners may debate as
policy agendas adapted to countries’ levels of they define their objectives and strategies more
economic development; identifying successful precisely. In the following pages, we focus on four
interventions and showing how they can be scaled issues where the historical survey has shown to be
up; and ensuring that social determinants are particularly crucial. In each of these four areas, we
lastingly anchored in health policy approaches at identify a specific question or questions on which
WHO and among other global actors. These are the Commission will need to achieve clarity.
the tasks the CSDH will take on.
3.2.1 The scope of change: defining
During its three-year span of activity, the entry points
Commission aims for changes whereby the societal
relationships and factors that influence health Efforts to promote change in health policy can
and health systems will be visible, understood be more or less ambitious in scope. This issue is
and recognized as important. Based on this the illustrated historically by the contrast between
opportunities for policy and action, and the costs comprehensive and selective primary health
of not acting, will be widely known and debated. A care, i.e., between the Health for All agenda as
growing number of institutions working in health protagonized by Mahler at Alma-Ata and the Child
at local, national and global level will be using Survival Revolution led by Grant and UNICEF in
this knowledge and implementing relevant public the 1980s. The CSDH will face its own version of
policy affecting health. Leadership, public interest the challenge and the choice embodied in these
and capable institutions within and beyond the two figures and their respective strategies. On
health sector will sustain this transformation. The the one hand, the Commission could understand

27
itself as leading a “Copernican revolution” in inequalities; through less ambitious, intermediate
thinking and action on health policy, with far- policies that seek to shield members of socially
reaching implications for social structures and disadvantaged groups against the worst health
for how governments do business in exercising consequences of their increased exposure to health
their responsibility for the health of populations. threats (examples would include anti-smoking
On the other hand, the CSDH could set its sights programmes targeted at low-income groups and
more modestly and aim simply to develop and occupational safety regulations that reduce health
promote a “toolkit” of interventions that states can risks connected with specific forms of low-prestige
implement swiftly, without significant changes to work); or by providing fairer medical care at the
their existing governance and budget structures end of the “social production chain”.
or their relationships with international financial
institutions and donors (the SDH equivalent of Linked to the question of entry points is the issue
the GOBI strategy). And of course the choice of universal versus targeted programmes. Graham
need not be cast as a binary alternative. Various and Kelly recall that evidence on the links between
compromise positions might be sought that could people’s socioeconomic circumstance and their
combine some of the strengths of both approaches. health has thus far generated two kinds of policy
Yet the fact remains that the CSDH will inevitably responses125. The first focuses on those in the
have to “come down somewhere” on what might poorest circumstances and the poorest health: on
be termed the Mahler-Grant problem. This the most socially excluded, those with most risk
positioning should be the result of a conscious, factors and those most difficult to reach. This focus
reasoned and collective choice, rather than simply has been important in linking health inequalities
emerge haphazardly from the Commission’s day- to the social exclusion agenda, and in focusing
by-day interactions with partners and the media. policies at local and community level. In policy
and intervention terms, this leads to approaches
At the communications level, this decision is that attempt to lift the worst off out of the extreme
about a choice of vocabulary for the Commission situation in which they find themselves. In effect,
(e.g., “social justice” vs. “efficiency” or “reducing such interventions help only a relatively small part
disparities”). At the level of country operations of the population. The second approach recognizes
and policy, it is about entry points. Decisions that, while those in the poorest circumstances are
about language are not “mere” linguistic subtleties, in the poorest health, this is part of a broader social
but have implications for the way the CSDH will gradient in health. This means that it is not only
work with countries and the types of policies it the poorest groups and communities who have
will seek to promote. As shown in the country poorer health than those in the most advantaged
examples above, policies and interventions to circumstances. In addition, there are large numbers
address SDH can engage social structures at a of people who, while they could not be described
variety of levels. The most ambitious policies may as socially excluded, are relatively disadvantaged in
seek dramatically to reduce gradients of wealth health terms. Preventive and other interventions
and power among different groups in society could produce major improvements in their health
through redistributive processes. At the other and proportionate savings for the healthcare system.
end of the spectrum, healthcare interventions Because universal programmes may be seen as
targeted at disadvantaged groups seek to repair or too costly, there is a risk that strategies will focus
palliate the damage inflicted by social inequality, primarily on targeted interventions addressing
once such inequality has already translated intermediary determinants, which simply manage
itself into physical illness affecting the bodies of the consequences of poverty, while the processes
disadvantaged individuals. Along this spectrum, it that cause it remain unchanged126. Indeed, some
will be crucial for the CSDH to identify the level(s) critics argue that an unintended effect of targeted
at which it will seek to promote change. A typology interventions may be to legitimize poverty, making
or mapping of entry points for policy action on it both more tolerable for individuals and less costly
SDH and health inequities was sketched earlier. for society127. Commissioners will want to reflect
carefully about the level(s) at which they want
In essence, this framework asks at what point(s) to promote change; the desirability/feasibility of
along the chain of social production of health/ selecting various policy entry points; the forces
illness it is desirable (and feasible) to intervene and capacities for action that must be aligned at
in a given context: through broad redistributive the various levels; and the appropriate political
policies that aim to alter fundamental social strategies for obtaining results.

28
Action on the social determinants of health: learning from previous experiences

Determinations about policy entry points and the the scope of the present paper. Some key points
content of recommended policies will vary with can be noted, however. National income will be
the specificities of national contexts. Successful an important differentiator, and wealthy countries
health policy to address SDH cannot adopt a will presumably in most cases have considerably
“one-size-fits-all” character. Different countries greater facility for implementing comprehensive
and jurisdictions find themselves at very different SDH policies than will poor countries. However,
stages of readiness for action on SDH and of as Good health at low cost made clear in the 1980s,
openness to more fundamental redistributive and as many subsequent studies have confirmed,
approaches88. The particularities of national and income is not the only relevant factor. Countries
local contexts will show which social determinants with roughly equivalent levels of national income
need to be addressed most urgently to improve exhibit very different levels of performance in
population health, and which policy tools are most areas of social achievement with relevance for
appropriate. National and local specificities, in health, such as access to adequate food for all
particular economic and political power relations, members of the population; housing quality; water
will define the opportunities and constraints for and sanitation; and education. The CSDH typology
action and indicate which constituencies may align will thus have to group countries not only by
themselves with an SDH agenda, and which may income level, but with reference to the other, in
offer resistance. Thus, the key question becomes some cases less easily quantifiable factors that
not only “What entry point(s) will be chosen?” will shape opportunities for action. In exploring
but also and more fundamentally, “How will you contextual influences on health systems, Roemer,
decide?” That is, what criteria will be utilized Kleczkowski and Van Der Werff 128 have proposed
to make decisions about the level of policies/ a typology of countries that points toward what
interventions to be recommended in particular may be relevant variables. They classify countries
cases? based on three criteria:
∏ The extent to which health is a priority
Presumably, in addition to a framework of entry in the governmental /societal agenda,
points for SDH interventions and policies, the reflected in the level of national resources
CSDH will need to develop a typology of countries allocated to health;
and/or subnational jurisdictions with respect to ∏ The degree to which responsibility for
their capacities for action on SDH. Elaborating financing and organizing the provision of
this typology will be an important task for the health services to individuals is assumed
Commission’s scientific team and lies well beyond as (1) a collective social responsibility
or (2) primarily the responsibility of the
individuals concerned;
DEFINING THE SCOPE OF CHANGE: ∏ The extent to which society (through

MAIN STRATEGIC QUESTIONS political authorities) assumes responsibility


for an equitable distribution of health
p How will the CSDH position itself resources.
on the “Mahler-Grant problem”:
i.e., choosing (or compromising) As the GHLC analyses acknowledged, but as
between: (1) a far-reaching technical planners sometimes forget, a country’s
structural critique based on political, economic and social history is deeply
a social justice vision and (2) relevant to understanding what policies will
promoting a number of tightly be appropriate and effective there 129. This
focused interventions that may principle applies a fortiori to efforts to mobilize
produce short-term results, but constituencies, engage policymakers and
risk leaving the deeper causes implement interventions on SDH.
of avoidable suffering and health
inequities untouched? Down the line, the issue of national specificities
and appropriate modes of engagement will raise
p What evaluation criteria a range of important strategic questions for the
will the CSDH put in place to Commission. These include how the CSDH will
identify appropriate policy entry co-operate with countries whose political structure
points for different countries/ is federal (see Canada example above), and what
jurisdictions? sorts of policy recommendations and support the

29
CSDH may seek to provide to constituencies in principle (via numerous declarations and official
countries whose economic and political situations statements) the urgent need for such action.
(including conflict and/or highly authoritarian, However, between that acknowledgement and
unresponsive governance) make major national the actual implementation of meaningful policies,
health policy action on SDH extremely unlikely political barriers have often emerged.
in the near and medium term. Will such countries
be (tacitly) “written off ” by the CSDH as cases in It is particularly important that the CSDH focus
which Commission resources and energy cannot on these issues at the very outset of its activities.
sensibly be invested, or will some effort be made to Designing and carrying through a process to
develop recommendations and policy dialogue in collect scientific evidence will in a sense be obvious
these settings that could begin to lay foundations and “natural” to many Commissioners and their
for long-term change? support staff; addressing the political barriers
may be less so. Yet if the political strategy is not
3.2.2 Anticipating potential well developed, the evidence collection, however
resistance to CSDH messages – and scientifically sound, may fail to generate the
preparing strategically concrete change the Commission seeks.

On the question of why policy action on SDH Scholars have begun to analyse the political/
has lagged in most settings, the existing literature structural aspect of resistance to SDH
presents two main explanatory strands. The first approaches89,130, but much work remains to be
sees the blockage as a problem of knowledge, the done. This paper cannot map the relevant power
second as a question of power130. According to relationships in exhaustive detail, since the
the first account, action to address SDH has been particularities of national and local contexts will
weak because the evidence base on which to build once again be crucial, and relevant constituencies
such action is inadequate, or existing evidence will vary across the range of thematic areas the
has not been effectively communicated to those Commission will address (e.g., food security,
in a position to effect change. The second account housing, social exclusion, etc.). This detailed
emphasizes the political-economic dimension political mapping will be a primary responsibility
of power and profit, and suggests that the most for the Commission’s Knowledge Networks and for
important barriers to action on SDH lie in this the co-ordinating groups in each partner country.
area. It sees policy failure on SDH not primarily What the present paper can do is identify several
as a symptom of ignorance, but as the logical broad constituencies likely to feel their interests are
consequence of existing power relations. Notably threatened by SDH policy approaches. By focusing
the fact that certain influential constituencies clearly on these constituencies and understanding
derive benefit from a status quo in which SDH are their respective stakes in processes related to SDH,
not addressed, and believe their interests would the Commission can develop strategies to draw
be compromised if policies were enacted to tackle them into the CSDH process through dialogue
social determinants aggressively. or, failing that, to minimize the damage caused by
their resistance.
The key objectives of the CSDH clearly include
filling gaps in the scientific evidence base relative The medical establishment
to social determinants and effective policies and SDH agendas, including efforts to advance health
interventions to address them. The very existence promotion and intersectoral action, have in the
of the Commission reflects the conviction that past encountered active or passive resistance
effective communication of SDH messages to on the part of many medical professionals and
policy-makers, health and development actors institutions14,16,89. It is reasonable to suppose that
and the broader public can help catalyse action this pattern will continue under the CSDH. A
that will significantly improve vulnerable people’s significant challenge for SDH and health equity
chances for health. However, the CSDH must agendas will be bringing the medical establishment
also take seriously the second explanatory strand on board as a constructive partner.
just evoked, centred on political-economic power
relations. Our historical survey has suggested that Health care providers, especially physicians, are
it is not primarily the lack of knowledge that has generally part of the social elite, and share its
thus far hampered action on SDH. Over the past values and class interests. Like other members
quarter century, the evidence available has been of privileged social categories, they will resent
sufficient for most countries to acknowledge in and often resist government policies that
30
Action on the social determinants of health: learning from previous experiences

redistribute resources from the more advantaged medical care resources”5. To the extent that SDH
to the less well-off in society. Furthermore, and programmes are seen as competing for these scarce
more importantly, physicians have a strong resources that might otherwise be invested in
group interest in maintaining their monopoly medical care, health care providers and other
over authoritative discourse and practice around constituencies that derive profit from patient care
health. Medical professionals are reluctant to see and related services may resist them.
control of health issues slip away from them to
other sectors and professional constituencies, or Within national governments
to cede to communities the power to set health SDH interventions represent major opportunities
agendas. The atrophy of intersectoral action to improve the health status of populations,
and the widespread discrediting of community particularly vulnerable groups, at relatively low
participation under Health for All partly reflected cost. National governments should be eager to
this persistent dynamic, although other causal pursue these policies. However, the desire and/
factors were also relevant. or the technical capacity of governments to
implement such approaches can by no means be
The reasons for this pattern have to do in part taken for granted.
with doctors’ desire to maintain their social
prestige, but the more fundamental issue is The Ministry of Health may be wary of social
economic. Individual physicians and the medical determinants approaches, because these may be
establishment as a whole make money by seen both as channelling health funds away from
providing curative interventions. They will not the MoH towards other government departments,
make money from the introduction of a school and as loosening the MoH’s scientific and political
feeding programme or improvements to the authority over health. Making health “everybody’s
housing stock in a slum neighbourhood. McGinnis business” should register as a highly constructive
et al. (2002) have underscored the inherent development, but it could also be seen as a
structural asymmetry between public health and diminishment of the power and prerogatives of
the provision of curative medical care, when it the MoH and health sector specialists. At the same
comes to political clout and the competition for time, earlier experiences in IAH suggest that non-
resources. This issue must be of concern to the health ministries and government officials may (at
Commission as it develops its approach to policy least initially) also be reluctant to commit time,
dialogue. 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
In many settings the structural quickly deliver tangible benefits to electors. They
configuration of health governance operate on a compressed time-frame and seek
institutions has combined with opportunities for “quick wins”, with a preference
moreover for policy options where the causal link
“interest group dynamics” to
between intervention and outcome is obvious. In
result in a “vacuum of political contrast, some SDH programmes might require
accountability for maintaining years or decades to really begin generating major
population health”. In contrast, measurable effects. Such efforts will do little to
“a well-defined set of actors – advance decision-makers’ immediate electoral
physicians and other health care interests. Furthermore, the lines of causality in
intersectoral action are notoriously complex,
providers – has responsibility for
making it difficult in many instances to prove
medical care5”. that a particular programme was the source of
a given health improvement. Added to this is
the consideration that the prime beneficiaries
In addition to their ethical commitment to of many SDH interventions would be poor and
deliver medical services to those who need them, marginalized constituencies who are often less
“providers have a strong financial incentive to likely to participate in the political process and
provide medical care, as well as an interest- thus to “pay off ” in terms of votes for politicians.
group incentives to lobby for increasingly more
31
As McGinnis et al. argue: priorities” and recommended actions with no
clear relationship to the structures and processes
currently in use.

The corporate sector


R e s i s t a n c e t o c e r t a i n C SD H p o l i c y
“It takes more than just evidence recommendations – as to previous attempts to
that social change would improve catalyse action on health risk factors such as
health to convince the general smoking and diet – is likely to come from some
corporate and commercial interests. Homedes
public [or a fortiori policymakers]
and Ugalde (2005) have shown that neoliberal
that such redistributive investments health sector reforms in Latin America have
should be undertaken. These primarily benefited large corporations. They
choices are very much about argue that under these reforms: “Excluded health
ideology and social values5”. policies are those that have a negative impact
on corporate profits such as safety programs in
factories and agriculture, accident reduction in
Some government leaders will be opposed to many vehicle transportation, tobacco reduction, the
aspects of an SDH programme on ideological promotion of generic drugs, and the promotion of
grounds, because they will see SDH interventions essential drug lists”54. If the corporate sector and
as largely constituting unnecessary government its allies have opposed such components within
interference in processes better left to market health sector programming, it is reasonable to
forces and individual choice/responsibility. The assume they will resist similar strategies proposed
resistance to the introduction of new, government- under the banner of SDH.
led redistributive policies will be encountered
among leaders of some wealthy countries eager to The most obvious tensions for an SDH agenda may
secure global dominance for the neoliberal “free arise with those corporations that profit directly
market” model; it can also be expected among from the marketing of potentially health-damaging
officials in some developing countries who are products and lifestyles: e.g., manufacturers of
strongly lobbied and influenced either by private tobacco products; sugar; fast food and junk foods;
sector interests or by major global institutions alcohol; automobiles; and weapons. As McGinnis
closely aligned with the neoliberal agenda. et al. note for the US context: “The behavioural
Moreover, even in countries interested in adopting issues that together account for so many deaths
redistributive mechanisms to address SDH, – tobacco, alcohol, dietary excess and sedentary
governments may be unable to implement such lifestyles – are all products in part of strong
programmes: because of lack of resources; as the commercial forces. Tobacco and alcohol represent
result of social sector spending ceilings and other US industries with annual sales of well over $100
constraints imposed by IFIs and donors; or because billion. The food industry spends billions just on
of the shortfalls they face in terms of human advertising and promotion”5.
and other resources for planning, implementing
and managing complicated social programmes. In this sense, the sustained effort to confront the
At the same time, many developing country tobacco industry and to establish the Framework
policymakers and programme implementers Convention on Tobacco Control may provide
exhibit an (understandable) level of “initiative lessons for the work of the CSDH131. Yet the
fatigue”, scepticism and resistance to priorities situation of an SDH agenda with respect to
seen as imposed from outside. Such resistance is an corporate interests is more complex that in the
inherent obstacle to the introduction of any major case of tobacco. Rather than a single industry
new programme initiative in some developing (and one moreover with a largely negative public
countries. Thus it will be crucial for the CSDH profile), SDH interventions may be seen as
to co-ordinate its policy recommendations with potentially threatening the interests of national
the existing structures and policy frameworks and transnational companies in a variety of
through which countries operate, and which different sectors, including some of the world’s
govern relationships between developing countries most powerful and beloved consumer product
and donors (e.g., PRSPs). The CSDH must not brands. The recommendations that will emerge
be seen as piling on yet another set of “global from the Commission’s Knowledge Networks

32
Action on the social determinants of health: learning from previous experiences

on employment/working conditions and new frameworks such as PRSPs do not necessarily


globalization/trade are particularly sensitive in signify changes in the underlying assumptions and
this regard. Numerous transnational corporations imperatives of the neoliberal model. Critics argue
are strongly inclined to fight government that the asymmetrical power relationships between
regulation and controls over questions such as the IFIs and countries and the sorts of policy
labour practices, workplace safety and the impact approaches recommended by the World Bank and
of corporate activities on the environment. IMF remain as before in many instances 68,133. The
Companies’ profitability often depends on eluding IFIs continue to advocate market liberalization and
such unwelcome constraints. This is in addition to privatization, a “leaner” state and strict ceilings on
companies’ perpetual motivation to minimize the public spending, including for health and social
sums they must pay in taxes. It is to be anticipated services. Their advice to countries may thus in
that many transnational corporations may perceive many cases run counter to the policy approaches
policies addressing social and environmental the CSDH will promote.
determinants of health as a threat, insofar as
such policies might raise companies’ production Moreover, both the IFIs and the bilateral
costs and impose additional regulations on their development agencies of powerful countries are
behaviour with regard to production processes, strongly influenced by corporate agendas. IFIs often
labour relations, environmental impacts and act to advance the interests of corporations with
marketing practices. close ties to their major shareholder governments.
Thus to the extent the Commission’s messages
Corporate interests likely to be made and policy advice are perceived as threatening to
uncomfortable by an SDH agenda include powerful influential corporate constituencies, the IFIs and
companies in the for-profit medical sector and bilaterals may seek to discredit the Commission
the pharmaceutical industry. The pharmaceutical and its recommendations, either through public
industry may regard the CSDH as threatening critiques or behind the scenes advice to national
for two reasons: first, because an “upstream” policymakers and other interlocutors. The CSDH
preventive-promotive approach to health will not may thus wish to consider advance outreach to key
generate profits for the industry (and might indeed constituencies within the IFIs, bilaterals and other
in the long run actually reduce demand for some donor agencies as a special priority, developing
of its products); second because of worries that and implementing targeted outreach strategies in
the globalization and trade Knowledge Network the early phase of its operations.
or other organs of the Commission might publicly
criticize the industry and/or generate policy
recommendations seen as contrary to its interests.
IDENTIFYING POTENTIAL
Within international organizations RESISTANCE:
and the development community MAIN STRATEGIC QUESTIONS
Institutions such as the World Bank and IMF
have immense power to influence health and p To interest political leaders, a
social policy in developing countries. The SDH policy agenda will have
struggles of the Alma-Ata agenda in the 1980s to offer opportunities for some
offer, among other things, a lesson about what is “quick wins”. This principle
likely to happen when health leaders recommend applies to country-level political
policies that are significantly out of step with the processes and at the global level
frameworks being promoted by the international to the Commission itself. What
financial institutions. To avoid a repetition of might “quick wins” look like,
this scenario, the CSDH will need to manage for countries tackling social
its relationship with the IFIs and other major determinants and for the CSDH?
development institutions strategically. This may
be a difficult challenge. While the IFIs’ policy p How will the Commission
approaches have evolved since the 1980s, some develop its relationship with
analysts caution that the changes have been more the major international financial
on the level of rhetoric than of substance. The institutions, in particular the
World Bank’s acknowledgement of the importance World Bank?
of a strong, capable state132 and the presence of

33
3.2.3 Identifying allies and political Most importantly, the MDGs by definition
opportunities constitute a framework for coordinated
international action, with commitment from
The level of the Commission’s success will depend major players already built in. To the extent the
to a considerable extent on its ability to construct CSDH can align its policy recommendations with
a network of alliances and partnerships with the MDGs, it can capitalize on the momentum of
influential actors at various levels, including: global and national commitment to the goals.
global institutions, national governments and
policymakers, the business sector and civil society The work of the UN Millennium Project, whose
organizations. Fortunately, while the CSDH can final report was published in January 2005, has
expect to encounter resistance from certain highlighted the interwovenness of the broad range
influential constituencies (and must be prepared of economic, health and environmental issues in
with appropriate strategies), the Commission will international development under the MDGs8. A
also enjoy distinctive opportunities. It will work in renewed sense of the urgent need for coordinated
a political context which, if managed appropriately, multisectoral action to improve the lives of the
offers chances for success beyond the reach of world’s most vulnerable citizens has emerged,
previous efforts. Arguably, Commissioners’ along with the model of a “global compact”
most pivotal responsibility will be using their between developed and developing countries that
personal networks and links to various spheres would dramatically increase investment in key
of influence (political, business, academic, sectors of direct interest to an SDH agenda, such
media, civil society) to build and maintain an as poverty and food security, education, women’s
expanding web of alliances that will support and empowerment, water and sanitation and living
publicize the Commission’s work, disseminate conditions in urban slums, as well as improved
its messages, and drive implementation of its medical services7. The CSDH must give a high
policy recommendations. To be fully effective, priority to positioning itself within the various
this network must be operative on several levels international fora and policy processes connected
simultaneously. with the MDGs, and to opening channels of
dialogue with key players that can ensure that the
Global actors CSDH is strongly profiled within these processes.
Buy-in and ongoing support from major global Relevant fora and institutions would include the
institutions, including the relevant UN agencies, UN Economic and Social Council; the advisory
will be essential to creating sustained momentum teams around the UN Secretary-General; the
around the SDH agenda and ensuring that it Millennium Campaign effort; and the High Level
is durably integrated into international health Forum on MDGs; as well as the various UN
policy and development models. The history of specialized agencies contributing to the MDG
the PHC vs. SPHC debate in the 1980s suggests effort and aligning their work according to MDG
that the increasing divergence in strategy between priorities.
WHO and UNICEF was a significant factor in
weakening global commitment to the Health for The importance of outreach to the major
All vision and to comprehensive PHC, with its international financial institutions has already been
intersectoral action component. Fortunately for underscored. Contestation around the policies
the Commission, the SDH agenda appears strongly of the IFIs remains strong. Debates continue
aligned with the current main thrust of UN and concerning the effects of PRSPs on developing
international development policy, built around countries’ capacity to strengthen their health care
the MDGs. Indeed, while certain aspects of the systems and to implement social policies that
MDG programme are of course criticisable from a promote health and health equity. Yet attitudes
health perspective (absence of noncommunicable and practices at the World Bank and some regional
diseases, lack of explicit focus on health systems), development banks may be changing in ways
the overall MDG framework provides an admirable that could facilitate the uptake of Commission
opportunity both to secure the central place of messages and the implementation of CSDH-
health in development work generally and, more recommended policy measures. Importantly, the
particularly, to promote understanding of the World Bank is publicly committed to the MDGs134,
linkages between health outcomes and underlying and relations between WHO and the Bank have
social/economic/political conditions. been strengthened through collaboration in the
High-Level Forum on MDGs. Meanwhile, the

34
Action on the social determinants of health: learning from previous experiences

World Bank and IDB have been instrumental Presidents of Brazil, Chile, France and Spain relate
in the success of programmes such as Mexico’s directly to Commission themes and may enable
PROGRESA/Oportunidades. The profile the synergies. The recent proposals by the UK on debt
World Bank is now giving to equity as a key cancellation and a possible “Marshall Plan” for
concern in international development135 presents Africa also underscore the degree to which at least
an opportunity for the CSDH to press its message some sectors of the global policy and development
that if countries and the global community are community are willing to envisage new strategies
serious about attacking health inequities, the most and to weigh bold innovations.
effective way is via SDH.
National actors
A key strategic advantage for the CSDH, in At national level, the Commission begins its work
comparison with efforts to promote intersectoral at a time when, as noted above, momentum for
action on health determinants during the 1990s, concerted action on SDH is building. A number of
is the strong and visible commitment to the SDH politically and economically influential countries
agenda from top leadership at WHO, including have enacted bold policies on SDH, and others
the Director-General. This high-level institutional may soon be ready to act. The problem of socially-
buy-in within WHO increases the chances that conditioned health inequalities has emerged as
an SDH approach to health policy design can be an important political issue in an increasing
“mainstreamed” within WHO during the life of number of jurisdictions88. The most substantial
the Commission and can become a permanent policy advances have so far been made in high-
dimension of the Organization’s technical work income countries, but as the Oportunidades
and policy dialogue with Member States. On the example shows, some developing countries are
other hand, across the global health community also introducing pioneering programmes. At the
and even within WHO itself, some constituencies January 2005 session of the WHO Executive Board,
will certainly greet an SDH approach with strong endorsements of the CSDH were expressed
scepticism. The architecture of the Commission by developing countries currently represented
and its Knowledge Networks, including special on the Board, including Bolivia, Ghana, Lesotho
focus on health systems and diseases of public and Thailand. Many developing countries appear
health priority, is designed to provide maximum ready to consider serious, pragmatic proposals for
chances to bring traditionally more biomedical policies and interventions that can reduce health
constituencies “on board” with SDH, showing inequality gaps through action on social factors.
them how SDH approaches can improve results
within their own programmes and contribute to A close relationship to country-level processes
the strengthening of integrated, sustainable health and the policymakers involved in them will be
systems. A high-level WHO Reference Group vital for the Commission’s success. Here again,
linked to the Commission will develop a specific Commissioners will make maximal use of their
WHO-internal action agenda to incorporate the personal networks and will play a role that is
Commission’s key recommendations into WHO above all political. An important function for the
policy and programming in a durable way. Commission will be brokering policy dialogue
and knowledge-sharing between countries on the
International fora such as the G-8, regional bodies “leading edge” that have already enacted health
and more or less formalized political alliances policies addressing SDH and countries that want
around specific issues such as global hunger will to implement such policies but have not yet done
also be key potential linkages for the Commission. so and are seeking practical advice and insights on
The concern of the G-8 nations with economic how to proceed.
and health inequalities offers an important entry
point for the CSDH, which the Commissioners The private sector
and their support staff should work to capitalize We have already discussed the challenge that
upon. African-led development initiatives such may be posed to the CSDH by possible tensions
as NEPAD, though criticized in some quarters between its messages and the interests of influential
as excessively influenced by neoliberal models, private sector actors, in particular transnational
signal creativity and fresh commitment to a corporations. Clearly, finding appropriate modes
comprehensive development approach that of engagement with the business sector will be
could offer opportunities for action on SDH. a major strategic concern for the Commission.
Development initiatives such as the global Recommendations for structural change to reduce
alliance against hunger recently launched by the social inequality through large-scale, government-
35
led redistribution of resources are unlikely to As we have noted, the impact of the Commission
find favour with the business community. on Macroeconomics and Health owed much
However, certain intermediate-level policies and to the CMH’s decision to justify its policy
interventions aimed to improve health through recommendations primarily in terms of economic
action on SDH may indeed be appealing to private gains, rather than via ethical arguments. Similarly,
sector actors, and may enable the Commission cost-savings arguments have been advanced by
to bring some industries and firms “on board” partisans of SDH policy approaches in a number of
with CSDH proposals. The recent ILO-sponsored countries that have begun to implement or at least
World Commission on the Social Dimension of consider public health strategies oriented towards
Globalization, which included Taizo Nishimuro, health determinants. Yet the scientific robustness of
Chairman of the Board of Toshiba Corporation, these arguments may be questionable. (Extending
may provide lessons 136. Some policies and the lives of people over 50 will not necessarily
interventions recommended by the Commission result in substantial long-term savings for health
can be cast as “business friendly”. For example, systems; much of course depends on the type
investment in early child development and in and quantity of health care and other services
education is highly advantageous for creating the people require over their longer life-spans.). Is
healthier, more skilled, more adaptable workforce it economically credible to present SDH policies
required by many modern industries in the as tools that will enable governments and health
technology and service sectors. Likewise, housing systems to save money? Is it morally right to do
improvement projects in urban slums could mean so? The Commission will need to reflect carefully
profits for the construction industry. Two recent about how possible economic arguments for SDH
reports on national business competitiveness (by policies relate to arguments based on equity, social
the World Economic Forum and World Bank) justice and/or human rights.
have found Nordic countries to be among the
world’s most competitive economies. These Civil society
countries’ strong investments in social equity and Since the pre-Alma-Ata era of community based
programmes addressing SDH do not hinder their health programmes, the active participation of
ability to compete in the global economy. On the civil society groups has regularly been cited as
contrary, according to an author of the World Bank a key success factor, in cases where intersectoral
study, “We found that social protection is good for policy on health determinants has worked well
business, it takes the burden off of businesses for at local and national levels14,27,42. Since the CSDH
health care costs and ensures a well-trained and aims to generate results and not just words, it
educated work force’’137. Such findings may open must take this correlation seriously and shape its
up useful lines of argument for the CSDH. strategies accordingly.

On the other hand, deeper methodological and The CSDH may benefit from the evolving role of
ethical questions underlie the issue of relations civil society at global, national and local levels. The
with the business sector and with governments influence of civil society organizations has grown
anxious about the financial “bottom line”. The in many parts of the world, as has the ability of
Commission must consider if and how to use such organizations to gather and share knowledge
cost-savings and cost-effectiveness arguments and to support each other’s efforts, increasingly
to promote health policies that embrace SDH. linking across political and spatial boundaries
Recourse to such arguments could of course through the use of new communications
be quite advantageous when promoting SDH technologies139,140,141. Civil society mobilization has
approaches to political decision-makers. As been a crucial factor in some of the key political
one senior policy adviser remarked in a recent processes of recent years (from the toppling of
workshop on evidence-based policymaking: apartheid to the “Orange Revolution” in Ukraine).
In health, the impact of the Bangladesh Rural
Advancement Committee (BRAC), South Africa’s
Treatment Action Campaign and other civil
society organizations has transformed traditional
“What makes evidence talk? relationships between the medical establishment,
Definitely financial impact…. What government, industry interests and communities.
is the best argument for getting
government to listen? Answer: Several major international NGOs have expressed
Money!”138 strong support for a SDH agenda, indeed some
36
Action on the social determinants of health: learning from previous experiences

3.2.4 Evidence, political processes


ALLIES AND POLITICAL and the CSDH “story line”
OPPORTUNITIES:
MAIN STRATEGIC QUESTIONS Scientific evidence is surely important to persuade
constituencies sceptical about the value of health
p How can the CSDH most policy oriented to SDH. But evidence by itself it is
effectively position itself rarely if ever sufficient to catalyse political action.
within the global and national In political terms, what may be at least as crucial
processes connected to the as the evidence itself is the “story” in which it is
Millennium Development Goals embedded.
(MDGs)?
This idea is of course not new. Indeed, it is as
p Is it scientifically credible, old as politics itself. However, the importance of
strategically desirable and/ this theme has been strongly confirmed in recent
or ethically acceptable for public health history. The primary health care
the CSDH to argue that health movement that arose in the 1970s was able to draw
policies tackling social on evidence from successful community-based
determinants are a wise health programmes in the preceding decade. Yet
investment that will “pay off” what enabled PHC and Health for All to become
in terms of enhanced economic the rallying cries of a global movement was not
performance and/or cost savings the evidence presented (which in the 1970s was
to health systems down the line? relatively scant). What drove this change was the
compelling narrative of justice, human flourishing
p Can the CSDH operate and social transformation told by PHC’s proponents
strategically to get “buy-in” and embodied by the epic figure of Mahler. In the
from the business community, same way, the subsequent victory of selective PHC
without losing credibility was less a matter of evidence per se than of shifting
with other key constituencies, political interests coupled with the emergence of
including civil society? How will a new and in some ways even more compelling
potential conflicts among these (because simpler) “story line”. This new story
interests be mediated within switched from a narrative about social justice to one
the Commission as its work focused on dying children and how quick action
proceeds? 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
did so well before the announcement of the SPHC/GOBI story elided or glossed over many of
Commission142. If the CSDH does engage civil the political and economic complexities with which
society groups as active partners in the various the proponents of the Alma-Ata vision had tried
phases of its work, the Commission can hope to grapple. But precisely this elemental, human
to harvest strength from the growing voice and simplicity made the force and marketability of
influence of civil society in leveraging policy SPHC and the child survival agenda.
change and ensuring the translation of good ideas
into concrete results. Recognizing the strategic The importance of the story element to policy
importance of this issue, the CSDH secretariat change in health has recently been confirmed by
is developing a comprehensive strategy for an intriguing research exercise. A team of leading
partnership with civil society organizations that public health experts studied the way scientific
will ensure space for civil society participation in information is actually used (or ignored) in
all aspects of the CSDH process, including partner policymaking processes by exploring this issue in a
countries and Knowledge Networks. CSDH qualitative residential workshop with senior policy
presence at the upcoming Second People’s Health advisers. Their findings should push public health
Assembly in Cuenca, Ecuador, in June 2005, is one scientists to renounce the belief that they can
important step in opening a substative dialogue. influence policy simply by providing government
37
officials with scientifically solid evidence. Policy- A social determinants “story line” must be able to
makers interviewed for the study stressed the need capture the attention of political decision-makers
for simple messages unclouded by jargon and and other stakeholders, inspiring them with the
argued that researchers should be more attentive sense that SDH are important and that action
to the timeframes within which governments to address these factors is feasible and timely.
operate. Sound evidence does not possess It must enable and encourage policymakers to
an inherent power to spur change, if it is not “sell” the SDH agenda to their colleagues and
presented compellingly and in a timely manner, constituents. Creating and collectively “owning”
and if its relevance to decision-makers’ current this compelling, coherent story line is arguably
concerns is not made clear. Many policymakers the most important challenge facing the CSDH.
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 A COMPELLING STORY LINE AND
make it. The face validity of a ‘good story’ is an EVIDENCE:
example of how presentation style can influence MAIN STRATEGIC QUESTION
politics”138.
p What story does the CSDH want
Participants argued that the importance of stories to tell about social conditions
is not antithetical to the idea of evidence-based and human well-being? What
policymaking. As one informant stressed, it is not narrative will capture the
a case of either/or. “Stories themselves can be used imaginations, feelings, intellect
in a credible way along with the evidence”. Indeed, and will of political decision-
the story is the humanizing vehicle through which makers and the broader public
the evidence takes on its full significance. and inspire them to action?

38
Action on the social determinants of health: learning from previous experiences

4 Conclusion

T
oday an unprecedented opportunity have been exposed and the need for alternative
exists to tackle the roots of suffering and development approaches widely recognized.
unnecessary death in the world’s poor Concern with health inequalities between and
and vulnerable communities. The roots of within countries has increased, while progress
most health inequalities and of the bulk of human in the scientific understanding of the social
suffering are social: the social determinants of determinants of health accelerated in the 1990s.
health. Over the past decade, scientific knowledge In a growing number of countries this scientific
on SDH has advanced dramatically, and today the evidence is being applied to shape bold new public
political conditions for action are more favourable policy approaches. For the moment, this trend
than ever before. This opportunity is too important remains largely concentrated in high-income
to let slip away. To seize it will require leadership countries, but several developing countries have
based on a mastery of the relevant science, but also begun to take innovative action on SDH, and
moral vision and political wisdom. This is why the more could be poised to do so. The Millennium
Commission on Social Determinants of Health has Development Goals adopted by 189 countries in
been constituted now. 2000 set a new integrated framework for global
development that has once again focused attention
This exceptional opportunity has emerged through on the interwovenness of development challenges
a long historical process. Strongly affirmed in the and the need for simultaneous, coordinated action
1948 WHO Constitution, the social dimensions across a range of sectors including macroeconomic
of health were eclipsed during the subsequent policy, food and agriculture, education, gender,
public health era dominated by technology-based and health. Without strong policy action on SDH,
vertical programmes. The social determinants the health-related MDGs will not be attained in
of health and the need for intersectoral action most low- and middle-income countries. This
to address them reemerged in the Alma- moment of “tidal shift” constitutes a historic
Ata period, and were central to the model of opportunity for action on social determinants and
comprehensive PHC proposed to drive the a chance to change theory and practice about what
Health for All agenda. During this period, some constitutes health policy – as opposed to policies
countries made important strides in addressing concerned with the delivery of health care services.
key social determinants such as nutrition and
women’s education. However, like other aspects of As the CSDH embarks on its mission, a sense of
comprehensive PHC, action on determinants was history will be a valuable resource. To maximize
weakened by the neoliberal economic and political its chances of success, the Commission must
consensus dominant in the 1980s and beyond, craft its strategies with an awareness of past SDH
with its focus on privatization, deregulation, efforts and the lessons these experiences can teach.
shrinking states and freeing markets. Under the This paper has attempted to provide a selective
prolonged ascendancy of variants of neoliberalism, historical overview of major efforts to address
state-led action to improve health by addressing SDH. It has traced in broad outlines the growth
underlying social inequities appeared unfeasible of knowledge on SDH and, equally important,
in many contexts. some of the political dynamics that shaped efforts
to intervene on the social dimensions of health
Recently, however, the tide has again begun to and contributed to their success or frustration.
turn. The flaws of neoliberal policy prescriptions The paper has not tried to offer prescriptions.
39
It will have fulfilled its function if it brings into tackling social determinants and for the
clearer focus some of the urgent issues with which CSDH?
the Commissioners must grapple, as the CSDH
establishes its identity, fixes its objectives and 4 How will the Commission develop its
frames its strategies. relationship with the major international
financial institutions, in particular the
In conclusion, we recall the 8 key strategic World Bank?
questions identified:
1 How will the CSDH position itself on the 5 How can the CSDH most effectively
“Mahler-Grant problem”: i.e., choosing position itself within the global and
(or compromising) between: (1) a far- national processes connected to the
reaching structural critique based on a Millennium Development Goals (MDGs)?
social justice vision and (2) promoting a
number of tightly focused interventions 6 Is it scientifically credible, strategically
that may produce short-term results, but desirable and/or ethically acceptable for
risk leaving the deeper causes of avoidable the CSDH to argue that health policies
suffering and health inequities untouched? tackling social determinants are a wise
If a more comprehensive, values-oriented investment that will “pay off ” in terms of
approach is taken, the CSDH may sacrifice enhanced economic performance and/or
short-term efficacy and measurable results. cost savings to health systems down the
If a more selective, intervention-focused, line?
pragmatic stance is adopted, critics may
well wonder why a global Commission 7 Can the CSDH operate strategically to get
was required for this job, rather than a “buy-in” from the business community,
much less costly technical working group. without losing credibility with other key
This issue fundamentally concerns how constituencies, including civil society
Commissioners understand their political organizations? How will potential conflicts
role, and the place they assign to moral among these interests be mediated within
values in an undertaking that aims to the Commission as its work proceeds?
leverage policy action and bring concrete,
measurable results rapidly. 8 Drawing together all these and other
issues is the question of “story”. This is
2 What evaluation structure will the CSDH not a mere footnote to the scientific and
put in place to identify appropriate policy political problems the Commission must
entry points for different countries/ confront, but is at the heart of the CSDH’s
jurisdictions? effort to catalyse change. What story do the
members of the CSDH collectively want
3 To interest political leaders, a SDH policy to tell about social conditions and human
agenda will have to offer opportunities for well-being? What narrative will capture
some “quick wins”. This principle applies to the imaginations, feelings, intellect and
country-level political processes and at the will of political decision-makers and the
global level to the Commission itself. What broader public and inspire them to action?
might “quick wins” look like, for countries

40
Action on the social determinants of health: learning from previous experiences

List of abbreviations

CCSS Caja Costarricense del Seguro Social (Costa Rica)


CBHP community-based health programmes
CMH Commission on Macroeconomics and Health
CSDH Commission on Social Determinants of Health
G-8 Group of Eight Nations
GHLC Good health at low cost (Rockefeller Foundation)
GOBI growth monitoring, oral rehydration, breastfeeding, immunization
HAZ Health Action Zones (United Kingdom)
HFA Health for All
HIPC Heavily Indebted Poor Countries Initiative
HSR health sector reform
IAH intersectoral action for health
IMF International Monetary Fund
IFIs international financial institutions
MoH Ministry of Health
MDGs Millennium Development Goals
NGO nongovernmental organization
PHC primary health care
PRSP Poverty Reduction Strategy Paper
RHP Rural Health Programme (Costa Rica)
SAPs structural adjustment programmes
SDH social determinants of health
SPHC selective primary health care
UK United Kingdom
UN United Nations
UNICEF United Nations Children’s Fund
USA United States of America
WHA World Health Assembly
WHO World Health Organization
WTO World Trade Organization

41
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142 See the 2000 People’s Health Charter. http://www.phmovement.org/charter/pch-index.html.

47
SOCIAL DETERMINANTS OF HEALTH
ACCESS TO POWER, MONEY AND RESOURCES AND THE CONDITIONS OF DAILY LIFE —
THE CIRCUMSTANCES IN WHICH PEOPLE ARE BORN, GROW, LIVE, WORK, AND AGE

[energy] [investment] [community/gov.] [water] [justice] [food]


[providers of services, education, etc.] [accessible & safe] [supply & safety]

A CONCEPTUAL FRAMEWORK FOR


ACTION ON THE SOCIAL DETERMINANTS
OF HEALTH
Social Determinants of Health Discussion Paper 2
ISBN 978 92 4 150085 2

WORLD HEALTH ORGANIZATION


AVENUE APPIA
1211 GENEVA 27
SWITZERLAND
DEBATES, POLICY & PRACTICE, CASE STUDIES
WWW.WHO.INT/SOCIAL_DETERMINANTS
A Conceptual
Framework for
Action on the Social
Determinants of
Health

World Health Organization


Geneva
2010
The Series:
The Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the social
determinants of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, and
capacity building. They aim to review country experiences with an eye to understanding practice, innovations, and encouraging
frank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed.

Background:
A first draft of this paper was prepared for the May 2005 meeting of the Commission on Social Determinants of Health held in
Cairo. In the course of discussions the members and the Chair of the CSDH contributed substantive insights and recommended
the preparation of a revised draft, which was completed and submitted to the CSDH in 2007. The authors of this paper are Orielle
Solar and Alec Irwin.

Acknowledgments:
Valuable input to the first draft of this document was provided by members of the CSDH Secretariat based at the former Department
of Equity, Poverty and Social Determinants of Health at WHO Headquarters in Geneva, in particular Jeanette Vega. In addition
to the Chair and Commissioners of the CSDH, many colleagues offered valuable comments and suggestions in the course of the
revision process. Thanks are due in particular to Joan Benach, Sharon Friel, Tanja Houweling, Ron Labonte, Carles Muntaner,
Ted Schrecker, and Sarah Simpson. Any errors are responsibility of the principal writers. Nicole Valentine edited the paper and
coordinated production.

Suggested Citation:
Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion
Paper 2 (Policy and Practice). Geneva, World Health Organization, 2010.

WHO Library Cataloguing-in- Publication Data


A conceptual framework for action on the social determinants of health.

(Discussion Paper Series on Social Determinants of Health, 2)

1.Socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. I.World Health Organization.

ISBN 978 92 4 150085 2 (NLM classification: WA 525)

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A conceptual framework for action on the social determinants of health

Contents

foreword 3

Executive Summary 4

1. Introduction 9

2. Historical trajectory 10

3. Defining core values: health equity, human rights,


and distribution of power 12

4. Previous theories and models 15

4.1 Current directions in SDH theory 15


4.2 Pathways and mechanisms through which SDH influence health 16
4.2.1 Social selection perspective 16
4.2.2 Social causation perspective 17
4.2.3 Life course perspective 18

5. CSDH conceptual framework 20

5.1 Purpose of constructing a framework for the CSDH 20


5.2 Theories of power to guide action on social determinants 20
5.3 Relevance of the Diderichsen model for the CSDH framework 23
5.4 First element of the CSDH framework: socio-economic and political context 25
5.5 Second element: structural determinants and socioeconomic position 27
5.5.1 Income 30
5.5.2 Education 31
5.5.3 Occupation 32
5.5.4 Social Class 33
5.5.5 Gender 33
5.5.6 Race/ethnicity 34
5.5.7 Links and influence amid socio-political context and structural determinants 34
5.5.8 Diagram synthesizing the major aspects of the framework shown thus far 35
5.6 Third element of the framework: intermediary determinants 36
5.6.1 Material circumstances 37
1
5.6.2 Social-environmental or psychosocial circumstances 38
5.6.3 Behavioral and biological factors. 39
5.6.4 The health system as a social determinant of health. 39
5.6.5 Summarizing the section on intermediary determinants 40
5.6.6 A crosscutting determinant: social cohesion / social capital 41
5.7 Impact on equity in health and well-being 43
5.7.1 Impact along the gradient 43
5.7.2 Life course perspective on the impact 44
5.7.3 Selection processes and health-related mobility 44
5.7.4 Impact on the socioeconomic and political context 44
5.8 Summary of the mechanisms and pathways represented in the framework 44
5.9 Final form of the CSDH conceptual framework 48

6. Policies and interventions 50

6.1 Gaps and gradients 50


6.2 Frameworks for policy analysis and decision-making 51
6.3 Key dimensions and directions for policy 53
6.3.1 Context strategies tackling structural and intermediary determinants 54
6.3.2 Intersectoral action 56
6.3.3 Social participation and empowerment 58
6.3.4 Diagram summarizing key policy directions and entry points 60

7. conclusion 64

List of abbreviations 66

References 67

LIST OF FIGURES
Figure A: Final form of the CSDH conceptual framework 6
Figure B: Framework for tackling SDH inequities 8
Figure 1: Model of the social production of disease 24
Figure 2. Structural determinants: the social determinants of health inequities 35
Figure 3: Intermediary determinants of health 41
Figure 4: Summary of the mechanisms and pathways represented in the framework 46
Figure 5: Final form of the CSDH conceptual framework 48
Figure 6: Typology of entry points for policy action on SDH 53
Figure 7: Framework for tackling SDH inequities 60

LIST OF TABLES
Table 1: Explanations for the relationship between income inequality and health 31
Table 2: Social inequalities affecting disadvantaged people 38
Table 3: Examples of SDH interventions 62

2
A conceptual framework for action on the social determinants of health

Foreword

C
onceptual frameworks in a public health context shall in the best of worlds serve two equally
important purposes: guide empirical work to enhance our understanding of determinants and
mechanisms and guide policy-making to illuminate entry points for interventions and policies.
Effects of social determinants on population health and on health inequalities are characterized
by working through long causal chains of mediating factors. Many of these factors tend to cluster
among individuals living in underprivileged conditions and to interact with each other. Epidemiology
and biostatistics are therefore facing several new challenges of how to estimate these mechanisms. The
Commission on Social Determinants of Health made it perfectly clear that policies for health equity
involve very different sectors with very different core tasks and very different scientific traditions. Policies
for education, labour market, traffic and agriculture are not primarily put in place for health purposes.
Conceptual frameworks shall not only make it clear which types of actions are needed to enhance their
“side effects” on health, but also do it in such a way that these sectors with different scientific traditions
find it relevant and useful.

This paper pursues an excellent and comprehensive discussion of conceptual frameworks for science
and policy for health equity, and in so doing, takes the issue a long way further.

Finn Diderichsen MD, PhD


Professor, University of Copenhagen
October, 2010

3
Executive summary

C
omplexity defines health. Now, more than ever, in the age of globalization, is this so. The
Commission on Social Determinants of Health (CSDH) was set up by the World Health
Organization (WHO) to get to the heart of this complexity. They were tasked with summarizing
the evidence on how the structure of societies, through myriad social interactions, norms and
institutions, are affecting population health, and what governments and public health can do about
it. To guide the Commission in its mammoth task, the WHO Secretariat conducted a review and
summary of different frameworks for understanding the social determinants of health. This review was
summarized and synthesized into a single conceptual framework for action on the social determinants
of health which was proposed to and, largely, accepted by, the CSDH for orienting their work. A key
aim of the framework is to highlight the difference between levels of causation, distinguishing between
the mechanisms by which social hierarchies are created, and the conditions of daily life which then
result. This paper describes the review, how the proposed conceptual framework was developed, and
identifies elements of policy directions for action implied by the proposed conceptual framework and
analysis of policy approaches.

A key lesson from history (including results from the previous “historical” paper - see Discussion
Paper 1 in this Series), is that international health agendas have tended to oscillate between: a focus
on technology-based medical care and public health interventions, and an understanding of health as
a social phenomenon, requiring more complex forms of intersectoral policy action. In this context,
the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutional
commitments to health equity and social justice.

Having health framed as a social phenomenon emphasizes health as a topic of social justice more broadly.
Consequently, health equity (described by the absence of unfair and avoidable or remediable differences
in health among social groups) becomes a guiding criterion or principle. Moreover, the framing of social
justice and health equity, points towards the adoption of related human rights frameworks as vehicles
for enabling the realization of health equity, wherein the state is the primary responsible duty bearer.
In spite of human rights having been interpreted in individualistic terms in some intellectual and legal
traditions, notably the Anglo-Saxon, the frameworks and instruments associated with human rights
guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having
been associated with historical struggles for solidarity and the empowerment of the deprived they form
a powerful operational framework for articulating the principle of health equity.

Theories on the social production of health and disease


With this general framing in mind, developing a conceptual framework on social determinants of health
(SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three
main theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2)
social production of disease/political economy of health; and (3) eco-social frameworks.

4
A conceptual framework for action on the social determinants of health

All three of these theoretical traditions, use the following main pathways and mechanisms to explain
causation: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives.
Each of these theories and associated pathways and mechanisms strongly emphasize the concept of
“social position”, which is found to play a central role in the social determinants of health inequities.

A very persuasive account of how differences in social position account for health inequities is found
in the Diderichsen’s model of “the mechanisms of health inequality”. Didierichsen’s work identifies how
the following mechanisms stratify health outcomes:
∏ Social contexts, which includes the structure of society or the social relations in society, create

social stratification and assign individuals to different social positions.


∏ Social stratification in turn engenders differential exposure to health-damaging conditions

and differential vulnerability, in terms of health conditions and material resource availability.
∏ Social stratification likewise determines differential consequences of ill health for more and

less advantaged groups (including economic and social consequences, as well differential health
outcomes per se).

The role of social position in generating health inequities necessitates a central role for a further two
conceptual clarifications. First, the central role of power. While classical conceptualizations of power
equate power with domination, these can also be complemented by alternative readings that emphasize
more positive, creative aspects of power, based on collective action as embodied in legal system class suits.
In this context, human rights embody a demand on the part of oppressed and marginalized communities
for the expression of their collective social power. The central role of power in the understanding of
social pathways and mechanisms means that tackling the social determinants of health inequities is a
political process that engages both the agency of disadvantaged communities and the responsibility of
the state. Second, it is important to clarify the conceptual and practical distinction between the social
causes of health and the social factors determining the distribution of these causes between more and less
advantaged groups. The CSDH framework makes a point of making clear this distinction.

On this second point of clarification, conflating the social determinants of health and the social processes
that shape these determinants’ unequal distribution can seriously mislead policy. Over recent decades,
social and economic policies that have been associated with positive aggregate trends in health-
determining social factors (e.g. income and educational attainment) have also been associated with
persistent inequalities in the distribution of these factors across population groups. Furthermore, policy
objectives are defined quite differently, depending on whether the aim is to address determinants of
health or determinants of health inequities.

The CSDH Conceptual Framework


Bringing these various elements together, the CSDH framework, summarized in Figure A, shows how
social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby
populations are stratified according to income, education, occupation, gender, race/ethnicity and other
factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary
determinants) reflective of people’s place within social hierarchies; based on their respective social status,
individuals experience differences in exposure and vulnerability to health-compromising conditions.
Illness can “feed back” on a given individual’s social position, e.g. by compromising employment
opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the
functioning of social, economic and political institutions.

“Context” is broadly defined to include all social and political mechanisms that generate, configure and
maintain social hierarchies, including: the labour market; the educational system, political institutions
and other cultural and societal values. Among the contextual factors that most powerfully affect health
are the welfare state and its redistributive policies (or the absence of such policies). In the CSDH
framework, structural mechanisms are those that generate stratification and social class divisions in
the society and that define individual socioeconomic position within hierarchies of power, prestige
and access to resources. Structural mechanisms are rooted in the key institutions and processes of the
socioeconomic and political context. 5
The most important structural stratifiers and their proxy indicators include: Income, Education,
Occupation, Social Class, Gender, Race/ethnicity.

Together, context, structural mechanisms and the resultant socioeconomic position of individuals are
“structural determinants” and in effect it is these determinants we refer to as the “social determinants
of health inequities.” The underlying social determinants of health inequities operate through a set
of intermediary determinants of health to shape health outcomes. The vocabulary of “structural
determinants” and “intermediary determinants” underscores the causal priority of the structural factors.
The main categories of intermediary determinants of health are: material circumstances; psychosocial
circumstances; behavioral and/or biological factors; and the health system itself as a social determinant.
∏ Material circumstances include factors such as housing and neighborhood quality, consumption

potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical
work environment.
∏ Psychosocial circumstances include psychosocial stressors, stressful living circumstances and

relationships, and social support and coping styles (or the lack thereof).
∏ Behavioral and biological factors include nutrition, physical activity, tobacco consumption and

alcohol consumption, which are distributed differently among different social groups. Biological
factors also include genetic factors.

The CSDH framework departs from many previous models by conceptualizing the health system itself
as a social determinant of health (SDH). The role of the health system becomes particularly relevant
through the issue of access, which incorporates differences in exposure and vulnerability, and through
intersectoral action led from within the health sector. The health system plays an important role in
mediating the differential consequences of illness in people’s lives.

Figure A. Final form of the CSDH conceptual framework

SOCIOECONOMIC
AND POLITICAL
CONTEXT

Governance
Socioeconomic
Material Circumstances
Macroeconomic Position
Policies (Living and Working,
Conditions, Food IMPACT ON
Availability, etc. ) EQUITY IN
Social Policies Social Class HEALTH
Labour Market, Gender
Housing, Land Behaviors and AND
Ethnicity (racism) Biological Factors WELL-BEING

Public Policies Psychosocial Factors


Education, Health, Education
Social Protection Social Cohesion &
Occupation Social Capital
Culture and
Societal Values Income

Health System

STUCTURAL DETERMINANTS
SOCIAL DETERMINANTS OF INTERMEDIARY DETERMINANTS
HEALTH INEQUITIES SOCIAL DETERMINANTS
OF HEALTH

6
A conceptual framework for action on the social determinants of health

The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in
discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features
that link it to both. Yet focus on social capital, depending on interpretation, risks reinforcing depoliticized
approaches to public health and the SDH, when the political nature of the endeavour needs to be an
explicit part of any strategy to tackle the SDH. Certain interpretations have not depoliticized social
capital, notably the notion of “linking social capital”, which have spurred new thinking on the role of the
state in promoting equity, wherein a key task for health politics is nurturing cooperative relationships
between citizens and institutions. According to this literature, the state should take responsibility for
developing flexible systems that facilitate access and participation on the part of the citizens.

Policy action
Finally, in turning to policy action on SDH inequities, three broad approaches to reducing health
inequities can be identified. These may be based on: (1) targeted programmes for disadvantaged
populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the
social health gradient across the whole population. A consistent equity-based approach to SDH must
ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health
gaps and gradients are not mutually exclusive. They can complement and build on each other.

Policy development frameworks can help analysts and policymakers to identify levels of intervention and
entry points for action on SDH, ranging from policies tackling underlying structural determinants to
approaches focused on the health system and reducing inequities in the consequences of ill health suffered
by different social groups. The review showed the framework that Diderichsen and colleagues proposed- a
typology or mapping of entry points for policy action on SDH inequities - to be very useful in the way
it is very closely aligned to theories of causation. They identify actions related to: social stratification;
differential exposure/ differential vulnerability; differential consequences and macro social conditions.

Considerations of these policy action frameworks lead to discussion of three key strategic directions for
policy work to tackle the SDH, with a particular emphasis on tackling health inequities: (1) the need for
strategies to address context; (2) intersectoral action; and (3) social participation and empowerment.

Policy action challenges for the CSDH


Arguably the single most significant lesson of the CSDH conceptual framework is that interventions
and policies to reduce health inequities must not limit themselves to intermediary determinants, but
must include policies specifically crafted to tackle the social mechanisms that systematically produce
an inequitable distribution of the determinants of health among population groups (see Figure B). To
tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.

7
Figure B. Framework for tackling SDH inequities

Context-specific
strategies tackling Key dimensions and directions for policy
both structural and
intermediary Intersectoral Social Participation
determinants Action and Empowerment

Globalization
Environment Policies on stratification to reduce inequalities,
mitigate effects of stratification
Macro Level:
Public Policies Policies to reduce exposures of disadvantaged
people to health-damaging factors

Mesa Level: Policies to reduce vulnerabilities of


Community disadvantaged people

Policies to reduce unequal consequences of


illness in social, economic and health terms
Micro Level:
Individual
interaction

Monitoring and follow-up of health equity and SDH

Evidence on interventions to tackle social


determinants of health across government

Include health equity as a goal in health


policy and other social policies

A key task for the CSDH will be:


1 to identify successful examples of intersectoral action on SDH in jurisdictions with different
levels of resources and administrative capacity; and to characterize in detail the political and
management mechanisms that have enabled effective intersectoral programmes to function
sustainably.
2 to demonstrate how participation of civil society and affected communities in the design
and implementation of policies to address SDH is essential to success. Empowering social
participation provides both ethical legitimacy and a sustainable base to take the SDH agenda
forward after the Commission has completed its work.
3 Finally, SDH policies must be crafted with careful attention to contextual specificities, which
should be rigorously characterized using methodologies developed by social and political science.

8
A conceptual framework for action on the social determinants of health

1 Introduction

O
n announcing his intention to create the The CSDH conceptual framework synthesizes
Commission on Social Determinants many elements from previous models, yet we
of Health (CSDH), World Health believe it represents a meaningful advance. We
Organization (WHO) Director-General ground the framework in a theorization of social
Lee Jong-wook identified the Commission as power and make clear our debt to the work of
part of a comprehensive effort to promote greater Diderichsen and colleagues. We present the
equity in global health in a spirit of social justice 1. core components of the framework, including:
The Commission’s goal, then, is to advance health (1) socioeconomic and political context; (2)
equity, driving action to reduce health differences structural determinants of health inequities; and
among social groups, within and between (3) intermediary determinants of health. Our
countries. Getting to grips with this mission answers to the first two questions above will be
requires finding answers to three fundamental articulated by way of these concepts. In the last
problems: section of the paper, we deduce key directions for
1 Where do health differences among social pro-equity policy action based on the framework,
groups originate, if we trace them back to providing broad elements of a response to the
their deepest roots? third question.
2 What pathways lead from root causes
to the stark differences in health status An important definitional issue must be clarified
observed at the population level? in advance. The CSDH has purposely adopted a
3 In light of the answers to the first two broad initial definition of the social determinants
questions, where and how should we of health (SDH). The concept encompasses the
intervene to reduce health inequities? full set of social conditions in which people live
and work, summarized in Tarlov’s phrase as
This paper seeks to make explicit a shared “the social characteristics within which living
understanding of these issues to orient the work takes place” 2. A broad initial definition of SDH
of the CSDH. We recall the historical trajectory of is important in order not to foreclose fruitful
which the CSDH forms a part; and then we make avenues of investigation; however, within the
explicit the Commission’s fundamental values, field encompassed by this concept, not all factors
in particular the concept of health equity and have equal importance. Causal hierarchies will be
the commitment to human rights. We describe ascertained, leading to crucial distinctions 3. Much
the broad outlines of current major theories on of this paper will be concerned with clarifying
the social determinants of health, and we review these distinctions and making explicit the
perspectives on the causal pathways that lead from relationships between underlying determinants
social conditions to differential health outcomes. of health inequities and the more immediate
Afterwards a new framework for analysis and determinants of individual health.
action on social determinants is presented as a
potential contribution of the CSDH to public
health - the “CSDH framework”.

9
2 Historical trajectory

H
ealth is a complex phenomenon, and it sector spending, constraining policy-makers’
can be approached from many angles. capacity to address SDH 7.
Over recent decades, international
health agendas have tended to oscillate Even as these market-oriented reforms were
between: (1) approaches relying on narrowly being applied in both developing and developed
defined, technology-based medical and public countries, new and more systematic analyses of
health interventions; and (2) an understanding of the powerful impact of social conditions on health
health as a social phenomenon, requiring more began to emerge. A series of prominent studies,
complex forms of intersectoral policy action, including those of McKeown and Illich, challenged
and sometimes linked to a broader social justice the dominant biomedical paradigm and debunked
agenda. the idea that better medical care alone can generate
major gains in population health 8,9,10,11,12. The
WHO’s 1948 Constitution clearly acknowledges UK’s Black Report on Inequalities in Health
the impact of social and political conditions (1980) marked a milestone in understanding
on health, and the need for collaboration with how social conditions shape health inequities.
sectors such as agriculture, education, housing Black and his colleagues argued that reducing
and social welfare to achieve health gains. During health gaps between privileged and disadvantaged
the 1950s and 1960s, however, WHO and other social groups in Britain would require ambitious
global health actors emphasized technology- interventions in sectors such as education, housing
driven, ‘vertical’ campaigns targeting specific and social welfare, in addition to improved clinical
diseases, with little regard for social contexts 4. care 13.
A social model of health was revived by the 1978
Alma-Ata Declaration on Primary Health Care Throughout the 1980s and early 1990s, the Black
and the ensuing Health for All movement, which Report sparked debates and inspired a series
reasserted the need to strengthen health equity by of national inquiries into health inequities in
addressing social conditions through intersectoral other countries, e.g. the Netherlands, Spain and
programmes 5. Sweden. The pervasive effects of social gradients
on health were progressively clarified, in particular
Many governments embraced the principle of by the Whitehall Studies of Comparative Health
intersectoral action on SDH, under the banner of Outcomes among British civil servants 14, 15.
Health for All; however, the neoliberal economic Important work at WHO’s European Office in the
models that gained global ascendancy during the early 1990s laid conceptual foundations for a new
1980s created obstacles to policy action. In the health equity agenda, and the vocabulary of SDH
health sector, neoliberal approaches mandated began to achieve wider dissemination 16, 17.
market-oriented reforms that emphasized
efficiency over equity as a system goal and By the late 1990s and early 2000s, in response
often reduced disadvantaged social groups’ to mounting documentation of the scope of
access to health care services 6. On the level of inequities, and evidence that existing health and
macroeconomic policy, the structural adjustment social policies had failed to reduce equity gaps 3,
programmes (SAPs) imposed on many developing 16, 18, 19
, health equity and the social determinants
countries by the international financial institutions of health had been embraced as explicit policy
mandated sharp reductions in governments’ social concerns by a growing number of countries,
10
A conceptual framework for action on the social determinants of health

particularly but not exclusively in Europe. In the commitments to health equity, social justice and
UK, the arrival in 1997 of a Labour government a reinvigoration of the values of Health For All.
explicitly committed to reducing health inequalities Lee’s first announcement of his intention to create
focused fresh attention on SDH. Australia and a Commission on Social Determinants of Health,
New Zealand explored options for addressing at the 2004 World Health Assembly, positioned
health determinants, with New Zealand’s 2000 the CSDH as a key component of his equity
health strategy reflecting a strong SDH focus 20. agenda. Lee welcomed rising global investments
In 2002, Sweden approved a new, determinants- in health, but affirmed that “interventions aimed
oriented national public health strategy, arguably at reducing disease and saving lives succeed only
the most comprehensive model of national policy when they take the social determinants of health
action on SDH. New policies focused on tackling adequately into account” 24. Lee charged the
health inequities were passed in England, Ireland, Commission to mobilize emerging knowledge
Italy, the Netherlands, Northern Ireland, Scotland on social determinants in a form that could be
and Wales during this period 3. Meanwhile, in turned swiftly into policy action in the low- and
developing regions, including sub-Saharan middle-income countries where needs are greatest.
Africa, Asia, the Eastern Mediterranean and In his speech at the launch of the CSDH in Chile
Latin America, resurgent critical traditions allying in March 2005, Lee noted that the Commission
health and social justice agendas, such as the Latin would deliver its report in 2008 for the thirtieth
American social medicine movement, refined anniversary of the Alma-Ata conference and sixty
their critiques of market-based, technology-driven years after the formal entry into force of the WHO
neoliberal health care models and called for action Constitution. He urged the Commission to carry
to tackle the social roots of ill-health 21, 22, 23. forward the values that had informed global public
health in its most visionary moments, translating
In 2003, Lee Jong-wook took office as Director- them into practical action for a new era.
General of WHO, on a platform marked by

Key messages from this section:

p Over recent decades, international health agendas have tended to oscillate


between: (1) a focus on technology-based medical care and public health
interventions; and (2) an understanding of health as a social phenomenon,
requiring more complex forms of intersectoral policy action.

p The 1978 Declaration of Alma-Ata and the subsequent Health for All movement
gave prominence to health equity and intersectoral action on SDH; however,
neoliberal economic models dominant during the 1980s and 1990s impeded the
translation of these ideals into effective policies in many settings.

p The late 1990s and early 2000s witnessed mounting evidence on the failure of
existing health policies to reduce inequities, and momentum for new, equity-
focused approaches grew, primarily in wealthy countries. The CSDH can ensure
that developing countries are able to translate emerging knowledge on SDH and
practical approaches into effective policy action.

p In his speech at the launch of the CSDH, WHO Director-General Lee Jong-
wook noted that the Commission will deliver its report in 2008 for the thirtieth
anniversary of the Alma-Ata conference and sixty years after the WHO
Constitution. He instructed the Commission to carry forward the values that have
informed global public health in its most visionary moments, translating them
into practical action.

p The CSDH revives WHO constitutional commitments to health equity and social
justice and reinvigorates the values of Health for All.
11
3 Defining core values:
health equity, human rights,
and distribution of power

P
olicy choices are guided by values, which may which profoundly compromise freedom. When such
be implicit or explicit. The concept of health inequalities arise systematically as a consequence of
equity is the explicit ethical foundation of an individual’s social position, governance has failed
the Commission’s work, while human rights in one of its prime responsibilities, i.e. ensuring
provide the framework for social mobilization and fair access to basic goods and opportunities that
political leverage to advance the equity agenda. condition people’s freedom to choose among life-
Realizing health equity requires empowering plans they have reason to value 30. Ruger argues
people, particularly socially disadvantaged groups, similarly for the importance of health equity as a
to exercise increased collective control over the goal of public policy, based on “the importance
factors that shape their health. of health for individual agency” 31. Nonetheless,
the causal linkages between health and agency are
WHO’s Secretariat (the (then) Department of Equity, not uni-directional. Health is a prerequisite for full
Poverty and Social Determinants of Health) defined individual agency and freedom; yet at the same time,
health equity (also referred to as socioeconomic social conditions that provide people with greater
health equity) as “the absence of unfair and agency and control over their work and lives are
avoidable or remediable differences in health among associated with better health outcomes 32. One can
population groups defined socially, economically, say that health enables agency, but greater agency
demographically or geographically” 25. In essence, and freedom also yield better health. The mutually
health inequities are health differences that are reinforcing nature of this relationship has important
socially produced, systematic in their distribution consequences for policy-making.
across the population, and unfair 26. Identifying a
health difference as inequitable is not an objective The international human rights framework is the
description, but necessarily implies an appeal to appropriate conceptual structure within which to
ethical norms 27. advance towards health equity through action on
SDH. The framework is based on the 1948 Universal
Primary responsibility for protecting and enhancing Declaration of Human Rights (UDHR). The UDHR
health equity rests in the first instance with national holds that ‘Everyone has the right to a standard of
governments. An important strand of contemporary living adequate for the health and well-being of
moral and political philosophy was built on the himself and his family, including food, clothing,
work of Amartya Sen to link the concepts of housing and medical care and necessary social
health equity and agency and to make explicit the services’ (Art. 25) 33, and additionally that ‘Everyone
implications for just governance 28. Joining Sen, is entitled to a social and international order in which
Anand stresses that health is a “special good” whose the rights and freedoms set forth in this Declaration
equitable distribution merits the particular concern can be fully realized’ (Art. 28). The human rights
of political authorities. There are two principal aspects of health, and in particular connections
reasons for regarding health as a special good: (1) between the right to health and social and economic
health is directly constitutive of a person’s well-being; conditions, were clarified in the 1966 International
and (2) health enables a person to function as an Covenant on Economic, Social and Cultural Rights
agent 29. Inequalities in health are thus recognized (ICESCR). In ICESCR Article 12, States signatories
as “inequalities in people’s capability to function” acknowledge “the right of everyone to the enjoyment
12
A conceptual framework for action on the social determinants of health

of the highest attainable standard of physical and Over recent years, the work of the United Nations
mental health”; and they commit themselves to Special Rapporteur on the Right to Health has
specific measures to pursue this goal, including been instrumental in advancing the political
improved medical care and also health-enabling agenda around the right to health at national and
measures outside the medical realm per se like the global levels 38.
“improvement of all aspects of environmental and
industrial hygiene” 34. While human rights have often been interpreted
in individualistic terms in some intellectual and
The General Comment on the Human Right to Health legal traditions, notably the Anglo-Saxon, human
released in 2000 by the UN Committee on Economic, rights guarantees also concern the collective
Social and Cultural Rights explicitly affirms that well-being of social groups and thus can serve to
the right to health must be interpreted broadly to articulate and focus shared claims and an assertion
embrace key health determinants including (but of collective dignity on the part of marginalized
not limited to) “food and nutrition, housing, access communities. In this sense, human rights
to safe and potable water and adequate sanitation, principles are intimately bound up with values
safe and healthy working conditions, and a healthy of solidarity and with historical struggles for the
environment” 35. The General Comment echoes empowerment of the disadvantaged 21, 39.
WHO’s Constitution and the 1978 Declaration of
Alma-Ata in asserting a government’s responsibility Alicia Yamin and others have shown that
to address social and environmental determinants in empowerment is central to operationalizing the
order to fulfil citizens’ rights to the highest attainable right to health and making it relevant to people’s
standard of health. lives. “A right to health based upon empowerment”
implies fundamentally that “the locus of decision-
Human rights offer more than a conceptual making about health shifts to the people whose
armature connecting health, social conditions and health status is at issue”. For Yamin, echoing Sen,
broad governance principles. Rights concepts and the full expression of empowerment is people’s
standards provide an instrument for turning diffuse effective freedom to “decide what the meaning
social demand into focused legal and political claims, of their life will be”. In this light, the right to
as well as a set of criteria by which to evaluate the health aims at the creation of social conditions
performance of political authorities in promoting under which previously disadvantaged and
people’s well-being and creating conditions for disempowered groups are enabled to “achieve
equitable enjoyment of the fruits of development 36. the greatest possible control over … their
As Braveman and Gruskin argue, health”. Increased control over the major factors
that influence their health is an indispensable
component of individuals’ and communities’
broader capacity to make decisions about how
they wish to live 40.
“A human rights perspective
removes actions to relieve poverty
and ensure equity from the voluntary
realm of charity … to the domain
of law”.The health sector can use
the “internationally recognized
human rights mechanisms for
legal accountability” to push for
aggressive social policies to tackle
health inequities, since international
human rights instruments “provide
not only a framework but also a
legal obligation for policies towards
achieving equal opportunity to be
healthy, an obligation that necessarily
requires consideration of poverty and
social disadvantage”37.
13
Key messages of this section:
p The guiding ethical principle for the CSDH is health equity, defined as the
absence of unfair and avoidable or remediable differences in health among
social groups.

p Primary responsibility for protecting health equity rests with governments.


p The international human rights framework is the appropriate conceptual and
legal structure within which to advance towards health equity through action on
SDH.

p The realization of the human right to health implies the empowerment of


deprived communities to exercise the greatest possible control over the factors
that determine their health.

14
A conceptual framework for action on the social determinants of health

4 Previous theories and


models

T
he CSDH does not begin in its conceptual stress from the ‘social environment’ alters
work in a vacuum. The concepts presented host susceptibility, affecting neuroendocrine
here build on the contributions of many function in ways that increase the organism’s
prior and contemporary analysts. In this vulnerability to disease. More recent
section, we first cite three important directions researchers, most prominently Richard
emerging recently in social epidemiology theory. Wilkinson, have sought to link altered
Then we review a number of perspectives on neuroendocrine patterns and compromised
the pathways through which social conditions health capability to people’s perception and
influence health outcomes. These discussions experience of their place in social hierarchies.
uncover important elements to be included in According to these theorists, the experience
a framework for action for the CSDH. Finally of living in social settings of inequality forces
we highlight areas that previous theories have people constantly to compare their status,
left insufficiently clarified, and upon which, the possessions and life circumstances with those
proposed CSDH framework can shed new light. of others, engendering feelings of shame
and worthlessness in the disadvantaged,
along with chronic stress that undermines
4.1 Current directions in SDH health. At the level of society as a whole,
theory meanwhile, steep hierarchies in income
and social status weaken social cohesion,
The three main theoretical directions invoked with this disintegration of social bonds also
by current social epidemiologists, which are not seen as negative for health. This research
mutually exclusive, can be designated as follows: has generated a substantial literature on the
(1) psychosocial approaches; (2) social production relationship between (perceptions of) social
of disease/political economy of health; and (3) inequality, psychobiological mechanisms,
ecosocial theory and related multi-level frameworks. and health status 47, 48, 49, 50, 51, 52.
All three approaches seek to elucidate principles ∏ A social production of disease/political

capable of explaining social inequalities in health, economy of health framework explicitly


and all represent what Krieger has called theories addresses economic and political
of disease distribution that cannot be reduced to determinants of health and disease.
mechanism–oriented theories of disease causation. Researchers adopting this theoretical
Where they differ is in their respective emphasis on approach also sometimes described as a
different aspects of social and biological conditions materialist or neo-materialist position, do
in shaping population health, how they integrate not deny negative psychosocial consequences
social and biological explanations, and thus their of income inequality. However, they argue
recommendations for action 41, 42, 43. that interpretation of links between income
∏ The first school places primary emphasis inequality and health must begin with the
on psychosocial factors, and is associated structural causes of inequalities, and not
with the view that people’s “perception and just focus on perceptions of that inequality.
experience of personal status in unequal Under this interpretation, the effect of
societies lead to stress and poor health” 44, income inequality on health reflects both
45
. This school traces its origins to a classic lack of resources held by individuals and
study by Cassel 46, in which he argued that systematic under-investments across a wide
15
range of community infrastructure 53, 54, 55. The basis of this selection is that health exerts a
Economic processes and political decisions strong effect on the attainment of social position,
condition the private resources available to resulting in a pattern of social mobility through
individuals and shape the nature of public which unhealthy individuals drift down the social
infrastructure—education, health services, gradient and the healthy move up. Social mobility
transportation, environmental controls, refers to the notion that an individual’s social
availability of food, quality of housing, position can change within a lifetime, compared
occupational health regulations—that forms either with his or her parents’ social status (inter-
the “neo­material” matrix of contemporary generational mobility) or with himself/herself at an
life. Thus income inequality per se is but earlier point in time (intra-generational mobility). It
one manifestation of a cluster of material is important to distinguish between inter- and intra-
conditions that affect population health. generational health selection, although few studies
∏ Recently, Krieger’s “ecosocial” approach and are available that examine selection in both ways.
other emerging multi-level frameworks have The literature on health and social mobility suggests
sought to integrate social and biological that, in general, health status influences subsequent
factors and a dynamic, historical and social mobility 56, 57, but evidence is patchy and not
ecological perspective to develop new entirely consistent across different life stages. Also,
insights into determinants of population there has been limited and inconclusive evidence on
distribution of disease and social inequities the effect that this could have on health gradients
in health 41, 42, 43. According to Krieger, multi- 58, 59, 60
. Recently, it was proposed that health-related
level theories seek to “develop analysis of social mobility does not widen health inequalities 61.
current and changing population patterns On this interpretation, people who are downwardly
of health, disease and well-being in relation mobile because of their health still have better
to each level of biological, ecological and health than the people in the class of destination,
social organization”, all the way from the upgrading this class. Similarly, upwardly mobile
cell to human social groupings at all levels people will nonetheless lower the mean health in
of complexity, through the ecosystem as a the higher socio-economic classes into which they
whole. In this context, Krieger’s notion of become incorporated 62, 57. Again, the evidence for
“embodiment” describes how “we literally this is inconsistent, with some studies suggesting
incorporate biological influences from the that health selection acts to reduce the magnitude
material and social world” and that “no of inequalities 63, 64, 65, 66, 67, whereas others do not 68.
aspect of our biology can be understood Some studies conclude that health selection cannot
divorced from knowledge of history and be regarded as the predominant explanation for
individual and societal ways of living” 41. health inequalities 69, 70.

Approaches to studying health


4.2 Pathways and mechanisms selection
through which SDH influence Several approaches have been used to study the
health role and magnitude of health selection on the
social gradient. One approach focuses on the effect
Having canvassed major theoretical approaches to of social mobility, that is all social mobility and
SDH, we now proceed to review specific models, not just that related to health status, on health or
and the supporting evidence, that purport to health gradients 71, 72. A second approach focuses
explain health inequities. We characterize these on the effect of health status at an earlier life
models as “perspectives”, adopting Mackenbach’s stage in relation to health gradients later on 73. A
classification. This term underscores that third approach has been suggested to overcome
the hypotheses examined have a potentially these difficulties by focusing on both prior health
complementary character and, like the theoretical status and social mobility 74, 75. It has been argued
“directions” described in section 4.1, should not be that health selection would have a stronger effect
regarded as necessarily mutually exclusive. around the time of labour market entry, when the
likelihood of social mobility is greatest 57.
4.2.1 Social selection perspective
It may be fruitful to distinguish between when
The social selection perspective implies that health illness influences the allocation of individuals
determines socioeconomic position, instead to socioeconomic positions (“direct selection”)
of socioeconomic position determining health. and when ill-health has economic consequences
16
A conceptual framework for action on the social determinants of health

owing to varying eligibility for and coverage by that have their sources in the material world.
social insurance or similar mechanisms (example Meanwhile, material factors and social (dis)
of “indirect selection”). Blane and Manor argue that advantages predictably intertwine, such that
the effect of the “direct selection” mechanism on the “people who have more resources in terms of
social gradient is small, and, therefore, direct social knowledge, money, power, prestige, and social
mobility cannot be regarded as a main explanation connections are better able to avoid risk … and to
for inequalities in health. More commonly social adopt the protective strategies that are available at
mobility is considered selective on determinants a given time and a given place” 76.
of health (hence “indirect selection”), not on
health itself 58. It is also important to take into Psychosocial factors are highlighted
account that the health determinants on which by the psychosocial theory described above.
indirect selection takes place could themselves Relevant factors include stressors (e.g. negative
arise from living circumstances of earlier stages life events), stressful living circumstances, lack
of life. Indirect selection would then be part of a of social support, etc. Researchers emphasizing
mechanism of accumulation of disadvantage over this approach argue that socioeconomic
the life course. The process of health selection may, inequalities in morbidity and mortality cannot
therefore, contribute to the cumulative effects of be entirely explained by well-known behavioral
social disadvantage across the life span, but, to or material risk factors of disease. For example,
date, the inclusion of health selection into studies in cardiovascular disease outcomes, risk factors
of life course relationships is scarce. such as smoking, high serum cholesterol and
blood pressure can explain less than half of the
4.2.2 Social causation perspective socioeconomic gradient in mortality. Marmot,
Shipley and Rose 142 have argued that the similarity
From this perspective, social position determines of the risk gradient for a range of diseases could
health through intermediary factors. Longitudinal indicate the operation of factors affecting general
studies in which socioeconomic status has been susceptibility. Meanwhile, the inverse relation
measured before health problems are present, between height and mortality suggests that factors
and in which the incidence of health problems operating from early life may influence adult death
has been measured during follow-up, show rates 77.
higher risk of developing health problem in
the lower socioeconomic groups, and suggest Behavioral factors, such as smoking, diet,
“social causation” as the main explanation for alcohol consumption and physical exercise,
socioeconomic inequalities in health 15. This are certainly important determinants of
causal effect of socioeconomic status on health health. Moreover, since they can be unevenly
is likely to be mainly indirect, through a number distributed between different socioeconomic
of more specific health determinants that are positions, they may appear to have important
differently distributed across socioeconomic weight as determinants of health inequalities.
groups. Socioeconomic health differences occur Yet this hypothesis is controversial in light of the
when the quality of these intermediary factors available evidence. Patterns differ significantly
are unevenly distributed between the different from one country to another. For example,
socioeconomic classes: socioeconomic status smoking is generally more prevalent among lower
determines a person’s behavior, life conditions, socioeconomic groups; however, in Southern
etc., and these determinants induce higher or Europe, smoking rates are higher among higher
lower prevalence of health problems. The main income groups, and in particular among women.
groups of factors that have been identified as The contribution of diet, alcohol consumption and
playing an important part in the explanation of physical activities to inequalities in health is less
health inequalities are material, psychosocial, and clear and not always consistent. However, there is
behavioral and/or biological factors. higher prevalence of obesity and excessive alcohol
consumption in lower socioeconomic groups,
Material factors are linked to conditions particularly in richer countries 19, 78, 79.
of economic hardship, as well as to health-
damaging conditions in the physical environment, The health system itself constitutes an
e.g. housing, physical working conditions, etc. additional relevant intermediary factor, though
For researchers who emphasize this aspect, one which has often not received adequate
health inequalities result from the differential attention in the literature. We will discuss this
accumulation of exposures and experiences topic in detail in subsequent sections of the paper.
17
4.2.3 Life course perspective effects of childhood social class by identifying
specific aspects of the early physical or psychosocial
A life course perspective explicitly recognizes the environment (such as exposure to air pollution or
importance of time and timing in understanding family conflict) or possible mechanisms (such as
causal links between exposures and outcomes nutrition, infection or stress) that are associated
within an individual life course, across generations, with adult disease will provide further etiological
and in population-level diseases trends. Adopting insights. Circumstances in early life are seen as the
a life course perspective directs attention to how initial stage in the pathway to adult health but with
social determinants of health operate at every level an indirect effect, influencing adult health through
of development—early childhood, childhood, social trajectories, such as restricting educational
adolescence and adulthood—both to immediately opportunities, thus influencing socioeconomic
influence health and to provide the basis for health circumstances and health in later life. Risk factors
or illness later in life. The life course perspective tend to cluster in socially patterned ways, for
attempts to understand how such temporal example, those living in adverse childhood social
processes across the life course of one cohort are circumstances are more likely to be of low birth
related to previous and subsequent cohorts and are weight, and be exposed to poor diet, childhood
manifested in disease trends observed over time at infections and passive smoking. These exposures
the population level. Time lags between exposure, may raise the risk of adult respiratory disease,
disease initiation and clinical recognition (latency perhaps through chains of risk or pathways over
period) suggest that exposures early in life are time where one adverse (or protective) experience
involved in initiating disease processes prior to will tend to lead to another adverse (protective)
clinical manifestations; however, the recognition experience in a cumulative way.
of early-life influences on chronic diseases does not
imply deterministic processes that negate the utility Ben-Shlomo and Kuh 80 argue that the life course
of later-life intervention. approach is not limited to individuals within a
single generation but should intertwine biological
In a table produced by Ben-Shlomo and Kuh 80 and social transmission of risk across generations.
the authors propose a simply classification of It must contextualize any exposure both within
potential life course models of health. Two main a hierarchical structure as well as in relation to
mechanisms are identified. geographical and secular differences, which may
be unique to that cohort of individuals. Recently
The “critical periods” model is when an the potential for a life course approach to aid
exposure acting during a specific period has lasting understanding of variations in the health and
or lifelong effects on the structure or function disease of populations over time, across countries
of organs, tissues and body systems that are not and between social groups has been given more
modified in any dramatic way by later experiences. attention. Davey Smith 70 and his colleagues suggest
This is also known as “biological programming”, that explanations for social inequalities in cause-
and it is sometimes referred to as a “latency” specific adult mortality lie in socially-patterned
model. This conception is the basis of hypotheses exposures at different stages of the life course.
on the fetal origins of adult diseases. This approach
does recognize the importance of later life effect
modifiers (e.g. in the linkage of coronary heart
disease, high blood pressure and insulin resistance
with low birth weight) 81.

The “accumulation of risk” model suggests


that factors that raise disease risk or promote
good health may accumulate gradually over the
life course, although there may be developmental
periods when their effects have greater impact on
later health than factors operating at other times.
This idea is complementary to the notion that as
the intensity, number and/or duration of exposures
increase, there is increasing cumulative damage
to biological systems. Understanding the health

18
A conceptual framework for action on the social determinants of health

Key messages of this section:


p In contemporary social epidemiology, three main theoretical explanations of
disease distribution are: (1) psychosocial approaches; (2) social production
of disease/political economy of health; and (3) eco-social and other emerging
multi-level frameworks. All represent theories which presume but cannot be
reduced to mechanism–oriented theories of disease causation.

p The main social pathways and mechanisms through which social determinants
affect people’s health can usefully be seen through three perspectives: (1)
“social selection”, or social mobility; (2) “social causation”; and (3) life course
perspectives.

p These frameworks/directions and perspectives are not mutually exclusive. On


the contrary, they are complementary.

p Certain of these frameworks have paid insufficient attention to political


variables. The CSDH framework will systematically incorporate these factors.

19
5 CSDH conceptual
framework

5.1 Purpose of constructing a 2 an existing model of the social production


framework for the CSDH of disease developed by Diderichsen
and colleagues, from which the CSDH
We now proceed to present in detail the specific framework draws significantly.
conceptual framework developed for the CSDH.
This is an action-oriented framework, whose With these background elements in place, we
primary purpose is to support the CSDH in proceed to examine the key components of the
identifying where CSDH recommendations will CSDH framework in turn, including:
seek to promote change in tackling SDH through 1 the socio-political context;
policies. A comprehensive SDH framework should 2 structural determinants and socioeconomic
achieve the following: position; and
∏ Identify the social determinants of health 3 intermediary determinants.
and the social determinants of inequities
in health; We conclude the presentation with a synthetic
∏ Show how major determinants relate to review of the framework as a whole. The issue
each other; of entry points for policy action will be taken up
∏ Clarify the mechanisms by which social explicitly in the next chapter.
determinants generate health inequities;
∏ Provide a framework for evaluating which

SDH are the most important to address; 5.2 Theories of power to guide
and action on social determinants
∏ Map specific levels of intervention and

policy entry points for action on SDH. Health inequities flow from patterns of social
stratification—that is, from the systematically
To include all these aspects in one framework is unequal distribution of power, prestige and
difficult and may complicate understanding. In an resources among groups in society. As a critical
earlier version of the CSDH conceptual framework, factor shaping social hierarchies and thus
drafted in 2005, we attempted to include all of conditioning health differences among groups,
these elements in a single synthetic diagram; “power” demands careful analysis from researchers
however, this approach was not necessarily the concerned with health equity and SDH.
most helpful. In the current elaboration of the Understanding the causal processes that underlie
framework, we separate out the various major health inequities, and assessing realistically what
components. may be done to alter them, requires understanding
how power operates in multiple dimensions of
We begin by sketching additional important economic, social and political relationships.
background elements not covered in the previous
theoretical frameworks and perspectives as The theory of power is an active domain of
follows: inquiry in philosophy and the social sciences.
1 insights from the theorization of social While developing a full-fledged theory of
power, which can help to clarify the power lies beyond the mandate of the CSDH,
dynamics of social stratification; and the Commission can draw on philosophical and

20
A conceptual framework for action on the social determinants of health

political analyses of power to guide its framing of Young terms this “structural oppression”, whose
the relationships among health determinants and forms are “systematically reproduced in major
its recommendations for interventions . economic, political and cultural institutions” 85.
For all their explanatory value, power theories
Power is “arguably the single most important which tend to equate power with domination leave
organizing concept in social and political theory” 82, key dimensions of power insufficiently clarified.
yet this central concept remains contested and As Angus Stewart argues, such theories must
subject to diverse and often contradictory be complemented by alternative readings that
interpretations. We review several approaches to emphasize more positive, creative aspects of power.
conceptualizing power.
A crucial source for such alternative more positive
First, classic treatments of the concept of power models is the work of philosopher Hannah
have emphasized two fundamental (and largely Arendt. Arendt challenged fundamental aspects
negative) aspects: (1) “power to”, i.e. what Giddens of conventional western political theory by
has termed “the transformative capacity of human stressing the inter-subjective character of power
agency”, in the broadest sense “the capability of in collective action. In Arendt’s philosophy,
the actor to intervene in a series of events so as “power is conceptually and above all politically
to alter their course”; and (2) “power over”, which distinguished, not by its implication in agency,
characterizes a relationship in which an actor or but above all by its character as collective action83.
group achieves its strategic ends by determining “Power corresponds to the human ability not just
the behavior of another actor or group. Power in to act, but to act in concert. Power is never the
this second, more limited but politically crucial property of an individual; it belongs to a group
sense may be understood as the capability to secure and remains in existence only so long as the group
outcomes where the realization of these outcomes keeps together” 86. From this vantage point, power
depends upon the agency of others. “Power over” is can be understood as:
closely linked to notions of coercion, domination
and oppression; it is this aspect of power which
has been at the heart of most influential modern
theories of power 83.

It is important to observe, meanwhile, that “a relation in which people are not


“domination” and “oppression” in the relevant dominated but empowered through
senses need not involve the exercise of brute critical reflection leading to shared
physical violence nor even its overt threat. In a action” 87.
classic study, Steven Lukes showed that coercive
power can take covert forms. For example,
power expresses itself in the ability of advantaged Recent feminist theory has further enriched these
groups to shape the agenda of public debate and perspectives. Luttrell and colleagues 88 follow
decision-making in such a way that disadvantaged Rowlands 89 in distinguishing four fundamental
constituencies are denied a voice. At a still types of power:
deeper level, dominant groups can mold people’s ∏ Power over (ability to influence or coerce)

perceptions and preferences, for example through ∏ Power to (organize and change existing

control of the mass media, in such a way that the hierarchies)


oppressed are convinced they do not have any ∏ Power with (power from collective action)

serious grievances. “The power to shape people’s ∏ Power within (power from individual

thoughts and desires is the most effective kind of consciousness).


power, since it pre-empts conflict and even pre-
empts an awareness of possible conflicts” 84. Iris They note that these different interpretations of
Marion Young develops related insights on the power have important operational consequences
presence of coercive power even where overt force for development actors’ efforts to facilitate the
is absent. She notes that “oppression” can designate, empowerment of women and other traditionally
not only “brutal tyranny over a whole people by a dominated groups. An approach based on
few rulers”, but also “the disadvantage and injustice “power over” emphasizes greater participation
some people suffer … because of the everyday of previously excluded groups within existing
practices of a well-intentioned liberal society”. economic and political structures. In contrast,

21
models based on “power to” and “power with”, previously oppressed groups. “Here the paradigm
emphasizing new forms of collective action, push case is not one of command, but one of enablement
towards a transformation of existing structures in which a disorganized and unfocused group
and the creation of alternative modes of power- acquires an identity and a resolve to act” 88.
sharing: “not a bigger piece of the cake, but a However, there can be little doubt that the political
different cake” 90. expression of vulnerable groups’ “enablement”
will generate tensions among those constituencies
This emphasis on power as collective action that perceive their interests as threatened. On
connects suggestively with a model of social the other hand, theories that highlight both the
ethics based on human rights. As one analyst overt and covert forms through which coercive
has argued: “Throughout its history, the struggle power operates provide a sobering reminder of
for human rights has a constant: in very different the obstacles confronting collective action among
forms and with very different contents, this oppressed groups.
struggle has consisted of one basic reality: a
demand by oppressed and marginalized social Theorizing the impact of social power on health
groups and classes for the exercise of their social suggests that the empowerment of vulnerable
power” 91. Understood in this way, a human rights and disadvantaged social groups will be vital to
agenda means supporting the collective action of reducing health inequities. However, the theories
historically dominated communities to analyze, reviewed here also encourage us to problematize
resist and overcome oppression, asserting their the concept of “empowerment” itself. They point
shared power and altering social hierarchies in the to the different (in some cases incompatible)
direction of greater equity. meanings this term can carry. What different
groups mean by empowerment depends on their
The theories of power we have reviewed are underlying views about power. The theories we
relevant to analysis and action on the social have discussed acknowledge different forms of
determinants of health in a number of ways. First, power and thus, potentially, different kinds and
and most fundamentally, they remind us that levels of empowerment. However, these theories
any serious effort to reduce health inequities will urge skepticism towards depoliticized models
involve changing the distribution of power within of empowerment and approaches that claim to
society to the benefit of disadvantaged groups. empower disadvantaged individuals and groups
Changes in power relationships can take place at while leaving the distribution of key social
various levels, from the “micro-level” of individual and material goods largely unchanged. Those
households or workplaces to the “macro-sphere” concerned to reduce health inequities cannot
of structural relations among social constituencies, accept a model of empowerment that stresses
mediated through economic, social and political process and psychological aspects at the expense
institutions. Power analysis makes clear, however, of political outcomes and downplays verifiable
that micro-level modifications will be insufficient change in disadvantaged groups’ ability to exercise
to reduce health inequities unless micro-level control over processes that affect their well-being.
action is supported and reinforced through This again raises the issue of state responsibility
structural changes. in creating spaces and conditions under which
the empowerment of disadvantaged communities
By definition, then, action on the social can become a reality. A model of community
determinants of health inequities is a political or civil society empowerment appropriate for
process that engages both the agency of action on health inequities cannot be separated
disadvantaged communities and the responsibility from the responsibility of the state to guarantee
of the state. This political process is likely to be a comprehensive set of rights and ensure the fair
contentious in most contexts, since it will be seen distribution of essential material and social goods
as pitting the interests of social groups against among population groups. This theme is explored
each other in a struggle for power and control of more fully below.
resources. Theories of power rooted in collective
action, such as Arendt’s, open the perspective of a
less antagonistic model of equity-focused politics,
emphasizing the creative self-empowerment of

22
A conceptual framework for action on the social determinants of health

Key messages of this section:


p An explicit theorization of power is useful for guiding action to tackle SDH to
improve health equity .

p Classic conceptualizations of power have emphasized two basic aspects: (1)


“power to” - the ability to bring about change through willed action; and (2)
“power over” - the ability to determine other people’s behavior, associated with
domination and coercion.

p Theories that equate power with domination can be complemented by


alternative readings that emphasize more positive, creative aspects of power,
based on collective action. In this perspective, human rights can be understood
as embodying a demand on the part of oppressed and marginalized communities
for the expression of their collective social power.

p Any serious effort to reduce health inequities will involve changing the
distribution of power within society to the benefit of disadvantaged groups.

p Changes in power relationships can range from the “micro- level” of individual
households or workplaces to the “macro- sphere” of structural relations
among social constituencies, mediated through economic, social and political
institutions. Micro-level modifications will be insufficient to reduce health
inequities unless supported by structural changes but structural changes that
are not cogniscent of incentives at the micro-level will also struggle for impact.

p This means that action on the social determinants of health inequities is a


political process that engages both the agency of disadvantaged communities
and the responsibility of the state.

5.3 Relevance of the determine the pattern of social stratification. The


Diderichsen model for the model emphasizes how social contexts create
CSDH framework social stratification and assign individuals to
different social positions. Social stratification in
The CSDH framework for action draws turn engenders differential exposure to health-
substantially on the contributions of many damaging conditions and differential vulnerability,
previous researchers, most prominently Finn in terms of health conditions and material
Diderichsen. Diderichsen’s and Hallqvist’s 1998 resource availability. Social stratification likewise
model of the social production of disease was determines differential consequences of ill health
subsequently adapted by Diderichsen, Evans and for more and less advantaged groups (including
Whitehead 92. The concept of social position is economic and social consequences, as well as
at the center of Diderichsen’s interpretation of differential health outcomes per se).
“the mechanisms of health inequality” 93. In its
initial formulation, the model emphasized the At the individual level, the figure depicts the
pathway from society through social position pathway from social position, through exposure
and specific exposures to health. The framework to specific contributing causal factors, and on to
was subsequently elaborated to give greater health outcomes. As many different interacting
emphasis to “mechanisms that play a role in causes in the same pathway might be related to
stratifying health outcomes” 94, including “those social position, the effect of a single cause might
central engines of society that generate and differ across social positions as it interacts with
distribute power, wealth and risks” and thereby some other cause related to social position 94, 95.
23
Figure 1. Model of the social production of disease

Source: Reproduced with permission from Diderichsen et al. (2001)

Diderichsen’s most recent version of the model


provides some additional insights 92, 94. Both
Key messages of this section: differential exposure (Roman numeral I in the
diagram above) and differential vulnerability (II)
p Social position is at the center of Diderichsen’s model of may contribute to the relation between social
“the mechanisms of health inequality”. position and health outcomes, as can be tested
empirically. In addition, differential vulnerability
p The mechanisms that play a role in stratifying health is about clustering and interaction between
outcomes operate in the following manner : those determinants that mediate the effect of
socio-economic health gradient. Ill health has
• Social contexts create social stratification and serious social and economic consequences due
assign individuals to different social positions. to inability to work and the cost of health care.
• Social stratification in turn engenders differential These consequences depend not only on the extent
exposure to health-damaging conditions and of disability, but also on the individual’s social
differential vulnerability, in terms of health position (III—differential consequences) and on
conditions and material resource availability. the society’s environment and social policies.
• Social stratification likewise determines The social and economic consequences of illness
differential consequences of ill health for more and may feed back into the etiological pathways and
less advantaged groups (including economic and contribute to the further development of disease in
social consequences, as well differential health the individual (IV). This effect might even, on an
outcomes per se). aggregate level, feed into the context of society, as
well, and influence aggregate social and economic
development.

Many of the insights from Diderichsen’s model


24 will be taken up into the CSDH framework that
A conceptual framework for action on the social determinants of health

we will now begin to explain, presenting its key in Kerala for the longest period during those
components one by one. 40 years 98. Chung and Muntaner find similarly
that few studies have explored the relationship
between political variables and population health
5.4 First element of the CSDH at the national level, and none has included a
framework: socio-economic comprehensive number of political variables to
and political context understand their effect on population health
while simultaneously adjusting for economic
The social determinants framework developed determinants 99. As an illustration of the powerful
by the CSDH differs from some others in the impact of political variables on health outcomes,
importance attributed to the socioeconomic- these researchers concluded in a recent study of 18
political context. This is a deliberately broad term wealthy countries in Europe, North America and
that refers to the spectrum of factors in society the Asia-Pacific region that 20 % of the differences
that cannot be directly measured at the individual in infant mortality rate among countries could be
level. “Context”, therefore, encompasses a broad explained by the type of welfare state. Similarly,
set of structural, cultural and functional aspects different welfare state models among the countries
of a social system whose impact on individuals accounted for about 10 % of differences in the rate
tends to elude quantification but which exert of low birth weight babies 99.
a powerful formative influence on patterns of
social stratification and, thus, on people’s health Raphael similarly emphasizes how policy decisions
opportunities. In this stated context, one will impact a broad range of factors that influence
find those social and political mechanisms that the distribution and effects of SDH across
generate, configure and maintain social hierarchies population groups. Policy choices are reflected,
(e.g. the labor market, the educational system and for example, in: family-friendly labor policies;
political institutions including the welfare state). active employment policies involving training
and support; the provision of social safety nets;
One point noted by some analysts, and which we and the degree to which health and social services
wish to emphasize, is the relative inattention to and other resources are available to citizens 44, 45.
issues of political context in a substantial portion The organization of healthcare is also a direct
of the literature on health determinants. It has result of policy decisions made by governments.
become commonplace among population health Public policy decisions made by governments
researchers to acknowledge that the health of are themselves driven by a variety of political,
individuals and populations is strongly influenced economic and social forces, constituting a complex
by SDH. It is much less common to aver that the space in which the relationship between politics,
quality of SDH is in turn shaped by the policies policy and health works itself out.
that guide how societies (re)distribute material
resources among their members 96. In the growing It is safe to say that these specifically political aspects
area of SDH research, a subject rarely studied is the of context are important for the social distribution
impact on social inequalities and health of political of health and sickness in virtually all settings,
movements and parties and the policies they adopt and they have been seriously understudied. On
when in government 97. the other hand, it is also the case that the most
relevant contextual factors (i.e. those that play the
Meanwhile, Navarro and other researchers greatest role in generating social inequalities) may
have compiled over the years an increasingly differ considerably from one country to another 99.
solid body of evidence that the quality of many For example, in some countries religion will be a
social determinants of health is conditioned by decisive factor and less so in others. In general, the
approaches to public policy. To name just one construction/mapping of context should include
example, the state of Kerala in India has been at least six points: (1) governance in the broadest
widely studied, showing the relationship between sense and its processes, including definition of
its impressive reduction of inequalities in the needs, patterns of discrimination, civil society
last 40 years and improvements in the health participation and accountability/transparence in
status of its population. With very few exceptions, public administration; (2) macroeconomic policy,
however, these reductions in social inequalities and including fiscal, monetary, balance of payments
improvements in health have rarely been traced and trade policies and underlying labour market
to the public policies carried out by the state’s structures; (3) social policies affecting factors
governing communist party, which has governed such as labor, social welfare, land and housing
25
distribution; (4) public policy in other relevant to workers or enhancing workers’ skills and
areas such as education, medical care, water and capacities, reducing labour supply, creating jobs or
sanitation; (5) culture and societal values; and (6) changing the structure of employment in favour of
epidemiological conditions, particularly in the disadvantaged groups (e.g. employment subsidies
case of major epidemics such as HIV/AIDS, which for target groups). Typical passive programmes
exert a powerful influence on social structures and are unemployment insurance and assistance and
must be factored into global and national policy- early retirement; typical active measures are labour
setting. In what follows, we highlight some of these market training, job creation in form of public and
contextual elements with particular focus on those community work programmes, programmes to
with major importance for health equity. promote enterprise creation and hiring subsidies.
We have adopted the UNDP definition of Active policies are usually targeted at specific
governance, which is as follows: groups facing particular labour market integration
difficulties: younger and older people, women
and those particularly hard to place such as the
disabled.”

The concept of the “welfare state” is one in which


“[the] system of values, policies the state plays a key role in the protection and
and institutions by which society promotion of the economic and social well-being
manages economic, political and of its citizens. It is based on the principles of
equality of opportunity, equitable distribution of
social affairs through interactions
wealth and public responsibility for those unable
within and among the state, civil to avail themselves of the minimal provisions for
society and private sector. It is the a good life. The general term may cover a variety
way a society organizes itself to of forms of economic and social organization. A
make and implement decisions”. fundamental feature of the welfare state is social
insurance. The welfare state also, usually, includes
public provision of basic education, health services
It comprises the mechanisms and processes for and housing (in some cases at low cost or without
citizens and groups to articulate their interests, charge). Anti-poverty programs and the system of
mediate their differences and exercise their personal taxation may also be regarded as aspects
legal rights and obligations. These are the rules, of the welfare state. Personal taxation falls into
institutions and practices that set limits and provide this category insofar as it is used progressively
incentives for individuals, organizations and firms. to achieve greater justice in income distribution
Governance, including its social, political and (rather than merely to raise revenue), and also
economic dimensions, operates at every level of insofar as it used to finance social insurance
human enterprise, be it the household, village, payments and other benefits not completely
municipality, nation, region or globe” 100, 101. It financed by compulsory contributions. In more
is important to acknowledge, meanwhile, that socialist countries the welfare state also covers
there is no general agreement on the definition of employment and administration of consumer
governance, or of good governance. Development prices 102, 103.
agencies, international organizations and academic
institutions define governance in different ways, One of the main functions of the welfare state is
this being generally related to the nature of their “income redistribution”; therefore, the welfare
interests and mandates. state framework has been applied to the fields
of social epidemiology and health policy as an
Regarding labour market policies, we adopt the amendment to the “relative income hypothesis”.
ideas proposed by the CSDH’s Employment Welfare state variables have been added to
Conditions Knowledge Network 102: “Labour measures of income inequality to determine the
market policies mediate between supply structural mechanism through which economic
(jobseekers) and demand (jobs offered) in the inequality affects population health status 104.
labour market, and their intervention can take
several forms. There are policies that contribute Chung and Muntaner provide a classification of
directly to matching workers to jobs and jobs welfare state types and explore the health effects

26
A conceptual framework for action on the social determinants of health

of their respective policy approaches. Their study In constructing a typology of health systems,
concludes that countries exhibit distinctive levels Kleczkowski, Roemer and Van der Werff have
of population health by welfare regime types, proposed three domains of analysis to indicate
even when adjusted by the level of economic how health is valued in a given society:
development (GDP per capita) and intra-country ∏ The extent to which health is a priority

correlations. They find, specifically, that Social in the governmental /societal agenda, as
Democratic countries exhibit significantly better reflected in the level of national resources
population health status, e.g. lower infant mortality allocated to health (care), with the need for
rate and low birth weight rate, compared to other health care signalling a grave ethical basis
countries 99, 105. for resource redistribution);
∏ The extent to which the society assumes

Institutions and processes connected with collective responsibility for financing and
globalization constitute an important dimension organizing the provision of health services.
of context as we understand it. “Globalization” is In maximum collectivism (also referred
defined by the CSDH Globalization Knowledge to as a state-based model), the system is
Network, following Jenkins, as: almost entirely concerned with providing
collective benefits, leaving little or no
choice to the individual. In maximum
individualism, ill health and its care are
viewed as private concerns; and
∏ The extent of societal distributional
“a process of greater integration responsibility. This is a measure of
within the world economy the degree to which society assumes
through movements of goods and responsibility for the distribution of
its health resources. Distributional
services, capital, technology and
responsibility is at its maximum when the
(to a lesser extent) labour, which society guarantees equal access to services
lead increasingly to economic for all 107, 108.
decisions being influenced by global
conditions”. These criteria are important for health systems
policy and evaluating systems performance. They
are also relevant to assessing opportunities for
– in other words, to the emergence of a global action on SDH.
marketplace 106 . Non-economic aspects of
globalization, including social and cultural aspects, To fully characterize all major components of
are acknowledged and relevant. However, economic the socioeconomic and political context is
globalization is understood as the force that has beyond the scope of the present paper. Here, we
driven other aspects of globalization over recent have considered only a small number of those
decades. The importance of globalization signifies components likely to have particular importance
that contextual analysis on health inequities will for health equity in many settings.
often need to examine the strategies pursued by
actors such as transnational corporations and
supranational political institutions, including the 5.5 Second element:
World Bank and International Monetary Fund. structural determinants and
socioeconomic position
“Context” also includes social and cultural values.
The value placed on health and the degree to which Graham observes that the concept of “social
health is seen as a collective social concern differs determinants of health” has acquired a dual
greatly across regional and national contexts. We meaning, referring both to the social factors
have argued elsewhere, following Roemer and promoting and undermining the health of
Kleczkowski, that the social value attributed to individuals and populations and to the social
health in a country constitutes an important and processes underlying the unequal distribution of
often neglected aspect of the context in which these factors between groups occupying unequal
health policies must be designed and implemented. positions in society. The central concept of “social

27
determinants” thus remains ambiguous, referring position in the social stratification system can be
simultaneously to the determinants of health and summarized as their socioeconomic position. (A
to the determinants of inequalities in health. The variety of other terms, such as social class, social
author notes that: stratum and social or socioeconomic status, are
often used more or less interchangeably in the
literature, despite their different theoretical bases.)

“using a single term to refer to The two major variables used to operationalize
both the social factors influencing socioeconomic position in studies of social
inequities in health are social stratification and
health and the social processes social class. The term stratification is used in
shaping their social distribution sociology to refer to social hierarchies in which
would not be problematic if the individuals or groups can be arranged along a
main determinants of health—like ranked order of some attribute. Income or
living standards, environmental years of education provide familiar examples.
influences and health behaviors— Measures of social stratification are important
predictors of patterns of mortality and morbidity.
were equally distributed between However, despite their usefulness in predicting
socioeconomic groups” 3. health outcomes, these measures do not reveal the
social mechanisms that explain how individuals
But the evidence points to marked socioeconomic arrive at different levels of economic, political and
differences in access to material resources, health- cultural resources. “Social class”, meanwhile, is
promoting resources, and in exposure to risk defined by relations of ownership or control over
factors. Furthermore, policies associated with productive resources (i.e. physical, financial and
positive trends in health determinants (e.g. a rise organizational) 112. This concept adds significant
in living standards and a decline in smoking) have value, in our view, and for that reason we have
also been associated with persistent socioeconomic chosen to include it as an additional, distinct
disparities in the distribution of these determinants component in our discussion of socioeconomic
(marked socioeconomic differences in living position. The particularities of the concept of
standards and smoking rates) 109, 110 .We have social class will be described in greater detail when
attempted to resolve this linguistic ambiguity by we analyze this concept below.
introducing additional differentiations within the
field of concepts conventionally included under the Two central figures in the study of socioeconomic
heading “social determinants”. We adopt the term position were Karl Marx and Max Weber. For
“structural determinants” to refer specifically to Marx, socioeconomic position was entirely
interplay between the socioeconomic-political determined by ‘‘social class’’, whereby an individual
context, structural mechanisms generating social is defined by their relation to the ‘‘means of
stratification and the resulting socioeconomic production’’ (for example, factories and land).
position of individuals. These structural Social class, and class relations, is characterized
determinants are what we include when referring by the inherent conflict between exploited workers
to the “social determinants of health inequities”. and the exploiting capitalists or those who control
This concept corresponds to Graham’s notion of the means of production. Class, as such, is not an
the “social processes shaping the distribution” of a priori property of individual human beings, but
downstream social determinants 3. When referring is a social relationship created by societies. One
to the more downstream factors, we will use the explicit adaptation of Marx’s theory of social class
term “intermediary determinants of health”. We that takes into account contemporary employment
attach to this term specific nuances that will be and social circumstances is Wright’s social class
spelled out in a later section. classification. In this scheme, people are classified
according to the interplay of three forms of
Within each society, material and other resources exploitation: (a) ownership of capital assets, (b)
are unequally distributed. This inequality can control of organizational assets, and (c) possession
be portrayed as a system of social stratification of skills or credential assets 113, 114.
or social hierarchy 111, 112. People attain different
positions in the social hierarchy according, Weber developed a different view of social class.
mainly, to their social class, occupational status, According to Weber, differential societal position
educational achievement and income level. Their is based on three dimensions: class, status and
28
A conceptual framework for action on the social determinants of health

party (or power). Class is assumed to have an these indicators may not be directly available.
economic base. It implies ownership and control Information on education, occupation and income
of resources and is indicated by measures of may be unavailable, and it may be necessary to
income. Status is considered to be prestige or use proxy measures of socioeconomic status like
honor in the community. Weber considers status to indicators of living standards (for example, car
imply “access to life chances” based on social and ownership or housing tenure).
cultural factors like family background, lifestyle
and social networks. Finally, power is related to Singh-Manoux and colleagues have argued that
a political context. In this paper, we use the term the social gradient is sensitive to the proximal/
“socioeconomic position”, acknowledging the distal nature of the indicator of socioeconomic
three separate but linked dimensions of social position employed116. The idea is that there is
class reflected in the Weberian conceptualization. valid basis for causal and temporal ordering in
the various measures of socioeconomic position.
Krieger, Williams and Moss highlight that An analysis of the socioeconomic status of
as “socioeconomic position” is an aggregate individuals at several stages of their lives showed
concept, its use in research needs to be clarified that socioeconomic origins have enduring effects
115
. It includes both resource-based and prestige- on adult mortality through their effect on later
based measures, and linked to both childhood socioeconomic circumstances, such as education,
and adult social class position. Resource-based occupation and financial resources. This approach
measures refer to material and social resources and is derived from the life course perspective, where
assets, including income, wealth and educational education is seen to structure occupation and
credentials; terms used to describe inadequate income. In this model, education influences
resources include “poverty” and “deprivation”. health outcomes both directly and indirectly
Prestige-based measures refer to individuals’ through its effect on occupation and income 116.
rank or status in a social hierarchy, typically The disadvantage with education is that it does
evaluated with reference to people’s access to and not capture changes in adult socioeconomic
consumption of goods, services and knowledge, circumstances or accumulated socioeconomic
as linked to their occupational prestige, income position.
and educational level. Given distinctions between
the diverse pathways by which resource-based and Reporting that educational attainment,
prestige-based aspects of socioeconomic position occupational category, social class and income
affect health across the life cycle, epidemiological are probably the most often used indicators of
studies need to state clearly how measures of current socioeconomic status in studies on health
socioeconomic position are conceptualized 115. inequalities, Lahelman and colleagues find that
Educational level creates differences between each indicator is likely to reflect both common
people in terms of access to information and impacts of a general hierarchical ranking in
the level of proficiency in benefiting from new society and particular impacts specific to the
knowledge, whereas income creates differences indicator. (1) Educational attainment is usually
in access to scarce material goods. Occupational acquired by early adulthood. The specific nature
status includes both these aspects and adds to them of education is knowledge and other non-material
benefits accruing from the exercise of specific jobs, resources that are likely to promote healthy
such prestige, privileges, power, and social and lifestyles. Additionally, education provides formal
technical skills. qualifications that contribute to the socioeconomic
status of destination through occupation and
Kunst and Mackenbach have argued that there income. (2) Occupation-based social class relates
are several indicators for socioeconomic position, people to social structure. Occupational social
and that the most important are occupational class positions indicate status and power, and
status, level of education and income level. they reflect material conditions related to paid
Each indicator covers a different aspect of social work. (3) Individual and household income derive
stratification, and it is, therefore, preferable to use primarily from paid employment. Income provides
all three instead of only one 111. They add that the individuals and families necessary material
measurement of these three indicators is far from resources and determines their purchasing power.
straightforward, and due attention should be paid Thus, income contributes to resources needed
to the application of appropriate classifications, in maintaining good health. Following these
for example, children, women and economically considerations, education is typically acquired
inactive people, for whom one or more of first over the life course. Education contributes
29
to occupational class position and through this association with health; it can influence a wide
to income. The effect of education on income range of material circumstances with direct
is assumed to be mediated mainly through implications for health 119, 114. Income also has a
occupation 117. cumulative effect over the life course, and it is
Socioeconomic position can be measured the socioeconomic position indicator that can
meaningfully at three complementary levels: change most on a short term basis. It is implausible
individual, household and neighborhood. that money in itself directly affects health, thus
Each level may independently contribute to it is the conversion of money and assets into
distributions of exposure and outcomes. Also, health enhancing commodities and services
socioeconomic position can be measured at via expenditure that may be the more relevant
different points of the lifespan (e.g. infancy, concept for interpreting how income affects health.
childhood, adolescence and adulthood in the Consumption measures are, however, rarely used
current, past 5 years, etc.). Relevant time periods in epidemiological studies; and they are, in fact,
depend on presumed exposures, causal pathways seriously flawed when used in health equity
and associated etiologic periods. Today it is also research, because high medical costs (an element
vital to recognize gender, ethnicity and sexuality of consumption) may make a household appear
as social stratifiers linked to systematic forms of non-poor 120.
discrimination 118.
Income is not a simple variable. Components
The CSDH framework posits that structural include wage earning, dividends, interest, child
determinants are those that generate or reinforce support, alimony, transfer payments and pensions.
social stratification in the society and that define Kunst and Mackenbach argued that this is a more
individual socioeconomic position. These proximate indicator of access to scarce material
mechanisms configure the health opportunities resources or of standard of living. It can be
of social groups based on their placement within expressed most adequately when the income level
hierarchies of power, prestige and access to is measured by: adding all income components
resources (economic status). We prefer to speak (this yield total gross income); subtracting
of structural determinants, rather than “distal deductions of tax and social contribution (net
factors”, in order to capture and underscore the income); adding the net income of all household
causal hierarchy of social determinants involved members (household income); or adjusting for
in producing health inequities. Structural the size of the household (household equivalent
social stratification mechanisms, joined to and income) 111.
influenced by institutions and processes embedded
in the socioeconomic and political context (e.g. While individual income will capture individual
redistributive welfare state policies), can together material characteristics, household income may
be conceptualized as the social determinants of be a useful indicator, since the benefits of many
health inequities. elements of consumption and asset accumulation
are shared among household members. This
We now examine briefly each of the major variables cannot be presumed, especially in the context
used to operationalize socioeconomic position. of gender divisions of labour and power within
First we analyse the proxies use to measure the household, in particular for women, who
social stratification, including income, education may not be the main earners in the household.
and occupation. Income and education can be Using household income information to apply to
understood as social outcomes of stratification all the people in the household assumes an even
processes, while occupation serves as a proxy for distribution of income according to needs within
social stratification. Having reviewed the use of the household, which may or may not be true;
these variables, we then turn to analyse social class, however, income is nevertheless the best single
gender and ethnicity that operate as important indicator of material living standards. Ideally,
structural determinants. data are collected on disposable income (what
individuals/households can actually spend); but
5.5.1 Income often data are collected instead on gross incomes
or incomes that do not take into account in-kind
Income is the indicator of socioeconomic transfers that function as hypothecated income.
position that most directly measures the material The meaning of current income for different age
resources component. As with other indicators, groups may vary and be most sensitive during the
such as education, income has a ‘‘dose-response’’ prime earning years. Income for young and older
30
A conceptual framework for action on the social determinants of health

Table 1. Explanations for the relationship between income inequality and health

Explanation Synopsis of the Argument


Psychosocial (micro): Social Income inequality results in “invidious processes of social comparison”
status that enforce social hierarchies causing chronic stress leading to poorer
health outcomes for those at the bottom.
Psychosocial (macro): Income inequality erodes social bonds that allow people to work together,
Social cohesion decreases social resources, and results in less trust and civic participation,
greater crime and other unhealthy conditions.
Neo-material (micro): Income inequality means fewer economic resources among the poorest,
Individual income resulting in lessened ability to avoid risks, cure injury or disease, and/or
prevent illness.
Neo-material (macro): Income inequality results in less investment in social and environmental
Social disinvestment conditions (safe housing, good schools, etc.) necessary for promoting
health among the poorest.
Statistical artifact The poorest in any society are usually the sickest. A society with high levels
of income inequality has high numbers of poor and, consequently, will
have more people who are sick.
Health selection People are not sick because they are poor. Rather, poor health lowers one’s
income and limits one’s earning potential.

adults may be a less reliable indicator of their true determined by parental characteristics 123, it
socioeconomic position, because income typically can be conceptualized within a life course
follows a curvilinear trajectory with age. Thus, framework as an indicator that in part
measures at one point in time may fail to capture measures early life socioeconomic position.
important information about income fluctuations Education can be measured as a continuous
121, 115
. Macinko et al. propose the following variable (years of completed education) or as
summary explanations for the relationship between a categorical variable by assessing educational
income inequality and health shown in Table 1 122. milestones, such as completion of primary or
high school, higher education diplomas, or
Galobardes et al. conversely, have argued that degrees. Although education is often used as
income primarily influences health through a a generic measure of socioeconomic position,
direct effect on material resources that are in turn specific interpretations explain its association
mediated by more proximal factors in the causal with health outcomes:
chain, such as behaviours 121. The mechanisms ∏ Education captures the transition from

through which income could affect health are: parents’ (received) socioeconomic position
∏ Buying access to better quality material to adulthood (own) socioeconomic
resources such as food and shelter; position and it is also a strong determinant
∏ Allowing access to services, which may of future employment and income. It
improve health directly (such as health reflects material, intellectual and other
services, leisure activities) or indirectly resources of the family of origin, it
(such as education); begins at early ages, it is influenced by
∏ Fostering self esteem and social standing access to and performance in primary
by providing the outward material and secondary school, and it reaches final
characteristics relevant to participation in attainment in young adulthood for most
society; and people. Therefore, it captures the long-term
∏ Health selection (also referred to as influences of both early life circumstances
“reverse causality”) may also be considered on adult health and the influence of adult
as income level can be affected by health resources (e.g. through employment status)
status. on health;
∏ The knowledge and skills attained through

5.5.2 Education education may affect a person’s cognitive


functioning, make them more receptive to
Education is a frequently used indicator in health education messages, or better enable
epidemiology. As formal education is frequently them to communicate with and access
completed in young adulthood and is strongly appropriate health services; and
31
∏ Ill health in childhood could limit predictive of inequalities in morbidity or mortality,
educational attendance and/or attainment especially among employed men 124, 125. The model
and predispose a person to adult disease, has five categories based on a graded hierarchy of
generating a health selection influence on occupations ranked according to skill (I Professional,
health inequalities. II Intermediate, IIIa Skilled non-manual IIIb Skilled
manual, IV Partly skilled, V Unskilled). Importantly,
Finally, measuring the number of years of these occupational categories are not necessarily
education or levels of attainment may contain no reflective of class relations.
information about the quality of the educational
experience, which is likely to be important if Most studies use the current or longest held
conceptualizing the role of education in health occupation of a person to characterize their adult
outcomes specifically related to knowledge, socioeconomic position. However, with increasing
cognitive skills and analytical abilities; but it may interest in the role of socioeconomic position
be less important if education is simply used as a across the life course, some studies include
broad indicator of socioeconomic position. parental occupation as an indicator of childhood
socioeconomic position in conjunction with
5.5.3 Occupation individuals’ occupations at different stages in adult
life. Some of the more general mechanisms that
Occupation-based indicators of socioeconomic may explain the association between occupation
position are widely used. Kunst and Mackenbach and health-related outcomes are as follows:
emphasize that this measure is relevant, because it ∏ Occupation (parental or own adult) is
determines people’s place in the societal hierarchy strongly related to income and, therefore,
and not just because it indicates exposure to specific the association with health may be one
occupational risk, such as toxic compounds 111. of a direct relation between material
Galobardes et al. suggest that occupation can be resources—the monetary and other
seen as a proxy for representing Weber’s notion tangible rewards for work that determines
of socioeconomic position, as a reflection of a material living standards—and health.
person’s place in society related to their social ∏ Occupations reflect social standing and

standing, income and intellect 121. Occupation can may be related to health outcomes because
also identify working relations of domination and of certain privileges—such as easier access
subordination between employers and employees to better health care, access to education
or, less frequently, characterize people as exploiters and more salubrious residential facilities—
or exploited in class relations. that are afforded to those of higher
standing.
The main issue, then, is how to classify people with ∏ Occupation may reflect social networks,

a specific job according to their place in the social work based stress, control and autonomy,
hierarchy. The most usual approach consists of and, thereby, affect health outcomes
classifying people based on their position in the through psychosocial processes.
labour market into a number of discreet groups or ∏ Occupation may also reflect specific toxic

social classes. People can be assigned to social classes environmental or work task exposures,
by means of a set of detail rules that use information such as physical demands (e.g. transport
on such items as occupational title, skills required, driver or labourer).
income pay-off and leadership functions. For
example, Wright’s typology distinguishes among One of the most important limitations of
four basic class categories: wage laborers, petty occupational indicators is that they cannot
bourgeois (self-employed with no more than one be readily assigned to people who are not
employee; small employers with 2-9 employees currently employed. As a result, if used as the
and capitalist with 10 or more employees). Also, only source of information on socioeconomic
other classifications - called “social class” but more position, socioeconomic differentials may be
accurately termed “occupational class”- have been underestimated through the exclusion of retired
used in European public health surveillance and people, people whose work is inside the home
research. Among the best known and longest lived (mainly affecting women), disabled people
of these occupational class measures is the British (including those disabled by work-related illness
Registrar General’s social class schema, developed and injury), the unemployed, students, and people
in 1913. This schema has proven to be powerfully working in unpaid, informal, or illegal jobs 121.

32
A conceptual framework for action on the social determinants of health

Given the growing prevalence of insecure and French industrial sociologists called this “l’usure
precarious employment, knowing a person’s de travai”—the usury of work. At the most obvious
occupation is of limited value without further level, the manager sits in an office while the routine
information about the individual’s employment workers are exposed to all the dangers of heavy
history and the nature of the current employment loads, dusts, chemical hazards and the like 127.
relationship. Furthermore, socioeconomic
indicators based on occupational classification The task of class analysis is precisely to understand
may not adequately capture disparities in working not only how macro structures (e.g. class relations
and living conditions across divisions of race/ at the national level) constrain micro processes
ethnicity and gender 115. (e.g. interpersonal behavior), but also how
micro processes (e.g. interpersonal behavior)
5.5.4 Social Class can affect macro structures (e.g. via collective
action) 128. Social class is among the strongest
Social class is defined by relations of ownership known predictors of illness and health and yet
or control over productive resources (i.e. physical, is, paradoxically, a variable about which very
financial and organizational). Social class provides little research has been conducted. Muntaner
an explicit relational mechanism (property, and colleagues have observed that, while there
management) that explains how economic is substantial scholarship on the psychology of
inequalities are generated and how they may affect racism and gender, little research has been done
health. Social class has important consequences for on the effects of class ideology (i.e. classism).
the lives of individuals. The extent of an individual’s This asymmetry could reflect that in most
legal right and power to control productive assets wealthy democratic capitalist countries, income
determines an individual’s strategies and practices inequalities are perceived as legitimate while
devoted to acquire income and, as a result, gender and race inequalities are not 128.
determines the individual’s standard of living. Thus
the class position of “business owner” compels its 5.5.5 Gender
members to hire “workers” and extract labour
from them, while the “worker” class position “Gender” refers to those characteristics of
compels its members to find employment and women and men which are socially constructed,
perform labour. Most importantly, class is an whereas “sex” designates those characteristics
inherently relational concept. It is not defined that are biologically determined 129. Gender
according to an order or hierarchy, but according involves “culture-bound conventions, roles and
to relations of power and control. Although there behaviors” that shape relations between and
have been few empirical studies of social class among women and men and boys and girls. In
and health, the need to study social class has been many societies, gender constitutes a fundamental
noted by social epidemiologists 126. basis for discrimination, which can be defined as
the process by which members of a socially defined
Class, in contrast to stratification, indicates group are treated differently especially unfairly
the employment relations and conditions of because of their inclusion in that group 41. Socially
each occupation. The criteria used to allocate constructed models of masculinity can have
occupations into classes vary somewhat between deleterious health consequences for men and
the two major systems presently in widespread use: boys (e.g. when these models encourage violence
the Goldthorpe schema and the Wright schema. or alcohol abuse). However, women and girls bear
According to Wright, power and authority are the major burden of negative health effects from
“organizational assets” that allow some workers gender-based social hierarchies.
to benefit from the abilities and energies of other
workers. The hypothetical pathway linking class In many societies, girls and women suffer
(as opposed to prestige) to health is that some systematic discrimination in access to power,
members of a work organization are expending prestige and resources. Health effects of
less energy and effort and getting more (pay, discrimination can be immediate and brutal (e.g. in
promotions, job security, etc.) in return, while cases of female infanticide, or when women suffer
others are getting less for more effort. So the less genital mutilation, rape or gender-based domestic
powerful are at greater risk of running down violence). Gender divisions within society
their stocks of energy and ending up in some also affect health through less visible biosocial
kind of physical or psychological “health deficit”. processes, whereby girls’ and women’s lower social

33
status and lack of control over resources exposes social, not biological, category”. The term refers to
them to health risks. Disproportionately high social groups, often sharing cultural heritage and
levels of HIV infection among young women in ancestry, whose contours are forged by systems in
some sub-Saharan African countries are fueled by which “one group benefits from dominating other
patterns of sexual coercion, forced early marriage groups, and defines itself and others through this
and economic dependency among women and domination and the possession of selective and
girls 130. Widespread patterns of underfeeding arbitrary physical characteristics (for example,
girl children, relative to their male siblings, skin colour)” 42.
provide another example of how gender-based
discrimination undermines health. As Doyal In societies marked by racial discrimination and
argues, “A large part of the burden of preventable exclusion, people’s belonging to a marginalized
morbidity and mortality experienced by women racial/ethnic group affects every aspect of their
is related directly or indirectly to the patterning status, opportunities and trajectory throughout
of gender divisions. If this harm is to be avoided, the life-course. Health status and outcomes
there will need to be significant changes in related among oppressed racial/ethnic groups are often
aspects of social and economic organization. In significantly worse than those registered in more
particular, strategies will be required to deal with privileged groups or than population averages.
the damage done to women’s health by men, Thus, in the United States, life expectancy for
masculinities and male institution” 131. African-Americans is significantly lower than
for whites, while an African-American woman
Gender-based discrimination often includes is twice as likely as a white woman to give birth
limitations on girls’ and women’s ability to obtain to an underweight baby 134, 135. Indigenous groups
education and to gain access to respected and well- endure racial discrimination in many countries
remunerated forms of employment. These patterns and often have health indicators inferior to those
reinforce women’s social disadvantages and, in of non-indigenous populations. In Australia, the
consequence, their health risks. Gender norms average life expectancy of Aboriginal and Torres
and assumptions define differential employment Strait Islanders lags 20 years behind that of non-
conditions for women and men and fuel differential Aboriginal Australians. Perhaps as a result of the
exposures and health risks linked to work. Women compounded forms of discrimination suffered
generally work in different sectors than men and by members of minority and oppressed races/
occupy lower professional ranks. “Women are more ethnicities, the “biological expressions of racism”
likely to work in the informal sector, for example in are closely intertwined with the impact of other
domes¬tic work and street vending” 132. Broadly, determinants associated with disadvantaged social
gender disadvantage is manifested in women’s positions (low income, poor education, poor
often fragmented and economically uncertain housing, etc.).
work trajectories: domestic responsibilities disrupt
career paths, reducing lifetime earning capacity 5.5.7 Links and influence amid
and increasing the risks of poverty in adulthood sociopolitical context and structural
and old age 133. For these reasons, Doyal argues determinants
that “the removal of gender inequalities in access
to resources” would be one of the most important A close relationship exists between the
policy steps towards gender equity in health. sociopolitical context and what we term the
“Since it is now accepted that gender identities are structural determinants of health inequities.
essentially negotiated, policies are needed which The CSDH framework posits that structural
will enable people to shape their own identities determinants are those that generate or reinforce
and actions in healthier ways. These could include stratification in the society and that define
a range of educational strategies, as well as … individual socioeconomic position. In all cases,
employment policies and changes in the structure structural determinants present themselves in
of state benefits” 131. a specific political and historical context. It is
not possible to analyze the impact of structural
5.5.6 Race/ethnicity determinants on health inequities or to assess
policy and intervention options, if contextual
Constructions of racial or ethnic differences are aspects are not included. As we have noted, key
the basis of social divisions and discriminatory elements of the context include: governance
practices in many contexts. As Krieger observes, patterns; macroeconomic policies; social policies;
it is important to be clear that “race/ethnicity is a and public policies in other relevant sectors,
34
A conceptual framework for action on the social determinants of health

among other factors. Contextual aspects, including socioeconomic position.


education, employment and social protection Moving to the right, in the next column of the
policies, act as modifiers or buffers influencing diagram, we have situated the main aspects of
the effects of socioeconomic position on health social hierarchy, which define social structure and
outcomes and well-being among social groups. social class relationships within the society. These
At the same time, the context forms part of the features are given according to the distribution
“origin” and sustenance of a given distribution of of power, prestige and resources. The principal
power, prestige and access to material resources domain is social class / position within the social
in a society and thus, in the end, of the pattern structure, which is connected with the economic
of social stratification and social class relations base and access to resources. This factor is also
existing in that society. The positive significance linked with people’s degree of power, which is in
of this linkage is that it is possible to address the turn is again influenced by the political context
effects of the structural determinants of health (functioning democratic institutions or their
inequities through purposive action on contextual absence, corruption, etc.). The other key domain
features, particularly the policy dimension. in this area encompasses systems of prestige and
discrimination that exist in the society.
5.5.8. Diagram synthesizing the
major aspects of the framework Again moving to the right, in the next column, we
shown thus far have described the main aspects of socioeconomic
position. Studies and evaluations of equity
In this diagram we have summarized the main frequently use income, education and occupation
elements of the social and political context that as proxies for these domains (power, prestige and
model and directly influence the pattern of economic status). When we refer to the domains of
social stratification and social class existing in prestige and discrimination, we find them strongly
a country. We have included in the diagram, in related to gender, ethnicity and education. Social
the far left column, the main contextual aspects class also has a close connection to these different
that affect inequities in health, e.g. governance, domains, as previously indicated. As an inherently
macroeconomic policies, social policies, public relational variable, class is able to provide greater
policies in other relevant areas, culture and understanding of the mechanisms associated with
societal values, and epidemiological conditions. the social production of health inequities.
The context exerts an influence on health through

Figure 2. Structural determinants: the social determinants of health inequities

SOCIOECONOMIC
AND POLITICAL Social Hierarchy Socioeconomic
CONTEXT Social Structure/
Social Class Position
Governance

Class: has
Macroeconomic an economic Social Class
Policies base and access
Labour Market Gender
resources Ethnicity SOCIAL
Structure IMPACT ON
DETERMINANTS
OF HEALTH EQUITY IN
Power is
Social Policies HEALTH AND
related to a (INTERMEDIARY
Labour Market, Education WELL-BEING
political FACTORS)
Housing, Land
context
Occupation
Public Policies Prestige or
Health, Education honor in the
Social Protection Income
community

Culture and
Discrimination
Societal Values

STRUCTURAL DETERMINANTS
SOCIAL DETERMINANTS OF HEALTH INEQUITIES

35
Key messages of this section:
p The CSDH framework is distinguished from some others by its emphasis on the
socioeconomic and political context and the structural determinants of health
inequity.

p “Context” is broadly defined to include all social and political mechanisms


that generate, configure and maintain social hierarchies, including: the labour
market; the educational system political institutions and other cultural and
societal values.

p Among the contextual factors that most powerfully affect health are the welfare
state and its redistributive policies (or the absence of such policies).

p In the CSDH framework, the structural mechanisms are those that interplay
between context and socio-economic position: generating and reinforcing class
divisions that define individual socioeconomic position within hierarchies of
power, prestige and access to resources. Structural mechanisms are rooted in
the key institutions and policies of the socioeconomic and political context. The
most important structural stratifiers and the proxy indicators include:
• Income
• Education
• Occupation
• Social Class
• Gender
• Race/ethnicity.

p Together, context, structural mechanisms and the resultant socioeconomic


position of individuals are “structural determinants” and in effect it is these
determinants we refer to as the “social determinants of health inequities.” We
began this study by asking the question of where health inequities come from.
The answer to that question lies here. The structural mechanisms that shape
social hierarchies, according to these key stratifiers, are the root cause of
inequities in health.

Meanwhile, the patterns according to which Together, context, structural mechanisms and
people are assigned to socioeconomic positions socioeconomic position constitute the social
can turn back to influence the broader context (e.g. determinants of health inequities, whose effect is
by generating momentum for or against particular to give rise to an inequitable distribution of health,
social welfare policies, or affecting the level of well-being and disease across social groups.
participation in trade unions).

Proceeding again to the next column to the right 5.6 Third element of the
(blue rectangle), we see that it is socioeconomic framework: intermediary
position as assigned within the existing social determinants
hierarchy that determines differences in exposure
and vulnerability to intermediary health-affecting The structural determinants operate through a
factors, (what we call the ‘social determinants series of what we will term intermediary social
of health’ in the limited and specific sense), factors or social determinants of health. The social
depending on people’s positions in the hierarchy. determinants of health inequities are causally
antecedent to these intermediary determinants,
which are linked, on the other side, to a set of

36
A conceptual framework for action on the social determinants of health

individual-level influences, including health- risk of infection 136. In addition to household


related behaviors and physiological factors. The amenities, household conditions like the presence
intermediary factors flow from the configuration of damp and condensation, building materials,
of underlying social stratification and, in turn, rooms in the dwelling and overcrowding are
determine differences in exposure and vulnerability housing-related indicators of material resources.
to health-compromising conditions. At the These are used in both industrialized and non-
most proximal point in the models, genetic and industrialized countries 136, 137. Crowding is
biological processes are emphasized, mediating calculated as the number of persons living in
the health effects of social determinants 3. The the household per number of rooms available
main categories of intermediary determinants of in the house. Overcrowding can plausibly affect
health are: material circumstances; psychosocial health outcomes through a number of different
circumstances; behavioral and/or biological factors; mechanisms: overcrowded households are
and the health system itself as a social determinant. often households with few economic resources
We once again review these elements in turn. and there may also be a direct effect on health
through facilitation of the spread of infectious
5.6.1 Material circumstances diseases. Galobardes et al. add that recent efforts
to better understand the mechanisms underlying
This includes determinants linked to the physical socioeconomic inequalities in health have lead
environment, such as housing (relating to both to the development of some innovative area level
the dwelling itself and its location), consumption indicators that use aspects of housing 121. For
potential, i.e. the financial means to buy healthy example, a ‘‘broken windows’’ index measured
food, warm clothing, etc., and the physical working housing quality, abandoned cars, graffiti, trashand
and neighborhood environments. Depending on public school deterioration at the census block
their quality, these circumstances both provide level in the USA 137.
resources for health and contain health risks.
An explicit definition incorporating the causal
Differences in material living standards are relationship between work and health is given by
probably the most important intermediary the Spanish National Institute of Work, Health and
factor. The material standards of living are Safety: “The variables that define the making of any
probably directly significant for the health status given task, as well as the environment in which it
of marginalized groups; and also for the lower is carried out, determine the health of the workers
socioeconomic position, especially if we include in a threefold sense: physical, psychological and
environmental factors. Housing characteristics social” 102. There are clear social differences in
measure material aspects of socioeconomic physical, mental, chemical and ergonomic strains
circumstances 109. A number of aspects of housing in the workplace. The accumulation of negative
have direct impact on health: the structure of environmental factors throughout working life
dwellings; and internal conditions, such as damp, probably has a significant effect on variations in
cold and indoor contamination. Indirect housing the general health of the population, especially
effects related to housing tenure, including when people are exposed to such factors over a
wealth impacts and neighborhood effects, are long period of time. Main types of hazards at the
seen as increasingly important. Housing as a workplace include physical, chemical, ergonomic,
neglected site for public health action include biological and psychosocial risk factors. General
indoor and outdoor housing condition, as well conditions of work define, in many ways, peoples’
as, material and social aspects of housing, and experience of work. Minimum standards for
local neighborhoods have an impact on health of working conditions are defined in each country,
occupants. Galobardes et al. propose a number of but the large majority of workers, including many
household amenities including access to hot and of those whose conditions are most in need of
cold water in the house, having central heating improvement, are excluded from the scope of
and carpets, sole use of bathrooms and toilets, existing labour protection measures. In many
whether the toilet is inside or outside the home, countries, workers in cottage industries, the urban
and having a refrigerator, washing machine, or informal economy, agricultural workers (except
telephone 121. These household amenities are for plantations), small shops and local vendors,
markers of material circumstances and may domestic workers and home workers are outside
also be associated with specific mechanisms of the scope of protective legislation. Other workers
disease. For example, lack of running water and a are deprived of effective protection because of
household toilet may be associated with increased weaknesses in labour law enforcement. This is
37
particularly true for workers in small enterprises, between the social strata. Social interaction is thus
which account for over 90 per cent of enterprises characterized by less solidarity and community
in many countries, with a high proportion of spirit 138. The people who lose most are those
women workers. at the bottom of the income hierarchy, who are
particularly affected by psychosocial stress linked
5.6.2 Social-environmental or to social exclusion, lack of self-respect and more
psychosocial circumstances or less concealed contempt from the people
around them. Secondly, there are significant social
This includes psychosocial stressors (for example, differences in the prevalence of episodes of stress
negative life events and job strain), stressful living occurrence of short-term and long-term episodes
circumstances (e.g. high debt) and (lack of) social of mental stress, linked to uncertainty about the
support, coping styles, etc. Different social groups financial situation, the labor market and social
are exposed in different degrees to experiences and relations. The same applies to the probability
life situations that are perceived as threatening, of experiencing violence or threats of violence.
frightening and difficult for coping in the everyday. Disadvantaged people have experienced far more
This partly explains the long-term pattern of social insecurity, uncertainty and stressful events in
inequalities in health. their life course, and this affects social inequalities
in health. This is illustrated in Table 2 published
Stress may be a causal factor and a trigger that in the Norwegian Action Plan to Reduce Social
directs many forms of illness; and detrimental, Inequalities in Health 2005-06 139.
long-term stress may also be part of the causal
complex behind many somatic illnesses. A person’s Some studies refer to the association between
socioeconomic position may itself be a source socio-economical status and health locus
of long-term stress, and it will also affect the control. This concept refers to the way people
opportunities to deal with stressful and difficult perceive the events related to their health — as
situations. However, there are also other, more controllable (internal control) or as controlled by
indirect explanations of the pathway from stress others (external control). People with education
to social inequalities in health. Firstly, there is an below university level more frequently identified
on-going international debate on what is often an external locus of control. Other important
called Wilkinson’s “income inequality and social challenges arise from increased incidence
cohesion” model. The model states that, in rich and prevalence of precarious and informal
societies, the size of differences in income is more employments; consequently, changes in the labor
important from a health point of view than the market raise many issues and challenges for health
size of the average income. Wilkinson’s hypothesis care providers, organizational psychologists,
is that the greater the income disparities are personnel and senior managers, employers and
in a society, the greater becomes the distance trade union representatives, and workers and their

Table 2. Social inequalities affecting disadvantaged people

Social Status:1
Percentages who have experienced in their adult life: Low: High:
- serveral episodes of 3+ months of unemployment 11% 1%
- lost their job several times (involuntarily) 7% 2%
- received social security benefits 11% 2%
- had a serious accident 21% 6%
- been unemployed at the age of 55 29% 7%
- been unmarried/had no cohabitant at the age of 55 26% 14%
- had low income at the age of 53 20% 2%
1
Low status = the third with the lowest occupational prestige, high status = the third with the highest occupational prestige.

Source: Reproduced with permission from the Norwegian Action Plan to Reduce Social Inequalities in Health 2005-2006

38
A conceptual framework for action on the social determinants of health

families. Job insecurity and non-employment are was related to SEP. Significant employment grade
also matters of concern to the wider community. differences in smoking were found in the Whitehall
II study, which examined a new cohort of 10,314
5.6.3 Behavioral and biological subjects from the British Civil Service beginning in
factors. 1985 15, 143. Moving from the lowest to the highest
employment grades, the prevalence of current
This includes smoking, diet, alcohol consumption smoking among men was 33.6%, 21.9%, 18.4%,
and lack of physical exercise, which again can 13.0%, 10.2% and 8.3%, respectively. For women,
be either health protecting and enhancing (like the comparable figures were 27.5%, 22.7%, 20.3%,
exercise) or health damaging (cigarette smoking 15.2%, 11.6% and 18.3%, respectively. Social class
and obesity); in between biological factors we differences in smoking are likely to continue,
are including genetics factors, as well as from the because rates of smoking initiation are inversely
perspective of social determinants of health, age related to SEP and because rates of cessation are
and sex distribution. positively related to SEP.

Social inequalities in health have also been Lifestyle factors are relatively accessible for
associated with social differences in lifestyle or research, so this is one of the causal areas we
behaviors. Such differences are found in nutrition, know a good deal about. Although descriptions
physical activity, and tobacco and alcohol of the correlation of lifestyle factors with social
consumption. This indicates that differences in status are relatively detailed and well-founded, this
lifestyle could partially explain social inequalities should not be taken to indicate that these factors
in health, but researchers do not agree on are the most important causes of social inequalities
their importance. Some regard differences in health. Other, more fundamental, factors may
in lifestyle as a sufficient explanation without cause variations in both lifestyle and health. Some
further elaboration, while others regard them surveys indicate that differences in lifestyle can only
as contributory factors that in turn result from explain a small proportion of social inequalities in
more fundamental causes. For example, Margolis health 14, 142. For instance, material factors may act
et al. found that the prevalence of both acute and as a source of psychosocial stress and psychosocial
persistent respiratory symptoms in infants showed stress may influence health-related behaviors. Each
dose response relationships with SEP. When risk of them can influence health through specific
factors such as crowding and exposure to smoking biological factors. A diet rich in saturated fat, for
in the household were adjusted for this condition, example, will lead to atherosclerosis, which will
relative risk associated with SEP was reduced but increase the risk of a myocardial infarction. Stress
still remained significant. The data further suggest will activate hormonal systems that may increase
that risk factors operated differently for different blood pressure and reduce the immune response.
SEP levels; being in day care was associated with Adoption of health-threatening behaviors is
somewhat reduced incidence in lower SEP families a response to material deprivation and stress.
but with increased incidence among infants from Environments determine whether individuals
high SEP families 140. Health risk behaviors such take up tobacco, use alcohol, have poor diets and
as cigarette smoking, physical inactivity, poor diet engage in physical activity. Tobacco and excessive
and substance abuse are closely tied to both SEP alcohol use, and carbohydrate-dense diets, are
and health outcomes. Despite the close ties, the means of coping with difficult circumstances 100.
association of SEP and health is reduced, but not
eliminated, when these behaviors are statistically 5.6.4 The health system as a social
controlled 141, 142, 143. determinant of health.
Cigarette smoking is strongly linked to SEP, As discussed, various models that have tried
including education, income and employment to explain the functioning and impact of SDH
status, and it is significantly associated with have not made sufficiently explicit the role of the
morbidity and mortality, particularly from health system as a social determinant. The role of
cardiovascular disease and cancer 15, 144, 145, 146. A the health system becomes particularly relevant
linear gradient between education and smoking through the issue of access, which incorporates
prevalence was also shown in a community sample differences in exposure and vulnerability. On
of middle-aged women. Additionally, among the other hand, differences in access to health
current smokers the number of cigarettes smoked care certainly do not fully account for the social

39
patterning of health outcomes. Adler et al. for disabilities, in particular, is often overlooked as
instance, have considered the role of access to a potential contributor to the reduction of health
care in explaining the SEP-health gradient and inequalities); (4) strengthening policies that
concluded that access alone could not explain the reproduce contextual factors such as social capital
gradient 146. that might modify the health effects of poverty;
and (5) protecting against social and economic
In a comprehensive model, the health system consequences of ill health though health insurance
itself should be viewed as an intermediary sickness benefits and labor market policies 92.
determinant. This is closely related to models for
the organization of personal and non-personal Even if there were some dispute as to whether the
health service delivery. The health system can health system can itself be considered an indirect
directly address differences in exposure and determinant of health inequities, it is clear that the
vulnerability not only by improving equitable system influences how people move among the
access to care, but also in the promotion of social strata. Benzeval, Judge and Whitehead argue
intersectoral action to improve health status. that the health system has three obligations in
Examples would include food supplementation confronting inequity: (1) to ensure that resources
through the health system and transport policies are distributed between areas in proportion to
and intervention for tackling geographic barrier their relative needs; (2) to respond appropriately
to access health care. A further aspect of great to the health care needs of different social groups;
importance is the role the health system plays in and (3) to take the lead in encouraging a wider
mediating the differential consequences of illness and more strategic approach to developing healthy
in people’s lives. The health system is capable of public policies at both the national and local level,
ensuring that health problems do not lead to a to promote equity in health and social justice 147.
further deterioration of people’s social status and On this point the UK Department of Health has
of facilitating sick people’s social reintegration. argued that the health system should play a more
Examples include programmes for the chronically active role in reducing health inequalities, not
ill to support their reinsertion in the workforce, as only by providing equitable access to health
well as appropriate models of health financing that care services but also by putting in place public
can prevent people from being forced into (deeper) health programmes and by involving other policy
poverty by the costs of medical care. Another bodies to improve the health of disadvantaged
important component to analyze relates to the way communities 147.
in which the health system contributes to social
participation and the empowerment of the people, 5.6.5. Summarizing the section on
if in fact this is defined as one of the main axes intermediary determinants
for the development of pro-equity health policy.
In this context, we can reflect on the hierarchical Socioeconomic-political context directly affects
and authoritarian structure that predominates in intermediary factors, e.g. through kind, magnitude
the organization of most health systems. Within and availability. But for the population, the
health systems, people enjoy little participatory more important path of influence is through
space through which to take part in monitoring, socioeconomic position. Socioeconomic
evaluation and decision-making about system position influences health through more specific,
priorities and the investment of resources. intermediary determinants. Those intermediary
factors include: material circumstances, such as
Diderichsen suggests that services through which neighborhood, working and housing conditions;
the health sector deals with inequalities in health psychosocial circumstances, and also behavioral
can be of five different types: (1) reducing the and biological factors. The model assumes that
inequality level among the poor with respect to the members of lower socioeconomic groups live in
causal factors that mediate the effects of poverty less favorable material circumstances than higher
on health in such areas as nutrition, sanitation, socioeconomic groups, and that people closer to
housing and working conditions; (2) reinforcing the bottom of the social scale more frequently
factors that might reduce susceptibility to health engage in health-damaging behaviors and less
effects from inequitable exposures, using various frequently in heath-promoting behaviors than
means including vaccination, empowerment and do the more privileged. The unequal distribution
social support; (3) treating and rehabilitating the of these intermediary factors (associated with
health problems that constitute the socioeconomic differences in exposure and vulnerability to
gap of burden of disease (the rehabilitation of health-compromising conditions, as well as
40
A conceptual framework for action on the social determinants of health

Figure 3. Intermediary determinants of health

SOCIO- Differential social,


ECONOMIC economic and health
CONTEXT consequences

Unequal
Socioeconomic distribution
Position of these
Social Structure/ factors
Social Class Material Circumstances
(Living and Working IMPACT ON
Conditions, Food EQUITY IN
Differences in HEALTH AND
exposure and Availability, etc. )
WELL-BEING
vulnerability to Behaviors and
health- Biological Factors
compromising
conditions Psychosocial Factors

Health System

POLITICAL INTERMEDIARY DETERMINANTS


CONTEXT OF HEALTH

with differential consequences of ill-health) and resource distribution approaches. The


constitutes the primary mechanism through communitarian approach defines social capital
which socioeconomic position generates health as a psychosocial mechanism, corresponding to
inequities. The model includes the health system a neo-Durkheimian perspective on the relation
as a social determinant of health and illustrates between individual health and society. This
the capacity of the heath sector to influence the school includes influential authors such as Robert
process in three ways, by acting upon: differences Putnam and Richard Wilkinson. Putnam defines
in exposures, differences in vulnerability and social capital as “features of social organization,
differences in the consequences of illness for such as networks, norms and social trust, that
people’s health and their social and economic facilitate coordination and cooperation for mutual
circumstances. benefit” 152. Social capital is looked upon as an
extension of social relationships and the norms
5.6.6 A crosscutting determinant: of reciprocity 154, influencing health by way of the
social cohesion / social capital 149, 150 social support mechanisms that these relationships
provide to those who participate on them. The
The concepts of social cohesion and “social network approach considers social capital in terms
capital” occupy an unusual (and contested) of resources that flow and emerge through social
place in understandings of SDH. Over the past networks. It begins with a systemic relational
decade, these concepts have been among the perspective; in other words, an ecological vision
most widely discussed in the social sciences is taken that sees beyond individual resources and
and social epidemiology. Influential researchers additive characteristics. This involves an analysis of
have proclaimed social capital a key factor in the influence of social structure, power hierarchies
shaping population health 151, 152, 153, 154. However, and access to resources on population health 155.
controversies surround the definition and This approach implies that decisions that groups or
importance of social capital. individuals make, in relation to their lifestyle and
In the most influential recent discussions, three behavioral habits, cannot be considered outside the
broad approaches to the characterization and social context where such choices take place. Two
analysis of social capital can be distinguished: of the most outstanding conceptualisations in this
communitarian approaches, network approaches regard have been elaborated by James Coleman
41
and Pierre Bourdieu, whose work has focused of social capital has not infrequently been deployed
primarily on notions of social cohesion. Finally, as part of a broader discourse promoting reduced
the resource distribution approach, adopting a state responsibility for health, linked to an emphasis
materialistic perspective, suggests that there is a on individual and community characteristics,
danger in promoting social capital as a substitute values and lifestyles as primary shapers of health
for structural change when facing health inequity. outcomes. Logically, if communities can take care
Some representatives of this group openly criticize of their own health problems by generating “social
psychosocial approaches that have suggested capital”, then government can be increasingly
social capital and cohesion as the most important discharged of responsibility for addressing health
mediators of the association between income and and health care issues, much less taking steps
health inequality 156. The resource distribution to tackle underlying social inequities. Navarro
approach insists that psychosocial aspects affecting suggests that foundational work on social capital,
population health are a consequence of material including Putnam’s, “reproduced the classical …
life conditions 157, 158. dichotomy between civil and political society, in
which the growth of one (civil society) requires
Recent work by Szreter and Woolcock has the contraction of the other (political society—
enriched the debates around social capital and the state)”. From this perspective, the adoption
its health impacts 155. These authors distinguish of social capital as a key for understanding and
between bonding, bridging and linking social promoting population health is part of a broader,
capital. Bonding social capital refers to the trust radically depoliticizing trend 160.
and cooperative relationships between members of
a network that are similar in terms of their social On the other hand, however, it can be argued that
identity. Bridging social capital, on the other hand, the recognition of linking social capital through
refers to respectful relationships and mutuality Szreter’s and Woolcock’s work has contributed
between individuals and groups that are aware to a higher consideration of the dimension of
that they do not possess the same characteristics power and of structural aspects in tackling social
in socio-demographic terms. Finally, linking social capital as a social determinant of health. This may
capital corresponds with the norms of respect help move discussions of social capital resolutely
and trust relationships between individuals, beyond the level of informal relationships and
groups, networks and institutions that interact social support. The idea of linking social capital
from different positions along explicit gradients has also been fundamental as a new element
of institutionalised power 153. when discussing the role that the state occupies
or should occupy in the development of strategies
Some scholars have critiqued what they see as that favour equity. Linking social capital offers
the faddish, ideologically driven adoption of the the opportunity to analyse how relationships
term “social capital”. Muntaner, for example, has that are established with institutions in general,
suggested that the term serves primarily as a and with the state in particular, affect people’s
“comforting metaphor” for those in public health quality of life. Such discussions highlight the
who wish to maintain that “capitalism … and social role of political institutions and public policy in
cohesion/social integration are compatible”. Beyond shaping opportunities for civic involvement and
such ideological reassurance, Muntaner argues, democratic behaviour 161, 162. The CSDH adopts the
the vocabulary of social capital provides few if any position that the state possesses a fundamental role
fresh insights, and may in fact provoke confusion. in social protection, ensuring that public services
Those innovations that have been achieved by are provided with equity and effectiveness. The
researchers investigating social capital could just as welfare state is characterized as systematic defense
well “have been carried out under the label of ‘social against social insecurity, this being understood as
integration’ or ‘social cohesion’. Indeed, it would be individuals’, groups’ or communities’ vulnerability
more adequate to use terms such as ‘cohesion’ and to diverse environmental threats 163. In this context,
‘integration’ to avoid the confusion and implicit while remaining alert to ways in which notions of
endorsement of [a specific] economic system that ‘social capital’ or community may be deployed to
the term [social capital] conveys” 159. excuse the state from responsibility for the well-
We share with Muntaner the concern that the being of the population 166, 165, 166, we can also look
current interest in “social capital” may further for aspects of these concepts that shed fresh light
encourage depoliticized approaches to population on key state functions.
health and SDH. Indeed, it is clear that the concept

42
A conceptual framework for action on the social determinants of health

The notion of linking social capital speaks to are found for rates of mortality and morbidity
the idea that one of the central points of from almost every disease and condition 167.
health politics should be the configuration of SEP is also linked to prevalence and course of
cooperative relationships between citizens and disease and self-rated health. Socioeconomic
institutions. In this sense, the state should assume health inequalities are evident in specific causes of
the responsibility of developing more flexible disease, disability and premature death, including
systems that facilitate access and develop real lung cancer, coronary heart disease, accidents and
participation by citizens. Here, a fundamental suicide. Low birth weight provides an additional
aspect is the strengthening of local or regional important example. This is a sensitive measure of
governments so that they can constitute concrete child health and a major risk factor for impaired
spaces of participation 162. The development of development through childhood, including
social capital, understood in these terms, is based intellectual development 168. There are marked
on citizen participation. True participation implies differences in national rates of low birth weight,
a (re)distribution of empowerment, that is to with higher rates in the US and UK and lower
say, a redistribution of the power that allows the rates in Nordic countries like Sweden, Norway
community to possess a high level of influence in and the Netherlands. These rates vary in line with
decision-making and the development of policies the proportion of the child population living in
affecting its well-being and quality of life. poverty (in households with incomes below 50%
The competing definitions and approaches of average income): at their lowest in low-poverty
suggest that “social capital” cannot be regarded countries like Sweden and Norway, and at their
as a uniform concept. Debate surrounds whether highest in relatively high-poverty countries like
it should be as seen a property of individuals, the UK and US 169.
groups, networks, or communities, and thus where
it should be located with respect to other features 5.7.1 Impact along the gradient
of the social order. It is unquestionably difficult
to situate social capital definitively as either a There is evidence that the association of SEP and
structural or an intermediary determinant of health occurs at every level of the social hierarchy,
health, under the categories we have developed not simply below the threshold of poverty. Not
here. It may be most appropriate to think of this only do those in poverty have poorer health than
component as “cross-cutting” the structural and those in more favored circumstances, but those
intermediary dimensions, with features that link at the highest level enjoy better health than do
it to both. those just below 142. The effects of severe poverty
on health may seem obvious through the impact
of poor nutrition, crowded and unsanitary
5.7 Impact on equity in health living conditions and inadequate medical care.
and well-being Identifying factors that can account for the link to
health all across the SEP hierarchy may shed light
This section summarizes some of the outcomes that on new mechanisms that have heretofore been
emerge at the end of the social “production chain” ignored because of a focus on the more readily
of health inequities depicted in the framework. apparent correlates of poverty. The most notable of
At this stage (far right side of the framework the studies demonstrating the SEP-health gradient
diagrams), we find the measurable impacts of is the Whitehall study of mortality (Marmot et al),
social factors upon comparative health status and which covered British civil servants over a period
outcomes among different population groups, of 10 years. Similar findings emerge from census
e.g. health equity. According to the analysis we data in the United Kingdom (Susser, Watson and
have developed, the structural factors associated Hopper) 170, 171. Surprisingly, we know rather little
with the key components of socioeconomic about how SEP operates to influence biological
position (SEP) are at the root of health inequities functions that determine health status. Part of
measured at the population level. This relationship the problem may be the way in which SEP is
is confirmed by a substantial body of evidence. conceptualized and analyzed. SEP has been almost
universally relegated to the status of a control
Socioeconomic health differences are captured in variable and has not been systematically studied
general measures of health, like life expectancy, all- as an important etiologic factor in its own right.
cause mortality and self-rated health 100. Differences It is usually treated as a main effect, operating
correlated with people’s socioeconomic position independently of other variables to predict health.

43
5.7.2 Life course perspective on the mental retardation were at higher risk of sensory
impact impairments and emotional difficulties; they were
also more likely to be in contact with psychiatric
Children born into poorer circumstances are at services. In adulthood, mild mental retardation
greater risk of the forms of developmental delay was associated with limiting long-term illness
associated with intellectual disability, including and disability, and, particularly for women, with
speech impairments, cognitive difficulties depressed mood.
and behavioral problems 172, 173. Some other
conditions, like stroke and stomach cancer, One might assume such effects to be inevitable. But
appear to depend considerably on childhood they are in part due to discriminatory practices,
circumstances, while for others, including deaths in part also to failures to adapt educational
from lung cancer and accidents/violence, adult institutions and working life to special needs. To
circumstances play the more important role. the extent that this is the case, social selection is
In another group are health outcomes where neither necessary, nor inevitable, nor fair. This
it is cumulative exposure that appears to be phenomenon particularly affects persons with
important. A number of studies suggest that disabilities, persons from immigrant backgrounds
this is the case for coronary heart disease and and, to a certain extent, women 3.
respiratory disease, for example 174.
5.7.4 Impact on the socioeconomic
5.7.3 Selection processes and health- and political context
related mobility
From a population standpoint, we observe that the
As discussed above, people with weaker health magnitude of certain diseases can translate into
resources, allegedly, have a tendency to end up direct effects on features of the socioeconomic
or remain low on the socioeconomic ladder. and political context, through high prevalence
According to some analysts, the status of research rates and levels of mortality and morbidity. The
on selection processes and health-related mobility HIV/AIDS pandemic in sub-Saharan Africa can
within the socioeconomic structure can be be seen in this light, with its associated plunge
summarized in three points: (1) variations in health in life expectancy and stresses on agricultural
in youth have some significance for educational productivity, economic growth, and sectoral
paths and for the kind of job a person has at the capacities in areas such as health and education.
beginning of his or her working career; (2) for The magnitude of the impact of epidemics and
those who are already established in working life, emergencies will depend on the historical, political
variations in health have little significance for the and social contexts in which they occur, as well as
overall progress of a person’s career; and (3) people on the demographic composition of the societies
who develop serious health problems in adult life affected. These are aspects that must be considered
are often excluded from working life, and often when analyzing welfare state structures, in
long before the ordinary retirement age. particular models of health system organization
that might respond to such challenges.
Graham argues that people with intellectual
disabilities are more exposed to the social
conditions associated with poor health and have 5.8 Summary of the
poorer health than the wider population 175. She mechanisms and pathways
adds that, for example, those with mild disabilities represented in the framework
are more likely than non-disabled people to have
employment histories punctured by repeated In this section, we summarize key features of the
periods of unemployment. Women with mild CSDH framework (or model) and begin to sketch
intellectual disabilities are further disadvantaged some of the considerations for policy-making to
by high rates of teenage motherhood 175. In both which the model gives rise. The next chapter will
childhood and adulthood, co-morbidity – the explore policy implications and entry points in
experience of multiple illnesses and functional greater depth.
limitations – disproportionately affects people
with intellectual disabilities. For example, in the
British 1958 birth cohort study, children with mild

44
A conceptual framework for action on the social determinants of health

Key messages of this section:


p The underlying social determinants of health inequities operate through a set of intermediary determinants of
health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants”
underscores the causal priority of the structural factors.

p The main categories of intermediary determinants of health are: material circumstances; psychosocial
circumstances; behavioral and/or biological factors; and the health system itself as a social determinant

p Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the
financial means to buy healthy food, warm clothing, etc.), and the physical work environment.

p Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and
social support and coping styles (or the lack thereof).

p Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol
consumption, which are distributed differently among different social groups. Biological factors also include
genetic factors.

p The CSDH framework departs from many previous models by conceptualizing the health system itself as a social
determinant of health. The role of the health system becomes particularly relevant through the issue of access,
which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the
health sector. The health system plays an important role in mediating the differential consequences of illness in
people’s lives.

p The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of
SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both.

p Focus on social capital risks reinforcing depoliticized approaches to public health and SDH; however, certain
interpretations, including Szreter’s and Woolcock’s notion of “linking social capital”, have spurred new thinking on
the role of the state in promoting equity.

p A key task for health politics is nurturing cooperative relationships between citizens and institutions. The state
should take responsibility for developing flexible systems that facilitate access and participation on the part of the
citizens.

p The social, economic and other consequences of specific forms of illness and injury vary significantly, depending
on the social position of the person who falls sick.

p Illness and injury have an indirect impact in the socioeconomic position of individuals. From the population
perspective, the magnitude of certain illnesses can directly impact key contextual factors (e.g. the performance of
institutions).

p Looking at the ultimate impact of social processes on health equity, we find that the structural factors associated
with the key components of socioeconomic position (SEP) are at the root of health inequities at the population
level. This relationship is confirmed by a substantial body of evidence.

p Differences correlated with people’s socioeconomic position are found for rates of mortality and morbidity from
almost every disease and condition. SEP is also linked to prevalence and course of disease and self-rated health.

p The magnitude of certain diseases can directly affect features of the socioeconomic and political context, through
high prevalence rates and levels of mortality and morbidity. The HIV/AIDS pandemic in sub-Saharan Africa
provides one example, with its impact on agriculture, economic growth and sectoral capacities in areas such as
health and education.

45
Figure 4 illustrates the main processes captured in but that this effect is not direct. Socioeconomic
the CSDH framework, as we have explored them, position influences health through more specific,
step by step, in the present chapter. The diagram intermediary determinants.
also highlights the reverse or feedback effects Based on their respective social status, individuals
through which illness may affect individual social experience differences in exposure and vulnerability
position, and widely prevalent diseases may affect to health-compromising conditions. Socioeconomic
key social, economic and political institutions. position directly affects the level or frequencies of
Reading the diagram from left to right, we see exposure and the level of vulnerability, in connection
the social (socioeconomic) and political context, with intermediary factors. Also, differences in
which gives rise to a set of unequal socioeconomic exposure can generate more or less vulnerability in
positions or social classes. (Phenomena related to the population after exposure.
socioeconomic position can also influence aspects
of the context, as suggested by the arrows pointing Once again, a distinctive element of this model
back to the left.) Groups are stratified according is its explicit incorporation of the health system.
to the economic status, power and prestige they Socioeconomic inequalities in health can, in fact, be
enjoy, for which we use income levels, education, partly explained by the “feedback” effect of health
occupation status, gender, race/ethnicity and other on socioeconomic position, e.g. when someone
factors as proxy indicators. This column of the experiences a drop in income because of a work-
diagram (Social Hierarchy) locates the underlying induced disability or the medical costs associated
mechanisms of social stratification and the creation with major illness. Persons who are in poor health
of social inequities. less frequently move up and more frequently move
down the social ladder than healthy persons. This
Moving to the right, we observe how the resultant implies that the health system itself can be viewed
socioeconomic positions then translate into as a social determinant of health. This is in addition
specific determinants of individual health status to the health sector’s key role in promoting and
reflecting the individual’s social location within the coordinating SDH policy, as regards interventions
stratified system. The model shows that a person’s to alter differential exposures and differential
socioeconomic position affects his/her health, vulnerability through action on intermediary

Figure 4. Summary of the mechanisms and pathways represented in the framework

Differential social,
economic and health
SOCIOECONOMIC consequences
POLITICAL
CONTEXT
Social Hierarchy
Social Structure/
Governance Social Class

Macroeconomic Class: has


an economic Differences in IMPACT ON
Policies
base and access Exposure to EQUITY IN
resources intermediary HEALTH AND
Social Policies factors
Labour Market, WELL-BEING
Housing, Land Power is
related to a
Public Policies political context
Health, Education
Social Protection Differences in
Prestige or Health
Vulnerability to
honor in the System
health-
community compromising
Culture and
conditions
Societal Values
Discrimination

STRUCTURAL DETERMINANTS INTERMEDIARY DETERMINANTS


SOCIAL DETERMINANTS SOCIAL DETERMINANTS
OF HEALTH INEQUITIES OF HEALTH

46
A conceptual framework for action on the social determinants of health

factors (material circumstances, psychosocial in determinants are not factored into the models,
factors and behavioral/biological factors). It may their central role in driving inequalities in health
be noted, in addition, that some specific diseases may not be recognized. They are designed to
can impact people’s socioeconomic position, not capture schematically the distinction between health
only by undermining their physical capacities, but determinants and health inequality determinants,
also through associated stigma and discrimination which can be obscured in the translation of research
(e.g. in the case of HIV/AIDS). Because of their into policy. Evidence points to the importance of
magnitude, certain diseases, such as HIV/AIDS representing the concept of social determinants to
and malaria, can also impact key contextual policymakers in ways that clarify the distinction
components directly, e.g. the labour market and between the social causes of health and the factors
governance institutions. The whole set of “feedback” determining their distribution between more and
mechanisms just described is brought together less advantaged groups. Our CSDH framework
under the heading of “differential social, economic attempts to fulfill this objective. Indeed, this is one
and health consequences”. We have included the of its most important intended functions.
impact of social position on these mechanisms,
indicating that path with an arrow. Graham argues that what is obscured in many
previous treatments of these topics:
We have repeatedly referred to Hilary Graham’s
warning about the tendency to conflate the social
determinants of health and the social processes that
shape these determinants’ unequal distribution,
by lumping the two phenomena together under a
single label. Maintaining the distinction is more “is that tackling the determinants of
than a matter of precision in language. As Graham health inequalities is about tackling
argues, blurring these concepts may lead to seriously the unequal distribution of health
misguided policy choices. “There are drawbacks
determinants”175.
to applying health-determinant models to health
inequalities.” To do so may “blur the distinction
between the social factors that influence health and
the social processes that determine their unequal Focusing on the unequal distribution of
distribution. The blurring of this distinction can feed determinants is important for thinking about
the policy assumption that health inequalities can be policy. This is because policies that have achieved
diminished by policies that focus only on the social overall improvements in key determinants such
determinants of health. Trends in older industrial as living standards and smoking have not reduced
societies over the last 30 years caution against inequalities in these major influences on health.
assuming that tackling ‘the layers of influence’ When health equity is the goal, the priority of
on individual and population health will reduce a determinants-oriented strategy is to reduce
health inequalities. This period has seen significant inequalities in the major influences on people’s
improvements in health determinants (e.g. rising health. Tackling inequalities in social position
living standards and declining smoking rates) is likely to be at the heart of such a strategy. For,
and parallel improvements in people’s health (e.g. according to Graham, social position is the pivotal
higher life expectancy). But these improvements point in the causal chain linking broad (“wider”)
have broken neither the link between social determinants to the risk factors that directly
disadvantage and premature death nor the wider damage people’s health.
link between socioeconomic position and health. As
this suggests, those social and economic policies that Graham emphasizes that policy objectives will be
have been associated with positive trends in health- defined quite differently, depending on whether
determining social factors have also been associated our aim is to address determinants of health or
with persistent inequalities in the distribution of determinants of health inequities:
these social influences.” 3, 175 ∏ Objectives for health determinants are

likely to focus on reducing overall exposure


Many existing models of the social determinants to health-damaging factors along the causal
of health may need to be modified in order to pathway. These objectives are being taken
help the policy community understand the social forward by a range of current national
causes of health inequalities. Because inequalities and local targets: for example, to raise

47
educational standards and living standards 5.9 Final form of the CSDH
(important constituents of socioeconomic conceptual framework
position) and to reduce rates of smoking (a
major intermediary risk factor). The diagram below brings together the key
∏ Objectives for health inequity determinants elements of the account developed in successive
are likely to focus on leveling up the stages throughout this chapter. This image seeks
distribution of major health determinants. to summarize visually the main lessons of the
How these objectives are framed will preceding analysis and to organize in a single
depend on the health inequities goals that comprehensive framework the major categories
are being pursued. For example, if the goal of determinants and the processes and pathways
is to narrow the health gap, the key policies that generate health inequities.
will be those which bring standards of
living and diet, housing and local services The framework makes visible the concepts and
in the poorest groups closer to those categories discussed in this paper. It can also serve
enjoyed by the majority of the population. to situate the specific social determinants on which
If the health inequities goal is to reduce the the Commission has chosen to focus its efforts,
wider socioeconomic gradient in health, and it can provide a basis for understanding how
then the policy objective will be to lift these choices were made (balance of structural and
the level of health determinants across intermediary determinants, etc.).
society towards the levels in the highest
socioeconomic group.

Figure 5. Final form of the CSDH conceptual framework

SOCIOECONOMIC
AND POLITICAL
CONTEXT

Governance
Socioeconomic
Material Circumstances
Macroeconomic Position
Policies (Living and Working,
Conditions, Food IMPACT ON
Availability, etc. ) EQUITY IN
Social Policies Social Class HEALTH
Labour Market, Gender
Housing, Land Behaviors and AND
Ethnicity (racism) Biological Factors WELL-BEING

Public Policies Psychosocial Factors


Education, Health, Education
Social Protection Social Cohesion &
Occupation Social Capital
Culture and
Societal Values Income

Health System

STUCTURAL DETERMINANTS
SOCIAL DETERMINANTS OF INTERMEDIARY DETERMINANTS
HEALTH INEQUITIES SOCIAL DETERMINANTS
OF HEALTH

48
A conceptual framework for action on the social determinants of health

Key messages of this section:


p This section recapitulates key elements of the CSDH conceptual framework and
begins to explore implications for policy.

p The framework shows how social, economic and political mechanisms give
rise to a set of socioeconomic positions, whereby populations are stratified
according to income, education, occupation, gender, race/ethnicity and other
factors; these socioeconomic positions in turn shape specific determinants
of health status (intermediary determinants) reflective of people’s place
within social hierarchies; based on their respective social status, individuals
experience differences in exposure and vulnerability to health-compromising
conditions.

p Illness can “feed back” on a given individual’s social position, e.g. by


compromising employment opportunities and reducing income; certain epidemic
diseases can similarly “feed back” to affect the functioning of social, economic
and political institutions.

p Conflating the social determinants of health and the social processes that shape
these determinants’ unequal distribution can seriously mislead policy; over
recent decades, social and economic policies that have been associated with
positive aggregate trends in health-determining social factors (e.g. income and
educational attainment) have also been associated with persistent inequalities
in the distribution of these factors across population groups.

p Policy objectives will be defined quite differently, depending on whether the


aim is to address determinants of health or determinants of health inequities.

p Thus, Graham argues for the importance of representing the concept of social
determinants to policy-makers in ways that clarify the distinction between the
social causes of health and the factors determining the distribution of these
causes between more and less advantaged groups. The CSDH framework
attempts to fulfill this objective.

49
6 Policies and interventions

I
n this section, we draw upon the conceptual significantly in their underlying values and
framework elaborated above to derive lessons implications for programming. Each offers specific
for policy action on SDH. First, we consider advantages and raises distinctive problems.
the issue of conceptualizing health inequities
and their distribution across the population in Programmes to improve health among low SEP
terms of “gaps” or of a continuous social gradient populations have the advantage of targeting a
in health. We then present two policy analysis clearly defined, fairly small segment of the
frameworks informed by the work of Stronks et al. population and of allowing for relative ease in
and Diderichsen et al. respectively that are useful monitoring and assessing results. Targeted
to illustrate the type of processes that can guide programmes to tackle health disadvantage may
policy decision-making on SDH. Then we review a align well with other targeted interventions in a
number of key directions, which the CSDH model governmental anti-poverty agenda, for example
suggests should guide policy choices as decision- social welfare programmes focused on particular
makers seek to tackle health inequities through disadvantaged neighborhoods. On the other hand,
SDH action. such an approach may be politically weakened
precisely by the fact that it is not a population-
wide strategy but instead benefits sub-groups
6.1 Gaps and gradients that make up only a relatively small percentage
of the population, thus undermining the politics
Today, health equity is increasingly embraced of solidarity that are important to maintaining
as a policy goal by international health agencies support for public provision 177. Furthermore,
and national policy-makers 176. However, political this approach does not commit itself to bringing
leaders’ commitment to “tackle health inequities” levels of health in the poorest groups closer to
can be interpreted differently to authorize a variety national averages. Even if a targeted programme
of distinct policy strategies. is successful in generating absolute health gains
among the disadvantaged, stronger progress
Three broad policy approaches to reducing among better-off groups may mean that health
health inequities can be identified: (1) improving inequalities widen.
the health of low SEP groups through targeted
programmes; (2) closing the health gaps between An approach targeting health gaps directly
those in the poorest social circumstances and confronts the problem of relative outcomes. The
better off groups; and (3) addressing the entire UK’s current health inequality targets on infant
health gradient, that is, the association between mortality and life expectancy are examples of such
socioeconomic position and health across the a gaps-focused approach. However, this model,
whole population. too, brings problems. For one thing, its objectives
will be technically more challenging than those
To be successful, all three of these options would associated with strategies conceived only to
require action on SDH. All three constitute improve health status among the disadvantaged.
potentially effective ways to alleviate the “Movement towards the [gap reduction] targets
unfair burden of illness borne by the socially requires both absolute improvements in the levels
disadvantaged. Yet the approaches differ of health in lower socioeconomic groups and a rate

50
A conceptual framework for action on the social determinants of health

of improvement which outstrips that in higher country-level contextual analysis and a pragmatic
socioeconomic groups” 175. Meanwhile, gaps- mapping of policy options and sequencing.
oriented approaches share some of the ambiguities
underlying the focus on health disadvantage.
Health-gaps models continue to direct efforts to 6.2 Frameworks for policy
minority groups within the population (they are analysis and decision-making
concerned with the worst-off, measured against
the best-off). By adopting this stance, “a health- Our review of the literature has identified
gaps approach can underestimate the pervasive several suggestive analytic frameworks for policy
effect which socioeconomic inequality has on development on SDH. One of the proposals most
health, not only at the bottom but also across relevant to current purposes was elaborated
the socioeconomic hierarchy” 175. By focusing in the context of the Dutch national research
too narrowly on the worst-off, gaps models can programme on inequalities in health 177. The
obscure what is happening to intermediary groups, programme report highlights phases of analysis for
including “next to the worst-off ” groups that may the implementation of interventions and policies
also be facing major health difficulties. on SDH. The first phase involves filling in the
social background on health inequalities in the
Tackling the socioeconomic gradient in health specific country or socioeconomic context. The
right across the spectrum of social positions impact of each social determinant on health varies
constitutes a much more comprehensive model within a given country according to different
for action on health inequities. With a health- socioeconomic contexts. Four intervention areas
gradient approach, “tackling health inequalities are identified:
becomes a population-wide goal: like the goal ∏ The first and the most fundamental
of improving health, it includes everyone”. On option is to reduce inequalities in the
the other hand, this model must clearly contend distribution of socioeconomic factors or
with major technical and political challenges. structural determinants, like income and
Health gradients have persisted stubbornly education. An example would be reducing
across epidemiological periods and are evident the prevalence of poverty.
for virtually all major causes of mortality, raising ∏ The second option relates to the specific
doubts about the feasibility of significantly or intermediary determinants that mediate
reducing them even if political leaders have the the effect of socioeconomic position
will to do so. Public policy action to address on health, such as smoking or working
gradients may prove complex and costly and, in conditions. Interventions at this level will
addition, yield satisfactory results only in a long aim to change the distribution of such
timeframe. Yet it is clear that an equity-based specific or intermediary determinants
approach to social determinants, carried through across socioeconomic groups, e.g. by
consistently, must lead to a gradients focus 175. reducing the number of smokers in lower
socioeconomic groups, or improving the
Strategies based on tackling health disadvantage, working conditions of people in lower
health gaps and gradients are not mutually status jobs.
exclusive. The approaches are complementary ∏ A third option addresses the reverse effect

and can build on each other. “Remedying health of health status on socioeconomic position.
disadvantages is integral to narrowing health gaps, If bad health status leads to a worsening
and both objectives form part of a comprehensive of people’s socioeconomic position,
strategy to reduce health gradients”. Thus inequalities in health might partly be
a sequential pattern emerges, with “each goal diminished by preventing ill people from
add[ing] a further layer to policy impact” 175. Of experiencing a fall in income, such as
course the relevance of these approaches and a consequence of job loss. An example
their sequencing will vary with countries’ levels would be strategies to maintain people with
of economic development and other contextual chronic illness within the workforce.
factors. A targeted approach may have little ∏ The fourth policy option concerns the

relevance in a country where 80% of the population delivery of curative healthcare. It becomes
is living in extreme poverty. Here the CSDH can relevant only after people have fallen
contribute by linking a deepened reflection on ill. One might offer people from lower
the values underpinning an SDH agenda with socioeconomic positions extra healthcare

51
or another type of healthcare, in other to and not central to health policy per se,
achieve the same effects as among people Diderichsen and colleagues argue that
in higher socioeconomic positions. addressing stratification is in fact “the
most critical area in terms of diminishing
This and other policy frameworks should be disparities in health”. They propose two
seen in the light of the preceding discussion general types of policies in this entry point:
on health disadvantage, gaps and gradients. first the promotion of policies that diminish
Following Graham, we argued that improving social inequalities, e.g. labor market,
the health of poor groups and narrowing health education and family welfare policies; and
gaps are necessary but not sufficient objectives. A second a systematic impact assessment of
commitment to health equity ultimately requires social and economic policies to mitigate
a health-gradients approach. A gradients model their effects on social stratification. In the
locates the cause of health inequalities not only figure below, this approach is represented
in the disadvantaged circumstances and health- by line A.
damaging behaviors of the poorest groups, but ∏ Decreasing the specific exposure to health-

in the systematic differences in life chances, damaging factors suffered by people in


living standards and lifestyles associated with disadvantaged positions. The authors
people’s unequal positions in the socioeconomic indicate that most health policies do not
hierarchy 178. While interventions targeted at the differentiate exposure or risk reduction
most disadvantaged may appeal to policymakers on strategies according to social position.
cost grounds or for other reasons, an unintended Earlier anti-tobacco efforts constitute
effect of targeted interventions may be to legitimize one illustration. Today there is increasing
economic disadvantage and make it both more experience with health policies aiming
tolerable for individuals and less burdensome for to combat inequities in health that
society 178, 179, 180. Health programmes (including target the specific exposures of people in
SDH programmes) targeted at the poor have a disadvantaged positions, including aspects
constructive role in responding to acute human like unhealthy housing, dangerous working
suffering. Yet the appeal to such strategies must conditions and nutritional deficiencies.
not obscure the need to address the structured Children living in extreme poverty (below
social inequalities that create health inequities in US$1 per day, according to the World Bank’s
the first place 181. contentious and problematic definition)
have very different mortality rates in
In another approach, Diderichsen and colleagues different countries; this shows that the
propose a typology or mapping of entry points for national policy context modifies the effect
policy action on SDH that is very closely aligned of poverty (Wagstaff 182). Living in a society
to theories of causation, as was mapped out for with strong safety nets, active employment
the Commission’s Framework. They identify policies, or strong social cohesion may
actions related to: social stratification; differential make day-today life less threatening and
exposure/differential vulnerability; differential relieve some of the social stress involved
consequences and macro social conditions. The in having very little money or being
figure elaborated by Diderichsen and colleagues unemployed (Whitehead et al. 96, 183). Below,
that illustrates these ideas is shown in Figure 6 94. this approach is represented by line B.
The following entry points are identified: ∏ Lessening the vulnerability of disadvantaged
∏ First, altering social stratification itself, by p e opl e to t he he a lt h - d amag i ng
reducing “inequalities in power, prestige, conditions they face. An alternative way
income and wealth linked to different of thinking about modifying the effect
socioeconomic positions” 93. For example, of exposures is through the concept of
policies aimed at diminishing gender differential vulnerability. Intervention
disparities will influence the position of in a single exposure may have no effect
women relative to men. In this domain, on the underlying vulnerability of the
one could envisage an impact assessment disadvantaged population. Reduced
of social and economic policies to mitigate vulnerability may only be achieved when
their effects on social stratification. While interacting exposures are diminished
social stratification is often seen as the or relative social conditions improve
responsibility of other policy sectors significantly. An example would be the

52
A conceptual framework for action on the social determinants of health

Figure 6. Typology of Entry Points for Policy Action on SDH

Social Position
Social
Context
A

Causes (Exposure)
E

Disease / injury

D
Policy
Context
Social and economic
consequences

Source: Reproduced with permission from Diderichsen et al. (2001)

benefits of female education as one of the implications of various public and private
most effective means of mediating women’s financing mechanisms and their use
differential vulnerability. This entry point by disadvantaged populations. In poor
is shown below by line C. This line is countries, the impoverishing effects of
bifurcated to emphasize that conditions of user fees play an increasing role in the
differential vulnerability exist previous to economic consequences of illness. Social
specific exposures. consequences of diseases have a much
∏ Intervening through the health system to steeper socioeconomic gradient than the
reduce the unequal consequences of ill- incidence and prevalence of the same
health and prevent further socioeconomic diseases. The entry point appears below as
degradation among disadvantaged line D.
people who become ill. Examples would ∏ Policies influencing macro-social conditions

include additional care and support (context). Social and economic policies
to disadvantaged patients; additional may influence social cohesion, integration
resources for rehabilitation programmes and social capital of communities.
to reduce the effects of illness on people’s Channels of influence and intervention
earning potential; and equitable health care can be defined for the development of
financing. Policy options should marshal redistributive policies, strengthening social
evidence for the range of interventions policies, in particular for the neediest and
(both disease-specific and related to most vulnerable social groups. This entry
the broader social environment) that point appears in the figure as line E.
will reduce the likelihood of unequal
consequences of ill health. For instance,
additional resources for rehabilitation 6.3 Key dimensions and
might be allocated to reduce the social directions for policy
consequences of illness. Equitable health
care financing is a critical component at On the basis of the model developed in the
this level. It involves protection from the preceding chapter and the policy analysis
impoverishment arising from catastrophic frameworks just reviewed, we can identify
illness, as well as an understanding of the fundamental orientations for policy action to

53
reduce health inequities through action on SDH. (for example, models of governance, labour market
We do not attempt here to recommend specific structures or the education system) may appear
policies and interventions, which will be the task too vast and intractable to be realistic targets for
of the Commission in its final report; rather, concerted action to bring change. The CSDH
our aim is to highlight broad policy directions may hesitate to recommend ambitious forms of
that the CSDH conceptual framework suggests policy action (particularly expanded redistributive
must be considered as decision-makers weigh policies) that could be considered quixotic. Yet
options and develop more specific strategies. significant aspects of the context in our sense --
The directions we take up here are the following: the established institutional landscape and broad
(1) the importance of context-specific strategies governance philosophies -- can be (and historically
and tackling structural as well as intermediary have been) changed. Such changes have taken
determinants; (2) intersectoral action; and (3) place through political action, often spurred by
social participation and empowerment as crucial organized social demand. The contextual factors
components of a successful policy agenda on SDH that powerfully shape social stratification and, in
and health equity. turn, the distribution of health opportunities are
not (entirely) beyond people’s collective control.
6.3.1 Context strategies tackling This is among the important implications of recent
structural and intermediary analyses of welfare state policies and health 98, 105.
determinants Social policies (covering the areas of “public” and
“social” policies from the conceptual framework)
A key implication of the CSDH framework, with matter for health and for the degree of social and
its emphasis on the impact of socio-political health equity that exists in society. Evidence-based
context on health, is that SDH policies must not action to alter key determinants of health inequities
pin their hopes on a “one-size-fits-all” approach, is by no means politically unachievable. Notably, in
but should instead be crafted with careful attention a 2005 strategy document named The Challenge of
to contextual specificities. Since the mechanisms the Gradient, the Norwegian Directorate for Health
producing social stratification will vary in different and Social Affairs argues that health inequities
settings, certain interventions or policies are will probably be most effectively reduced through
likely to be effective for a given socio-political “social equalization policies”, though the authors
context but not for all. Meanwhile, the timing of acknowledge the political challenges involved in
interventions with respect to local processes must implementation 139. Indeed, the most significant
be considered, as well as partnerships, availability lesson of the CSDH conceptual framework may
of resources, and how the intervention and/or be that interventions and policies to reduce
policy under discussion is conceptualized and health inequities must not limit themselves to
understood by participants at national and local intermediary determinants; but they must include
levels 184. policies specifically crafted to tackle the underlying
structural determinants of health inequities.
In addition to specificities related to sub-national,
national and regional factors, context also includes a Not all major determinants have been targeted for
global component which is of growing importance. interventions. In particular, social factors rarely
The actions of rich and powerful countries, in appear to have been the object of interventions
particular, have effects far outside their borders. aimed at reducing inequity. In contrast,
Global institutions and processes increasingly interventions are more frequently aimed at the
influence the socio-political contexts of all countries, accessibility of health care and at behavioral risk
in some cases threatening the autonomy of national factors. Regarding the accessibility of health care, a
actors. International trade agreements, the majority of policies are concerned with financing.
deployment of new communications technologies, A notably high proportion of interventions are
the activities of transnational corporations and aimed at those determinants that fall within the
other phenomena associated with globalization domain of regular preventative care, including
impact health determinants (in)directly through behavioral factors (individual health promotion
multiple pathways; hence, the importance of the and education). Indeed, interventions and policies
findings and recommendations of the CSDH that address structural determinants of health
Knowledge Network on globalization for countries constitute orphan areas in the determinants
seeking to frame effective SDH policies. field. More work has been done on intermediary
Some of the major institutions and processes determinants (decreasing vulnerability and
situated in the socioeconomic and political context exposure); but interventions at this level frequently
54
A conceptual framework for action on the social determinants of health

target only one determinant, without relation causes, so as to allow evaluation of their different
to other intermediary factors or to the deeper roles in mediating the effect of social position and
structural factors. poverty on health.

Recent discussions on resource allocation formulas National policies in Sweden have recently given
in England have introduced the issue of reducing strong priority to psychosocial working conditions
inequalities in health, not only in access to as well as tobacco smoking and alcohol abuse
medical care. Growing political concern about as major causes mediating the effect of social
the persistence of social inequalities in health position on health. A similar British overview
has led the government to add a new resource put strong emphasis on living conditions and
allocation objective for the NHS: to contribute health behaviors of mothers and children 185, 187.
to the reduction in avoidable health inequalities The World Health Report 2002 emphasized the
183, 185
. The review is not yet finalized, and as an enormous potential impact of improvements
interim solution an index of mortality (years of in nutrition and vaccination programs on the
life lost under age 75) has been proposed. Resource poverty-related burden of disease 187. Common to
allocation to disease prevention to improve health proposals in both rich and poor countries is the
equity has to be based on an understanding of emphasis on strong coordination between social
some of the causal relationships outlined above. policies and health policies in any effort to mitigate
Efforts should, therefore, be made to break-up social inequalities in health.
socioeconomic inequality in health into its different

Dahlgren and Whitehead on policy approaches

Dahlgren and Whitehead 188 have produced a list of broad recommendations for policy approaches to reduce underlying social inequities. Their primary
focus is on income inequalities, but the principles apply to other structural determinants. Their recommendations for national policy directions include
the following:

∏ Describe present and future possibilities to reduce social inequalities in income through cash benefits, taxes and subsidized public services. The
magnitude of these transfers can be illustrated by an example from the United Kingdom 186:

“Before redistribution the highest income quintile earn 15 times that of the lowest income quintile. After
distribution of government cash benefits this ratio is reduced to 6 to 1, and after direct and local taxes the ratio
falls further to 5 to 1. Finally, after adjustment for indirect taxes and use of certain free government services such
as health and education, the highest income quintile enjoys a final income 4 times higher than the lowest income
quintile”.

∏ Regulate the invisible hand of the market with a visible hand, promoting equity-oriented and labour-intensive growth strategies. A strong labour
movement is important for promoting such policies, and it should be coupled with a broad public debate with strong links to the democratic or
political decision-making process. Within this policy framework, the following special efforts should be made:
• Maintain or strengthen active wage policies, where special efforts are made to secure jobs with adequate pay for those in the weakest
position in the labour market. Secure minimum wage levels through agreements or legislation that are adequate and that eliminate the risk of
a population of working poor.
• Introduce or maintain progressive taxation, related both to income and to different tax credits, so that differences in net income are reduced
after tax.
• Intensify efforts to eliminate gender differences in income, by securing equal pay for equal jobs – regardless of sex. Some gender differences
in income are also brought about when occupations that are typically male receive greater remuneration than occupations that are seen as
female, because women are concentrated in them. These differences also need to be challenged.
• Increase or maintain public financing of health, education and public transport. The distributional effects of these services are significant – in
particular for health services – in universal systems financed according to ability to pay and utilized according to need 188.

55
6.3.2 Intersectoral action political factors (e.g. political backing, political
style, values and ideology), policy issues (such as
As the preceding discussion has begun to suggest, consensus on the nature of problems and their
a commitment to tackle structural, as well as solutions), and specific technical factors related to
intermediary, determinants has far-reaching the policy field(s) in question 192.
implications for policy. This focus notably requires
intersectoral action, because structural determinants Shannon and Schmidt propose a “conceptual
of health inequities can only be addressed by policies framework for emergent governance”193 that suggests
that reach beyond the health sector. If the aim is how levels of decision-making from global to local
attacking the deepest roots of health inequities, an can be brought into flexible but coherent connection
intersectoral approach is indispensable. (“loose coupling”) by linking intersectoral
policy-making and participatory approaches.
Intersectoral action for health has been defined as: “Participatory approaches” in this context means
“political processes that self-consciously and directly
engage the people interested in and affected by
[policy] choices”, as well as the officials charged
with making and carrying out policy. These authors
argue that intersectoral action and participation
A recognized relationship between can work together to enable more collaborative,
part or parts of the health sector responsive modes of governance. Specific elements
and part or parts of another sector, of collaboration in governance include “sharing
resources (including staff and budgets), working
that has been formed to take action
to craft joint decisions, engaging the opposition in
on an issue or to achieve health creative solutions to shared problems, and building
outcomes in a way that is more new relationships as needs and problems arise” 194.
effective, efficient or sustainable
than could be achieved by the Three frequent approaches to intersectoral
health sector working alone 189. action involve policies and interventions defined
according to: (1) specific issues; (2) designated
target groups within the population; and (3)
Since the Alma-Ata era, WHO has recognized a particular geographical areas (‘area-based
wide range of sectors with the potential to influence strategies’). These approaches can be implemented
the determinants of health and, in some cases, the separately or combined in various forms.
underlying structures responsible for determinants’ 1 Dahlgren and Whitehead 188 have stressed
inequitable distribution among social groups. the importance of intersectoral approaches
Relevant sectors include agriculture, food and for reducing health inequities and provided
nutrition; education; gender and women’s rights; illustrative intersectoral strategies focused on
labour market and employment policy; welfare the specific issue of improving health equity
and social protection; finance, trade and industrial through education. Policies approaching
policy; culture and media; environment, water health from the angle of education can be
and sanitation; habitat, housing, land use and universal in scope (addressed to the whole
urbanization 190. population), for example a nationwide
Healthy Schools programme or a universal
Collaboration with these and other relevant sectors programme to provide greater support
offers distinctive opportunities, while also raising in the transition from school to work.
specific challenges. Numerous approaches to On the other hand, thematically defined
planning and implementing intersectoral action intersectoral policies can be linked with
exist, and a substantial literature has grown up social or geographical targeting. Examples
around the facilitators and inhibitors of such action would include introducing comprehensive
191
. Challis et al. 192 divide potential facilitating and support programmes for children from less
obstructing factors into two categories: behavioral privileged families, to promote preschool
and structural. Behavioral elements concern development 188.
individual attitudes and comportments among 2 Some intersectoral strategies are built around
those being asked to work collaboratively across the needs of specific vulnerable groups
sectoral boundaries. Structural influences include within the population. This is the case of

56
A conceptual framework for action on the social determinants of health

Chile’s “Puente” programme, for example, result had been to: “redefine health care
which seeks to provide a personalized less as a social right and more as a market
benefits package to the country’s poorest commodity”. Muntaner et al. argue that
families to help them assume increased “popular resistance to neoliberalism” helped
control of their own lives and enjoy drive the creation of Barrio Adentro and the
measurably improved life quality across 53 array of innovative social welfare measures
indicators of social well-being. The Puente with which the programme is intertwined.
programme, aimed at the “hard core” of They suggest that Barrio Adentro “not only
Chilean families living in long-term poverty, provides a compelling model of health care
is constructed to coordinate support services reform for other low- to middle-income
from multiple sectors, including health, countries, but also offers policy lessons to
education, employment and social welfare, wealthy countries” 197.
while strengthening families’ social networks
and their planning, conflict resolution, Of course, the intersectoral nature of SDH challenges
relational and life-management skills. A 2005 adds considerably to their complexity. While WHO
evaluation of the Puente programme found and other health authorities have long recognized
mixed results after Puente’s first three years of the importance of intersectoral action for health,
operation, revealing both successful aspects effective implementation of intersectoral policies has
and limitations of the effort to construct often proven elusive, and the Commission does not
a network model of integrated service underestimate the challenges involved 190. Stronks
provision at the local level. Effectiveness and Gunning-Schepers 198 argue that: “Although
of service networking was inconsistent and there is great potential for improving the distribution
highly dependent on the quality of local of health through intersectoral action … there very
leadership within the municipalities where often will be a conflict of interest with other societal
the programme operates. The evaluation goals. … The major constraint in trying to redress
concluded that despite its problems, the socio-economic health differences results from
Puente model “stands out through its the fact that interventions on most determinants
requirement that services connect up in of health will have to come from [government]
networks to coordinate provision to very departments other than the department of public
poor sectors” 194. Another example of health. … Whereas the primary goal of health
intersectoral action crafted to meet the policy is (equality in) health, other policy fields
needs of specific groups is the New Zealand have other primary goals.” (For example, in the area
government’s programming for health of employment and workforce policies, loosening
improvement among the country’s Maori regulation in the hope of raising the number of
minority 195. new jobs may take precedence over concerns for
3 A third form of intersectoral policy-making maintaining a living wage or for workplace safety).
is oriented to designated geographical areas. …“In intersectoral action, conflicts between the goal
A widely discussed (and contested) recent of equity in health and goals in other policy fields,
example is provided by the United Kingdom’s especially economic policies, are to be expected”.
Health Action Zones (HAZ) 196. Venezuela’s In light of such concerns, important tasks for the
Barrio Adentro (“Inside the Neighborhood”) CSDH will be: (1) to identify successful examples
programme offers a very different model of intersectoral action on SDH at the national and
of an area-focused healthcare programme sub-national level in jurisdictions with different
incorporating intersectoral elements. Barrio levels of resources and administrative capacity; (2) to
Adentro forms part of a multi-dimensional characterize in detail the political and management
national policy effort introduced by the mechanisms that have enabled effective intersectoral
government of President Hugo Chavez to programmes to function sustainably; and (3) to
improve health and living conditions for identify key examples of intersectoral action, and
residents of fragile, historically marginalized needs for future action, in the international frame
urban neighborhoods. Barrio Adentro of reference. These will often require initiatives by
was consciously constructed as an equity- several countries acting jointly, within or outside
focused response to the neoliberal health the framework provided by existing multilateral
care reforms implemented throughout Latin institutions.
America during the 1980s and 90s, whose.

57
6.3.3 Social participation and ∏ Consulting: To obtain feedback from
empowerment affected communities on analysis,
alternatives and/or decisions.
A final crucial direction for policy to promote ∏ Involving: To work directly with

health equity concerns the participation of communities throughout the process


civil society and the empowerment of affected to ensure that public concerns and
communities to become active protagonists in aspirations are consistently understood
shaping their own health. and considered.
∏ Collaborating: To partner with affected

Broad social participation in shaping policies to communities in each aspect of the decision,
advance health equity is justified on ethical and including the development of alternatives
human rights grounds, but also pragmatically. and the identification of the preferred
Human rights norms concern processes as well solution.
as outcomes. They stipulate that people have the ∏ Empowering: To ensure that communities
right to participate actively in shaping the social have “the last word” – ultimate control over
and health policies that affect their lives. This the key decisions that affect their well-
principle implies a particular effort to include being.
groups and communities that have tended
to suffer acute forms of marginalization and Policy-making on social determinants of health
disempowerment. Meanwhile, from a strategic equity should work towards the highest form of
point of view, promoting civil society ownership participation as authentic empowerment of civil
of the SDH agenda is vital to the agenda’s long- society and affected communities.
term sustainability. The task of implementing the
Commission’s recommendations and advancing As noted above, of course, definitions of
action for health equity must be taken up by “empowerment” are diverse and contested. To
governments. In turn, governments’ commitment some, empowerment is a “political concept that
in pursuing this work will depend heavily on the involves a collective struggle against oppressive
degree to which organized demand from civil social relations” and the effort to gain power
society holds political leaders accountable. By over resources. To others, it “refers to the
nurturing civil society participation in action consciousness of individuals, or the power to
on SDH during its lifetime, the Commission is express and act on one’s desires” 88. When
laying the groundwork for sustained progress promoting “empowerment” and “participation”
in health equity in the long term. The Cuenca as key aspects of policy strategies to tackle heath
Declaration, adopted at the Second People’s inequities, we must be aware of the historical
Health Assembly, rightly states that the best and conceptual ambiguities that surround these
hope for equitable health progress comes when terms. The concept of empowerment in particular
empowered communities ally with the state has generated a voluminous and often polemical
in action against the economic and political recent literature 84, 201. Here, we cannot hope to
interests currently tending to undermine the reflect all the nuances of these debates. However,
public sector 199. we can highlight relevant aspects that clarify
our interpretation of these concepts and their
While the primary responsibility for promoting implications for policy-making.
health equity and human rights lies with
governments, participation in decision-making Historically, key sources of the concept of
processes by civil society groups and movements empowerment include the Popular Education
is “vital in ensuring people’s power and control movement and the women’s movement. The
in policy development” 200. As proposed by the Popular Education approach gained prominence
International Association for Public Participation in Latin America and elsewhere in the 1970s.
(IAP2), when governments solicit social It is based on the pioneering work of Paulo
participation, this term can have a wide range of Freire in the education of oppressed people, and
meanings 201: notably on Freire’s model of consciencization
∏ Informing: To provide people with (conscientisaçao). In the 1980s, movements
balanced and objective information inspired by Popular Education played an important
to assist them in understanding the role in progressive political struggles and resistance
problem, alternatives, opportunities and/ against authoritarian governments in Latin
or solutions. America 202. The actual term “empowerment” first
58
A conceptual framework for action on the social determinants of health

achieved wide usage in the women’s movement, on control” 90. Indeed, the increased ability of
which drew inspiration from Freire’s work. Luttrell oppressed and marginalized communities to
and colleagues argue that, in contrast to other control key processes that affect their lives is the
progressive intellectual currents dominated by essence of empowerment as we understand it.
voices from the global north, groundbreaking Their capacity to promote such control should be
work on empowerment and gender emerged from a significant criterion in evaluating policies on the
the south, for example through the movement of social determinants of health.
Development Alternatives from Women from
a New Era (DAWN), which shaped grassroots A framework originally developed by Longwe 203
analysis and strategies for women challenging provides a useful way of distinguishing among
inequalities 90. Subsequently, notions of collective different levels of empowerment, while also
empowerment became central to the liberation suggesting the step-wise, progressive nature of
movements of ethnic minorities, including empowerment processes. The framework describes
indigenous groups in Latin America and African- the following levels:
Americans in the United States. 1 The welfare level: where basic needs are
satisfied. This does not necessarily require
During the 1990s, the association between structural causes to be addressed and tends
empowerment and progressive politics tended to to assume that those involved are passive
break down. In the context of neoliberal economic recipients.
and social policies and the rolling-back of the 2 The access level: where equal access to
state, “notions of participation and empowerment, education, land and credit is assured.
previously reserved to social movements and 3 The conscientisation and awareness-
NGOs, were reformulated and became a central raising level: where structural and
part of the mainstream discourse” 90; a substantially institutional discrimination is addressed.
depoliticized model of empowerment emerged. 4 The participation and mobilisation level:
Whereas it was linked to progressive political where the equal taking of decisions is
agendas, empowerment now came increasingly enabled.
to appear as a substitute for political change. 5 The control level: where individuals can
During this same period, the vocabulary of make decisions and are fully recognized
empowerment was being adopted by mainstream and rewarded.
international development agencies, including the
World Bank. Thus, empowerment came to suffer This framework stresses the importance of gaining
ambiguities similar to those surrounding social of control over decisions and resources that
capital 90. Today, critics argue that the embrace of determine the quality of one’s life and suggests
empowerment by leading development actors has that “lower” degrees of empowerment are a pre-
not led to any meaningful changes in development requisite for achieving higher ones .
practice. Some critiques go further to suggest that
the use of the term allows organisations to say they Importantly, the empowerment of disadvantaged
are “tackling injustice without having to back any communities, as we understand it, is inseparably
political or structural change, or the redistribution intertwined with principles of state responsibility.
of resources” (Fiedrich et al., 2003)90. This point has fundamental implications for
policy-making on SDH. The empowerment of
In contrast to this depoliticized understanding, we marginalized communities is not a psychological
follow recent critics in adopting a political model process unfolding in a private sphere separate
of the meaning and practice of empowerment. from politics. Empowerment happens in ongoing
Empowerment, as we understand it, is inseparably engagement with the political, and the deepening of
linked to marginalized and dominated that engagement is an indicator that empowerment
communities gaining effective control over the is real. The state bears responsibility for creating
political and economic processes that affect their spaces and conditions of participation that can
well-being. Like these critics, we value participation enable vulnerable and marginalized communities
but question whether participation alone can to achieve increased control over the material,
be considered genuinely empowering, without social and political determinants of their own
attention to outcomes, namely, the redistribution well-being. Addressing this concern defines a
of resources and power over political processes. crucial direction for policy action on health equity.
We endorse the call to “mov[e] beyond mere It also suggests how the policy-making process
participation in decision-making to an emphasis itself, structured in the right way, might open space
59
for the progressive reinforcement of vulnerable communities. These broad directions for policy
people’s collective capacity to control the factors action can utilize various entry points or levels
that shape their opportunities for health. of engagement, represented in the image by the
cross-cutting horizontal bars.
6.3.4 Diagram summarizing key
policy directions and entry points Moving from the lower to the higher bars
(from more “downstream” to more structural
The diagram below summarizes the main approaches), these entry points include: seeking
ideas presented in the preceding sections and to palliate the differential consequences of illness;
attempts to clarify their relationships via a visual seeking to reduce differential vulnerabilities
representation. It recalls that the Commission’s and exposures for disadvantaged social groups;
broad aim, politically speaking, is to promote and, ultimately, altering the patterns of social
context-specific strategies to address structural, stratification. At the same time, policies and
as well as intermediary determinants. Such interventions can be targeted at the “micro” level
strategies will necessarily include intersectoral of individual interactions; at the “meso” level of
policies, through which structural determinants community conditions; or at the broadest “macro”
can be most effectively addressed, and will aim level of universal public policies and the global
to ensure that policies are crafted so as to engage environment.
and ultimately empower civil society and affected

Figure 7. Framework for tackling SDH inequities


Context-specific
strategies tackling Key dimensions and directions for policy
both structural and
intermediary Intersectoral Social Participation
determinants Action and Empowerment

Globalization
Environment Policies on stratification to reduce inequalities,
mitigate effects of stratification
Macro Level:
Public Policies Policies to reduce exposures of disadvantaged
people to health-damaging factors

Mesa Level: Policies to reduce vulnerabilities of


Community disadvantaged people

Policies to reduce unequal consequences of


illness in social, economic and health terms
Micro Level:
Individual
interaction

Monitoring and follow-up of health equity and SDH

Evidence on interventions to tackle social


determinants of health across government

Include health equity as a goal in health


policy and other social policies

60
A conceptual framework for action on the social determinants of health

The CSDH and policy partners must also be He continues: “Each of the core concerns of social
concerned with an additional set of issues relevant policy—need, deserts and citizenship—are social
to all these types of policies (summarized in the box at constructs that derive full meaning from the
the lower right): monitoring of the effects of policies cultural and ideological definition of ‘deserving
and interventions on health equity and determinants; poor’, ‘entitlement’ and ‘citizens’ rights’. Although in
assembling and disseminating evidence of effective current parlance, the choice between targeting and
interventions, including intersectoral strategies; and universalism is couched in the language of efficient
advocating for the incorporation of health equity allocation of resources subject to budget constraints
as a goal into the formulation and evaluation of and the exigencies of globalization, what is actually
health and all social policies (covering the areas at stake is the fundamental question about a polity’s
labelled “public” and “social” policies identified in values and its responsibilities to all its members. The
the conceptual framework). technical nature of the argument cannot conceal
the fact that, ultimately, value judgments matter not
As Stewart-Brown 204 points out, to date, public health only with respect to determining the needy and how
research has focused more on the impact of social they are perceived, but also in attaching weights to
inequalities than on their causes, or a fortiori on the types of costs and benefits of approaches chosen.
realistic political strategies to address underlying Such a weighting is often reflective of one’s ideological
causes. Studies of interventions to mitigate the impact predisposition. In addition, societies chose either
of social inequalities have tended to focus on methods targeting or universalism in conjunction with other
of reducing the level of disease at the lower end of policies that are ideologically compatible with the
the income distribution. The application of public choice, and that are deemed constitutive of the
health theory, however, suggests that the causes of desired social and economic policy regime” 205.
social inequalities are likely to lie as much with the
attributes of high-income groups as with those of Mkandawire highlights the contradictions of
low-income groups 204. This insight sharpens our dominant approaches: “One remarkable feature
sense of the political challenges. Solutions such as of the debate on universalism and targeting is the
redistribution of income that may appear simple in disjuncture between an unrelenting argumentation
the abstract are anything but simple to achieve in for targeting, and a stubborn slew of empirical
reality. evidence suggesting that targeting is not effective in
addressing issues of poverty (as broadly understood).
Fundamental to formulating effective policy in this Many studies clearly show that identifying the poor
area is the vexed problem of universal vs. targeted with the precision suggested in the theoretical
approaches. Thandika Mkandawire, while director models involves extremely high administrative
of the United Nations Research Institute for Social costs and an administrative sophistication and
Development, summarized the issue as follows 205: capacity that may simply not exist in developing
countries. An interesting phenomenon is that while
the international goals are stated in international
conferences, in universalistic terms (such as
“For much of its history, social policy ‘education for all’ and ‘primary health care for all’),
has involved choices about whether the means for reaching them are highly selective and
the core principle behind social targeted. The need to create institutions appropriate
provisioning will be ‘universalism’ or for targeting has, in many cases, undermined the
selectivity through ‘targeting’. Under capacity to provide universal services. Social policies
‘universalism’ the entire population is not only define the boundaries of social communities
the beneficiary of social benefits as and the position of individuals in the social order of
a basic right; while under ‘targeting’, things, but also affect people’s access to material well-
being and social status. This follows from the very
eligibility to social benefits involves
process of setting eligibility criteria for benefits and
some kind of means-testing to rights. The choice between universalism and targeting
determine the “truly deserving”. Policy is therefore not merely a technical one dictated by the
regimes are hardly ever purely universal need for optimal allocation of limited resources.
or purely based on targeting, however; Furthermore, it is necessary to consider the kind of
they tend to lie somewhere between political coalitions that would be expected to make
the two extremes on a continuum and such policies politically sustainable. Consequently,
are often hybrid, but where they lie there is a lot of reinvention of the wheel, and wasteful
on this continuum can be decisive in and socially costly experimentation with ideas that
spelling out individuals’ life chances and 61
in characterizing the social order.” 205
have been clearly demonstrated to be the wrong ones ‘targeting within universalism’, in which extra benefits
for the countries in which they are being imposed. are directed to low-income groups within the context
There is ample evidence of poor countries that have of a universal policy design (Skocpol 1990) and
significantly reduced poverty through universalistic involves the fine-tuning of what are fundamentally
approaches to social provision, and from whose universalist policies” 205.
experiences much can be learnt (Ghai 1999; Mehrotra
and Jolly 1997a, 1997b). Although we have posed the We now present a summary of examples of SDH
issue in what Atkinson calls ‘gladiator terms’, in reality interventions, organized according to the
most governments tend to have a mixture of both framework for action developed in this paper.
universal and targeted social policies. However, in the This summary draws, among other sources, on
more successful countries, overall social policy itself the policy measures discussed in the Norwegian
has been universalistic, and targeting has been used Health Directorate’s 2005 publication named
as simply one instrument for making universalism The Challenge of the Gradient 139.
effective; this is what Theda Skocpol has referred as

Table 3. Examples of SDH interventions

Strategies
Entry Point
Universal Selective
Social Stratification: ∏ Active policies to reduce income inequality ∏ Social security schemes for specific population
Policies to reduce through taxes and subsidized public services. groups in disadvantaged positions.
inequalities and ∏ Free and universal services such as health, ∏ Child welfare measures: Implement Early Child
mitigate effects of education, and public transport. Development programmes including the provision
stratification. ∏ Active labour market policies to secure jobs with of nutritional supplements, regular monitoring
adequate payment. Labour intensive growth of child development by health staff. Promotion
strategies. of cognitive development of children at pre-
∏ Social redistribution policies and improved schooling age. Promote pre-school development.
mechanisms for resource allocation in health care
and other social sectors.
∏ Promote equal opportunities for women and
gender equity.
∏ Promote the development and strengthening of
autonomous social movements.
Exposure: ∏ Healthy and safe physical neighbourhood ∏ Policies and programs to address exposures for
Policies to reduce environments. Guaranteed access to basic specific disadvantaged groups at risk (cooking
exposure of neighbourhood services. fuels, heating, etc).
disadvantaged ∏ Healthy and safe physical and social living ∏ Policies on subsidized housing for disadvantaged
people to health environments. Access to water and sanitation. people.
damaging factors. ∏ Healthy and safe working environments.
∏ Policies for health promotion and healthy lifestyle
(e.g. smoking cessation, alcohol consumption,
healthy eating and others).
Vulnerability: ∏ Employment insurance and social protection ∏ Extra support for students from less privileged
Policies to reduce policies for the unemployed. families facilitating their transition from school to
vulnerability of ∏ Social protection policies for single mothers work.
specific groups. and programs for access to work and education ∏ Free healthy school lunches.
opportunities. ∏ Additional access and support for health
∏ Policies and support for the creation and promotion activities.
development of social networks in order to ∏ Income generation, employment generation
increase community empowerment. activities through cash benefits or cash transfers.
Unequal ∏ Equitable health care financing and protection ∏ Additional care and support for disadvantaged
Consequences: from impoverishment for people affected by patients affected by chronic, catastrophic illness
Policies catastrophic illness. and injuries.
to reduce ∏ Support workforce reintegration of people affected ∏ Additional resources for rehabilitation programs
the unequal by catastrophic or chronic illness. for disadvantaged people.
consequences of ∏ Active labour policies for incapacitated people.
social, economic,
∏ Social and income protection for people affected
and ill-health for
disadvantaged with chronic illness and injuries.
people.

62
A conceptual framework for action on the social determinants of health

Key messages of this section:


p Three broad approaches to reducing health inequities can be identified, based
on: (1) targeted programmes for disadvantaged populations; (2) closing health
gaps between worse-off and better-off groups; and (3) addressing the social
health gradient across the whole population.

p A consistent equity-based approach to SDH must ultimately lead to a gradients


focus. However, strategies based on tackling health disadvantage, health gaps
and gradients are not mutually exclusive. They can complement and build on
each other.

p Policy development frameworks, including those from Stronks et al. and


Diderichsen, can help analysts and policymakers to identify levels of
intervention and entry points for action on SDH, ranging from policies tackling
underlying structural determinants to approaches focused on the health system
and reducing inequities in the consequences of ill health suffered by different
social groups.

p The CSDH framework suggests a number of broad directions for policy action.
We highlight three:
• Context-specific strategies to tackle both structural and intermediary
determinants
• Intersectoral action
• Social participation and empowerment.

p SDH policies must be crafted with careful attention to contextual specificities,


which should be rigorously characterized using methodologies developed by
social and political science.

p Arguably the single most significant lesson of the CSDH conceptual framework
is that interventions and policies to reduce health inequities must not limit
themselves to intermediary determinants, but must include policies specifically
crafted to tackle underlying structural determinants through addressing structural
mechanisms that systematically produce an inequitable distribution of the
determinants of health among population groups. These mechanisms are rooted in
the key institutions and policies of the socioeconomic and political context.

p To tackle structural, as well as intermediary, determinants requires intersectoral


policy approaches. A key task for the CSDH will be: (1) to identify successful
examples of intersectoral action on SDH in jurisdictions with different levels
of resources and administrative capacity; and (2) to characterize in detail the
political and management mechanisms that have enabled effective intersectoral
policy-making and programmes to function sustainably.

p Participation of civil society and affected communities in the design and


implementation of policies to address SDH is essential to success. Empowering
social participation provides both ethical legitimacy and a sustainable base to
take the SDH agenda forward after the Commission has completed its work.

63
7 Conclusion

T
his paper has sought to clarify shared features of the socioeconomic and political context
understandings around a series of that mediate their impact, and constitute the social
foundational questions. The architects determinants of health inequities. The structural
of the CSDH gave it the mission of mechanisms that shape social hierarchies,
helping to reduce health inequities, understood as according to key stratifiers, are the root cause of
avoidable or remediable health differences among health inequities.
population groups defined socially, economically,
demographically or geographically. Getting to Our answer to the second question, about
grips with this mission requires finding answers pathways from root causes to observed inequities
to three basic problems: in health, was elaborated by tracing how the
1 If we trace health differences among social underlying social determinants of health inequities
groups back to their deepest roots, where operate through a set of what we call intermediary
do they originate? determinants of health to shape health outcomes.
2 What pathways lead from root causes to the The main categories of intermediary determinants
stark differences in health status observed of health are: material circumstances; psychosocial
at the population level? circumstances; behavioral and/or biological
3 In light of the answers to the first two factors; and the health system itself as a social
questions, where and how should we determinant. We argued that the important
intervene to reduce health inequities? complex of phenomena toward which the
unsatisfactory term “social capital” directs our
The framework presented in these pages has attention cannot be classified definitively under
been developed to provide responses to these the headings of either structural or intermediary
questions and to buttress those responses with determinants of health. “Social capital” cuts across
solid evidence, canvassing a range of views among the structural and intermediary dimensions, with
theorists, researchers and practitioners in the field features that link it to both. The vocabulary of
of SDH and other relevant disciplines. To the first “structural determinants” and “intermediary
question, on the origins of health inequities, we determinants” underscores the causal priority of
have answered as follows. The root causes of health the structural factors.
inequities are to be found in the social, economic
and political mechanisms that give rise to a set of This paper provides only a partial answer to
hierarchically ordered socioeconomic positions the third and most important question: what
within society, whereby groups are stratified we should do to reduce health inequities. The
according to income, education, occupation, Commission’s final report will bring a robust set
gender, race/ethnicity and other factors. The of responses to this problem. However, we believe
fundamental mechanisms that produce and the principles sketched here to be of importance in
maintain (but that can also reduce or mitigate suggesting directions for action to improve health
effect) this stratification include: governance; equity. We derive three key policy orientations
the education system; labour market structures; from the CSDH framework:
and redistributive welfare state policies (or their 1 Arguably the single most significant lesson
absence). We have referred to the component of the CSDH conceptual framework is
factors of socioeconomic position as structural that interventions and policies to reduce
determinants. Structural determinants, include the health inequities must not limit themselves
64
A conceptual framework for action on the social determinants of health

to intermediary determinants, but must and management mechanisms that have


include policies crafted to tackle structural enabled effective intersectoral policy-
determinants. In conventional usage, the making and programmes to function
term “social determinants of health” has sustainably.
often encompassed only intermediary 3 Participation of civil society and
determinants. However, interventions affected communities in the design and
addressing intermediary determinants can implementation of policies to address SDH
improve average health indicators while is essential to success. Social participation
leaving health inequities unchanged. For is an ethical obligation for the CSDH
this reason, policy action on structural and its partner governments. Moreover,
determinants is necessary. To achieve solid the empowerment of civil society and
results, SDH policies must be designed communities and their ownership
with attention to contextual specificities; of the SDH agenda is the best way to
this should be rigorously characterized build a sustained global movement for
using methodologies developed by social health equity that will continue after the
and political science. Commission completes its work.
2 Inters ec toral p olic y-ma king and
implementation are crucial for progress The broad policy directions mapped by this
on SDH. This is because structural framework are empty unless translated into
determinants can only be tackled through concrete action. To be effective, however, action
strategies that reach beyond the health in the complex field of health inequities must be
sector. Key tasks for the CSDH will be guided by careful theoretical analysis grounded
to: (1) identify successful examples in explicit value commitments. The framework
of intersectoral action on SDH in offered here proposes basic conceptual foundations
jurisdictions with different levels of for the Commission’s work in, we hope, a clear
resources and administrative capacity; form, so that they can be subjected to examination
and (2) characterize in detail the political and reasoned debate.

65
List of abbreviations

CSDH Commission on Social Determinants of Health

SDH Social determinants of health

UNDP United Nations Development Programme

SEP Socioeconomic position

66
A conceptual framework for action on the social determinants of health

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75
SOCIAL DETERMINANTS OF HEALTH
ACCESS TO POWER, MONEY AND RESOURCES AND THE CONDITIONS OF DAILY LIFE —
THE CIRCUMSTANCES IN WHICH PEOPLE ARE BORN, GROW, LIVE, WORK, AND AGE

[energy] [investment] [community/gov.] [water] [justice] [food]


[providers of services, education, etc.] [accessible & safe] [supply & safety]

MONITORING SOCIAL WELL-BEING TO SUPPORT POLICIES


ON THE SOCIAL DETERMINANTS OF HEALTH: THE CASE
OF NEW ZEALAND’S “SOCIAL REPORTS/TE PŪRONGO
ORANGA TANGATA”
Social Determinants of Health Discussion Paper 3
ISBN 978 92 4 150086 9

WORLD HEALTH ORGANIZATION


AVENUE APPIA
1211 GENEVA 27
SWITZERLAND
DEBATES, POLICY & PRACTICE, CASE STUDIES
WWW.WHO.INT/SOCIAL_DETERMINANTS
MONITORING SOCIAL
WELL-BEING TO SUPPORT
POLICIES ON THE SOCIAL
DETERMINANTS OF
HEALTH:
THE CASE OF NEW
ZEALAND’S “SOCIAL
REPORTS/ TE PŪRONGO
ORANGA TANGATA”

World Health Organization


Geneva
2010
The Series:
The Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the social determinants
of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, and capacity building. They aim to
review country experiences with an eye to understanding practice, innovations, and encouraging frank debate on the connections between
health and the broader policy environment. Papers are all peer-reviewed.

Background:
The idea of this paper and the case study it describes was generated in discussions between WHO and Don Matheson who represented New
Zealand on the country stream of work of the Commission on Social Determinants of Health (CSDH). The country stream of work aimed at
galvanizing political will for tackling the social determinants of health and supporting knowledge sharing across countries on how to
implement the social determinants agenda. The principal investigator was Frank Pega, who also developed the first draft of the paper. The paper
was written by Frank Pega, Nicole Valentine and Don Matheson.
This paper provides a historical overview of how New Zealand’s social indicators reports came to be generated, describing the contextual issues
related to the use of the report for monitoring social progress. It attempts to make a first assessment of the policy impact of the social
indicators reports.

Acknowledgments:
The authors want to thank Orielle Solar (WHO Geneva), Teresa Wall (Ministry of Health, New Zealand), Martin Tobias (Ministry of Health,
New Zealand) and Kumanan Rasanathan (WHO Geneva) for their comments on the paper and the key informant survey prepared to
document the case study. Particular thanks are extended to five key-informants from the New Zealand Ministries of Health and Social
Development and to 24 respondents who participated in a survey. Frank Pega was supported by a BRCSS Travel Award and an International
Travel Award from the Royal Society of New Zealand (Ref: ITF08-01) to work on earlier drafts of this paper. He developed and finalized this
paper under contract to the Department of Ethics, Equity, Trade and Human Rights at WHO. Nicole Valentine edited the paper and
coordinated production.

Suggested Citation:
Pega F, Valentine N, Matheson D. Monitoring Social Well-being to Support Policies on the Social Determinants of Health: the case
of New Zealand’s Social Reports / Te Pūrongo Oranga Tangata. Social Determinants of Health Discussion Paper 3 (Case Studies). Geneva,
World Health Organization, 2010.

WHO Library Cataloguing-in- Publication Data


Monitoring social well-being to support policies on the social determinants of health: the case of New Zealand’s “social reports/ te pūrongo
oranga tangata”.

(Discussion Paper Series on Social Determinants of Health, 3)

1.Socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. 5.Health policy. 6.New Zealand. I.World
Health Organization.

ISBN 978 92 4 150086 9 (NLM classiification: WA 525)

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Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Contents
EXECUTIVE SUMMARY 2

1. INTRODUCTION 5

2. BACKGROUND 7
2.1 The Social Indicator Movement 7
2.2 Right to health monitoring and indicators 8

3. METHODOLOGY 10

4. FINDINGS 12
4.1 New Zealand’s Social Reports [http://www.socialreport.msd.govt.nz/] 12
4.2 The political history of the Social Reports 13
4.2.1 Building momentum 13
4.2.2 Establishing the Social Reports 14
4.2.3 Refining the Social Reports 17
4.3 An assessment of the Social Reports’ policy impact 19
4.3.1 Currency in government 20
4.3.2 Currency “beyond government” 23

5. INNOVATIVE FEATURES OF THE SOCIAL REPORTS 26


5.1 Assuring civil society participation, transparency and accessibility 26
5.2 Monitoring the SDH 27
5.3 Monitoring social equity in the Social Reports 28
5.4 Using social reporting to foster inter-sectoral action 32
5.5 Broadening understandings of health and health determinants 32
5.6 Highlighting strengths and using language that is responsive to policy opportunity 33
5.7 Developing social indicators in societies with indigenous populations 33
5.8 Securing on-going, regular, “neutral” social reporting 35

6. KEY LESSONS LEARNT 36

LIST OF ABBREVIATIONS 41

REFERENCES 42

ANNEXES 49
Annex 1: Selected national social reporting schemes 49
Annex 2: Selected supranational and international social reporting schemes 51
Annex 3: E-mail survey 52
Annex 4: Social outcomes domains, desired outcomes and social indicators 54

FIGURES
Figure 1: Pyramidal framework covering outcomes indicators for the Social Reports’
Health domain as proposed to the Ministry of Social Development
by the advisory group assembled by the Ministry of Health 16
Figure 2: Diagrammatic comparison of selected indicators of Social Well-being
for Pacific Peoples, relative to New Zealand Europeans, 2004-2006 30
Figure 3: Summary of findings from the Health domain, 2007 Social Report 30

1
Executive summary

S
ince the “Social Indictor Movement” was pioneered in the mid 1960s, national social reports have
become established tools for the monitoring of social well-being outcomes in many countries. In
line with their mandate, international organizations, including the United Nations system, have
contributed to these efforts with the publication of international social reports. They have also
provided encouragement, technical and conceptual support for Member States to establish national
social reporting schemes and set internationally ratified standards and norms around definitions
and measurement of social outcomes. Intersecting these previous achievements in the area of social
monitoring and the quest for health equity, the recent work of the United Nations Special Rapporteur
on the “right to health” promoted a right-based approach to the monitoring of the realization of the right
to health, implying that health indicators need to include the determinants or conditions for health,
as outlined in the General Comment. In sum, this national and international work has generated a
comprehensive body of theoretical and practical knowledge on social indicators.

Investigating the case of New Zealand’s “Social Reports/ te pūrongo oranga tangata”, the core aim of this
discussion paper is to contribute to answering the research question of how monitoring social well-being
supports a policy agenda aimed at addressing the social determinants of health to improve health equity.
Hence, this study contributes to the WHO goal for improving the dissemination of knowledge to support
action on the broader determinants of population health and health equity (which we term “the social
determinants of health”) - both within and outside the health and government sectors. It builds on the
work of the WHO Secretariat in supporting the global Commission on Social Determinants of Health
and is a contribution by New Zealand, as a country partner, to the body of knowledge on institutions and
mechanisms for supporting implementation of the social determinants of health agenda in countries.

The paper provides a historical overview of how New Zealand’s social indicators reports came to be
generated, describing some of the contextual issues related to the use of the report for monitoring
social progress, and attempts to make a first assessment of their policy impact. Methodologically, the
paper draws on the social reports themselves, as well as diverse secondary academic texts and white
papers of relevance. In addition, the paper draws on structured key-informant interviews, which were
undertaken with five senior policy staff from the Ministries of Health and Social Development and
results of an e-mail survey of 24 key informants, mostly civil society representatives from a range of
different economic sectors.

In New Zealand, a nation with a history of strong social welfare policy, the establishment of social
reports was preceded by a short and jagged pre-history of national interest in and action on social
reporting dating to the early 1970s. These early endeavors were interrupted by governments focusing
singularly on national free-market economic policy reforms which were implemented in the 1980s
and 1990s, eventually leading to a standstill of the national social indicator work. However, motivated
by a change of government in 1999, New Zealand’s emphasis shifted from a sole focus on economic
growth as a measure of progress to include the achievement of social progress, as marked by social
indicators. As part of this general policy re-orientation the New Zealand government also enacted
a broad cross-government initiative aimed at “Closing the Gaps” (later terminology changed to

2
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

“Reducing Inequalities”) between the indigenous Māori and ethnic minority Pacific peoples on
the one hand and non-Māori, non-Pacific New Zealanders on the other in terms of economic and
social outcomes. In this era, achievement of equal rights and a more equitable society again became
central benchmarks of policy. Changes of Administrative changes, such as the formation of the New
Zealand Ministry of Social Development, accompanied these political navigations. The establishment
of the series of New Zealand Social Reports/ te pūrongo oranga tangata (the “Social Reports”), the
first report of which was launched in 2001 by the Ministry of Social Development, was embedded
in these policy and administrative changes. Conceptually grounded in findings from two national
Royal Commissions of Inquiry into Social Security and Social Policy, the reports detail, over time
and often in comparison with OECD reference populations, social well-being organized in ten social
outcomes domains, including a health domain. Following its first release, the reporting underwent
a two-year phase of development, which was marked by careful evaluation (i.e. nation-wide public
and stakeholder consultations) and major conceptual and technical improvements. This resulted in
governmental commitment to on-going, annual publication of the reports. Since 2003, while retaining
the overall conceptual framework, the annual reports have been refined and up-dated, for instance
through the further upgrading of social indicator measures and by using new data sources, when those
become available. There have been attempts to put some legislative or compulsory reporting into formal
government accountability systems around these indicators, but these efforts have been unsuccessful.

In terms of policy impact, the Social Reports have gained some level of prominence in central and local
government. For sectoral public agencies, the Social Reports appear to constitute a valuable policy tool
to foster intersectoral thinking and joint action on the social determinants across sectors. Senior health
officials from the Ministry of Health unanimously agreed that the institution of routine social reports
and the content of these reports have assisted in both raising awareness and stimulating action to address
the social determinants of health to improve health equity, both within and outside the health sector.
However, government agencies concerned with national policies related to economic development and
the Treasury made negligible use of the national social reporting, which significantly limited the report’s
impact. Amongst civil society actors, the Social Reports have gained a good level of currency, especially
amongst health advocacy agencies, health service providers, Māori organizations, academic audiences
and the media. However, the Social Reports have not influenced the business sector.

Some key lessons have arisen from the New Zealand experience of social reporting with respect to
addressing the social determinants of health and health equity. Firstly, social reports can be successfully
used for monitoring social determinants of health and social (including health) equity. To measure
within-country equity, social reports ought to present data disaggregated along the “social determinants
of health inequity”, whereas in order to account for between-country equity, national level social reports
need to include cross-countries comparisons of equity. Social reports need to be published over time,
preferably periodically, to assure time-series of social outcomes are available for equity trend analyses.
It needs to be ensured that an on-going focus on findings with respect to equity, which have arisen from
social reporting, is maintained.

3
Secondly, social reports can catalyse policy action on the social determinants of health, within and
outside the health sector, in government and beyond. They can generate some political will, and action,
with respect to addressing the social determinants of health to achieve health equity. Social reports
can be used to validate and strengthen a health-sector approach focused on addressing the social
determinants, and can enhance intersectoral coordination in support of determinants-based policy-
action. For policy actors from civil society that are concerned with health equity, social reports present a
good advocacy tool by providing official, authoritative, government-sourced data on health (and social)
equity. Social reports can meaningfully be used as a platform to raise awareness of the health outcomes
of disadvantaged populations of specific policy interest (i.e. indigenous people). Social reporting extends
the health-sector focus on health and well-being to the intersectoral notion of social well-being. Such
reporting can also assist in generating national agreement on standard social indicators for national
and international benchmarking.

Thirdly, social reports have the potential to inform the evaluation and design of public policy and
intervention. They can be used to assess the medium and long-term impact of policy initiatives to
reduce social and health inequity. Preferably, social reports explicitly link to policy action and clearly
demonstrate the interconnectedness between their individual outcomes domains.

Finally, social reports need to be developed with a number of core process, conceptual and technical
considerations in mind. If the public, especially diverse disproportionately burdened populations, have
the chance to actively participate in the conceptual development of social reports, and if the reports are
transparent with respect to changes made and easily available free of charge, an emphasis on equity in
social reports is likely be strengthened and public debate and up-take of the reports’ findings increased.
If possible, social reports should be based on positive, as opposed to deficit-based, concepts to enhance
up-take, especially from civil society. To be able to guide action towards addressing between-country
inequities, country-level social reporting ought to be aligned with international social reporting, i.e. by
using internationally standardized social indicators. Only when social reports link their health outcomes
findings to accurate research into the cause/effect relationship between social determinants of health,
policy actions and health outcomes, conclusions can be drawn with respect to causality. Countries
with indigenous populations appear to have the collective need for a distinct set of social indicators
that, developed by indigenous people, have the ability to document trends in indigenous people’s social
(including health) outcomes. It seems advisable to anchor a responsibility to publish social reports in
national legislation.

4
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te
Rep
eports/t
s/tee pū
ppūrongo
ūrongoo oranga tangata”

1 Introduction

I
t has become a widely accepted fact that health impact of social factors in the way they design and
and well-being cannot be addressed from run their health services and programs. Historic
within the health sector alone. In other words, a strategies to address the SDH through intersectoral
multiplicity of social factors influences the health action have been documented (Solar & Irwin,
outcomes of populations. A synthesis of existing 2006), but there is a need for further international
theoretical models (Solar & Irwin, 2010) has exchange of experiences and sharing of learnings
shown that what we term the “social determinants with respect to policy tools, including related
of health”, hereafter SDH, can be divided up institutions, facilitating intersectoral action on
into three distinct blocks: The “socioeconomic the SDH. In the policy context of trying to impact
and political context” (labor market; education on the determinants of health, it is obvious that
system; social policies; and culture, religion monitoring performs a critical function. Across
and human rights), describing the “causes of sectors, it can be used to support accountability
the causes”; the “social determinants of health of different actors who may not form part of the
inequities” (socioeconomic position and social same line ministry or sector impacting on health.
class as expressed through an individual’s or social
group’s income, education, occupation, gender and The human rights literature refers to the monitoring
ethnicity); and, finally, the “intermediary factors” function at the national level as including the
(the material circumstances, psychosocial factors, following mechanisms: (1) administrative, policy,
and behavioral and biological factors, as well as the political mechanisms; (2) judicial mechanisms;
health system and its impact on the distribution and (3) national human rights institutions (see
of sickness, disability and other consequences like the OHCHR/WHO document on “The Right to
impoverishment from catastrophic expenditures). Health” available online PDF [52p.] at: http://www.
Social cohesion and social capital act across the ohchr.org/Documents/Publications/Factsheet31.
two later blocks of determinants to mitigate some pdf). This paper focuses on a somewhat narrower
of the effects of social stratification or intermediary public health and epidemiological definition
factors. The SDH influence the distribution of of “monitoring” by discussing the tracking of
health along the socioeconomic spectrum, causing quantitative trends and relationships between
health inequities, and, as decomposition analysis social and health variables.
has evidenced, for many health outcomes the
SDH contribute more to health inequities than The routine analysis of health inequities
the entire health system (Hosseinpoor et al., 2006; (monitoring in its narrower sense) has been well-
WHO, 2006, 2007a). explored on a conceptual level (i.e. Braveman,
2003, 2006; Gakidou, Murray & Frenk, 2000; Sen,
As a consequence, national governments and 2001) and methodologically (Braveman, 2006;
international health agencies are increasingly Gakidou, Murray & Frenk, 2000; Harper & Lynch,
becoming aware that no matter whether the goal 2006; Keppel et al., 2005; Manor, Matthews, &
is to enhance overall health outcomes or to achieve Power, 1997; Sen, 2001; Wagstaff, Paci, & van
greater health equity, sectors outside the health Doorslaer, 1991; Wolfson, & Rowe, 2001). Health
arena need to be influenced. For health policy- equity monitoring enjoys popularity and has
makers this means thinking and working between become a well-established policy tool in a number
and across sectors as well as considering the of countries. The monitoring of SDH, while still

5
an emerging approach, is attracting increasing forward. However, changes need to be made
national and international attention. For example, to add an equity dimension to this important
the Basket of Health Inequality Indicators 1 international monitoring instrument, as it is
produced by the London Health Observatory currently possible to achieve the MDGs but make
covers a significant number of measures on social equity worse. At WHO itself the WHO Advisory
and economic determinants of health that are Committee on Health Statistics and Monitoring
available down to local authority-level and also (2006) has recommended equity monitoring. This
relevant at the local level, both for monitoring renews efforts towards the institutionalizing of
and for taking actions. To provide a second an operational health equity surveillance system
example, the Netherlands are introducing a multi- from the late 1990s (i.e. Braveman, 1998). Further
level surveillance system for monitoring health to this, the Report of the Commission on Social
inequalities, targeting with their set of indicators Determinants of Health recommends monitoring
those topics aligned with specific governmental of SDH both by WHO and the United Nations
policy objectives (see Case study 16 in Kelly et (UN) system as a whole. After all, countries and
al., 2007). the international community can only know about
with certainty, and act upon, equity trends, if these
The “Social Indicators Movement” has arisen, in are systematically reported.
some senses, in parallel to efforts for health equity
monitoring. It convenes a diverse group of actors This paper aims to contribute to the existing
that more often have statistical or social welfare scholarship on both social indicators and health
backgrounds than “health” backgrounds. equity monitoring through a focus on “how” social
reporting it is done in one country. It explores how
At the international level, the Millennium a tool for reporting on social well-being (“social
Development Goals (MDGs) bring together reporting”) can support a policy agenda aimed
health and social development considerations and at addressing the social determinants of health to
provide a tracking system for the “average” levels improve health equity by conducting a case study
of several social and health variables. Such an of the New Zealand Social Reports/ te pūrongo
approach of following a number of development oranga tangata (hereafter the “Social Reports”).
indicators at the global level is a major step

1 See http://www.lho.org.uk/

6
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

2 Background

S
ocial reporting has become an established in the 1970s, the “Social Indicators Movement”
academic and public policy discipline, sparked, and maintained up to today, world-
enjoying a long tradition both nationally wide interest in the public monitoring of social
and in international settings (e.g. OECD, outcomes (Zapf, 2000). A great number of
European Barometer). To contextualize our New countries have since published national level
Zealand case study, a brief overview of national and social reports (see Annex 1 for a list of selected
international contributions to the “Social Indicator national social reports). Such reporting regimes
Movement” and recent efforts to establish a system are often spearheaded by a government’s statistics
of right to health monitoring and indicators needs department and vary in structure, depending on
to be given. the respective administrative needs they serve.
To provide examples, the German government
has funded an external research agency, the
2.1 The Social Indicator German Social Science Infrastructure Service
Movement (GESIS), to develop the science-based German
System of Social Indicators1, which covers 14 social
Mancur Olson has in his well-known definition outcomes domains with almost 400 indicators and
called a social indicator ‘a statistic of direct over 3000 time series since its initiation at the
normative interest which facilitates concise, beginning of the 1950s. Another well-documented
comprehensive and balanced judgements about example is the emergence of the South Africa Social
the condition of major aspects of a society´. He Indicators series produced by the Center for Social
goes on to say and Developmental Studies biannually between
1983 and 1998 (Møller, 1997) and Statistics South
Africa’s utilization of social indicators to report on
international goals of development (Udjo, Orkin,
& Simelane, 2000).

“It is in all cases a direct measure International organisations and supranational


of welfare and is subject to the administrations have made a three-fold
interpretation that if it changes in contribution to the “Social Indicator Movement”:
Firstly, they have prepared international social
the ‘right’ direction, while other
reports that monitor social outcomes across
things remain equal, things have their various Member States (see Annex 2 for
gotten better, or people are ‘better a list of selected international social reports).
off.’’ For example, the Organisation for Economic
Cooperation and Development (OECD) has
US Department of Health, Education and Welfare played a crucial role in recent times by reviving
its Society at a Glance: OECD Social Indicators
(1968), p97.
publication series (a follow-on from its Living
Conditions in OECD Countries report published
Since its birth in the United States of the mid-
1960s, for instance with Bauer’s (1966) milestone
1 See http://www.gesis.org/en/social_monitoring/social_indicators/Data/System/index.
publication Social Indicators, and its boom period htm
7
only once in 1986) since 2001 (OECD, 2001; needs of all Members States. As another reaction,
2002; 2005; 2006), based on the heavily influential conceptual framing for social indicators servicing
conceptual “OECD Programme of Work on Social the needs of low- and middle-income countries
Indicators” (OECD, 1982). Secondly, as will be was provided in 1979 (UN, 1979). A phase of
demonstrated below with reference to the work in-house debate about the relationship between
of the UN agencies, international organizations social indicators and the overall framework
have taken an international coordination role that they were embedded in followed. The core
with the major goals being to encourage Member contention was ‘whether indicators should
States to develop social reporting regimes at the be viewed as outputs of the overall system or
national level and to offer an on-going technical whether they should be developed in relation to
guidance and support function. Finally, realizing specific policy needs.’ (Menozzi, 2003: 9) and the
the importance of working towards internationally Statistical Commission came to the conclusion
comparable reporting, international organizations that ‘a pragmatic approach, oriented towards
have enhanced the “Social Indicator Movement” user needs should have priority, but that co-
significantly on a conceptual and technical level; ordination and improvement of the underlying
they have set internationally ratified standards data should proceed in parallel, and that a detailed
and norms around definitions and measurement overall system was clearly impractical.’ (Menozzi,
of social outcomes domains and social indicators, 2003: 10). As a response, several lists of social
for instance by compiling social indicator lists. indicators have been compiled since, amongst the
most prominent of which are principal indicator
Within the UN system, social indicator work lists such as the Minimum National Social Data
was often driven by the United Nations Statistics Set (UN, 1996) and the MDGs (UN, 2001).
Division (UNSD) and, according to Menozzi Harmonization and rationalisation of development
(2003) and colleagues (Banda & Menozzi, 2003), indicators (including social indicators) across
has developed in various distinct, yet interrelated international organizations and across countries
phases. The first phase was marked by the has played a major role in recent times (UN, 2000;
publication of a groundbreaking 1954 twin report 2001; 2002), also in the context of the MDGs (UN,
titled International definition and measurement of 2003). Today, the UNSD remains to report on a
standards and levels of living (UN, 1954a, b) and, range of principal social indicators through its
eventually, an interim guide (UN, 1961) which “Social Indicator Programme”2, guided by a report
identified specific social indicators aligned under summarizing the statistical implications of major
twelve distinct components of social outcomes. UN conferences, especially the World Summit for
The major achievement of this early work was that Social Development (1996).
it advocated a ‘component approach’ (UN, 1954a:
18) to social outcomes, hierarchically ranking the
various proposed statistical indicators and, in turn, 2.2 Right to health monitoring
identifying a selected set of indicators of primary and indicators
conceptual importance (Menozzi, 2003). In a
second phase, inspired by the perceived desirability One additional stream of work of the UN provides
of establishing a closer link between social and further context for this case study, namely current
economic statistics, the United Nations Social and efforts to establish a system of right to health
Economic Council (ECOSOC) advanced the field indicators. A right to health approach is strongly
by proposing an integrated “System of Social and linked to, and complements, the notion of health
Demographic Statistics” (UN, 1970). This work, equity. Like a social determinants of health
lead by Noble-prize laureate Sir Richard Stone, approach, it reframes health discourse towards
laid the foundation for the proposal of the UN’ the health of populations as influenced by ‘the
1975 “Framework for Social Statistics”, which social characteristics within which living takes
marked the beginning of the third phase of the place’ (Tarlov, 1996: 72), as opposed to a narrow
“Social Indicator Movement” within international focusing on the health of individuals and the
organizations and mounted in the publication of individualizing notion of “lifestyle factors”, and
preliminary guidelines (1978) and a handbook emphasizes governments responsibility for the
(1989) on social indicators. This work was driven health of all of their citizens, particularly though
by the need to develop a more dynamic and for disadvantaged individuals and populations.
flexible approach to social reporting (hence the The former Special Rapporteur of the United
terminological shift from the more dogmatic
“system” to “framework”) which better suited the 2 See http://unstats.un.org/unsd/demographic/products/socind/
8
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Nations Commission on Human Rights on the process-4 and outcome indicators5 (UN, 2006)
right of everyone to enjoy the highest attainable (the classic framework made popular in health
standard of physical and mental health [“the by Donabedian, 1980). Initially he thought of
right to health”], Mr Paul Hunt (2004: 58), has identifying a list of robust rights to health
stated that ‘in addition to the classic human rights indicators that would then be benchmarked and
methodologies, we need new skills and techniques outcomes monitored along the set targets as a way
if we are to engage effectively in policy-making. of identifying whether governments have fulfilled
For example, we need indicators, benchmarks their international obligations with respect to
and impact assessments that address the right to the realization of the right to health (UN, 2003).
health.’ For him, right to health indicators can fulfil However, concluding findings from his global
two central purposes: First, to assist governments consultation, the former Special Rapporteur
in the monitoring of their progressive realization shifted thinking in his 2006 report, then arguing
of the international right to health; and second, to for a human rights-based approach6 to health
act as an accountability measure for governments indicators. According to the former Special
in relation to their implementation of the right to Rapporteur,
health (UN, 2006).

The former Special Rapporteur in his term from


2003-2008 advocated and conceptually progressed
a system of right to health indicators, arguing
in his first interim report to the UN General “A human rights-based approach
Assembly that ‘what tends to distinguish a right to health indicators is not a radical
to health indicator from a health indicator is departure from existing indicator
less its substance than (i) its explicit derivation
methodologies. Rather, it uses
from specific right to health norms; and (ii)
the purpose to which it is put, namely right to many commonly used health
health monitoring with a view to holding duty- indicators, adapts them so far
bearers to account.’ (UN, 2003: 6). He adds that as necessary (e.g. by requiring
a system of right to health indicators ‘should not disaggregation), and adds some
only reflect specific right to health norms, but new indicators to monitor
also related human rights provisions, including
issues (e.g. participation and
non-discrimination and equality’, emphasizing
repeatedly the particular importance of social accountability) that otherwise tend
disaggregation of the indicators in relation to as to be neglected. In short, a human
many of the internationally prohibited grounds rights-based approach to health
of discrimination as possible as a means to indicators reinforces, enhances
reveal, whether or not marginalized individuals and supplements commonly used
and communities are exposed to de facto
indicators.”
discrimination (UN, 2006: 7).

In his last enterprise, aimed at developing a UN (2006), p8


manageable set of right to health indicators to
4 ‘Process indicators measure programmes, activities and interventions. They measure,
assist governments to monitor the implementation as it were, governments’ effort. For example, the following are process indicators: the
of their national, and international, obligation with proportion of births attended by skilled health personnel; the number of facilities
per 500,000 population providing basic obstetric care; the percentage of pregnant
respect to the right to health, the former Special women counselled and tested for HIV; the percentage of people provided with health
Rapporteur focused attention on structural-3, information on maternal and newborn care, family planning services and sexually
transmitted infections; the number of training programmes and public campaigns on
sexual and reproductive health rights organized by a national human rights institution in
the last five years. Such process indicators can help to predict health outcomes. ‘(United
Nations, 2006: 15)
5 ‘Outcome indicators measure the impact of programmes, activities and interventions
on health status and related issues. Outcome indicators include maternal mortality,
child mortality, HIV prevalence rates, and the percentage of women who know about
contraceptive methods.’ (United Nations, 2006: 15)
3 ‘Structural indicators address whether or not key structures and mechanisms that are 6 The Special Rapporteur explains: ‘Very briefly, in general terms a human rights-based
necessary for, or conducive to, the realization of the right to health, are in place. They are approach requires that special attention be given to disadvantaged individuals and
often (but not always) framed as a question generating a yes/no answer. For example, communities; it requires the active and informed participation of individuals and
they may address: the ratification of international treaties that include the right to health; communities in policy decisions that affect them; and it requires effective, transparent
the adoption of national laws and policies that expressly promote and protect the right to and accessible monitoring and accountability mechanisms. The combined effect of these
health; or the existence of basic institutional mechanisms that facilitate the realization of – and other features of a human rights-based approach – is to empower disadvantaged
the right to health, including regulatory agencies.’ (United Nations, 2006: 15) individuals and communities’. (United Nations, 2006: 7)
9
3 Methodology

D
rawing on the case of New Zealand, To fulfil these objectives, a range of white papers
this study aims to investigate the and secondary, academic texts were collected and
overarching research question of how analysed: All Social Reports were studied in their
monitoring social well-being can support entirety (content; technical aspects; form); the
a policy agenda aimed at addressing the social analysis of the reports informed all four aspects
determinants of health to improve health equity. of the study. Secondary academic literature on
the Social Reports, sourced through a standard
university library search and using the Google
TO ANSWER THIS QUESTION, THE CASE STUDY Scholar databases, informed all aspects of the
AIMS AT FOUR KEY OBJECTIVES: study. Finally, national white papers and media
statements mentioning the New Zealand’s Social
p To document the pre-history, establishment and Reports were sourced through the national Te
refinement of the Social Reports with a particular Puna Web Directory; this data was particularly
emphasis on the associated political climates and useful with regards to contextualizing the policy
motivations and, as part of this historical analysis, to impact evaluation of the Social Reports, and
explore the Social Report’s embedding in broader policy thereby informing the aspects three and four of
initiative addressing the SDH. Findings of this aspect the analysis.
of the analysis are reported in the section titled The
political history of the Social Reports. In addition, given the lack of previous academic
work in this area, key-informant interviews were
conducted to assess the currency of New Zealand’s
p To evaluate the Social Report’s impact on public policy Social Reports in government (objective three).
by assessing the reports’ currency in government, Semi-structured, face-to-face key-informant
especially the public health policy sector, and their interviews of between 45 minutes and 90 minutes
acceptability as progress markers in broader society. duration were conducted in Wellington, New
Findings from this aspect of the analysis are reported in Zealand, with five senior policy-makers  from
the section titled An assessment of the Social Reports’ the Ministries of Health (three informants) and
policy impact. Social Development (two informants) between
February and April 2008. Interviews were audio-
p To describe innovative process, content and technical taped and transcribed. Key-informants were
features of New Zealand’s social reporting scheme, selected on the basis of holding central decision-
with an emphasis on exploring their contribution to making roles in the establishment and on-going
supporting policies concerned with addressing the SDH. development of the Social Reports, and  the
Findings from this aspect of the analysis are reported reports’ health domain respectively.  For each
in the section titled Innovative features of the Social key-informant an individual question catalogue
Reports. was designed to cover the respective informant’s
area of expertise optimally. In this way, the key-
p To synthesize the findings by describing Key lessons
informants’ institutional knowledge about the
political contexts and motivations surrounding
learnt.
the establishment and development of the Social

10
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Reports could optimally be sourced, informing Informants were identified on advice of the
various aspects of the case study (especially previously interviewed key-informant policy-
objectives two and three). However, the main aim makers from the Ministries of Health and
of the key-informant interviews was to assess the Social Development and drawn to represent a
Social Reports’ currency in government from the cross-section of New Zealand society in terms
perspectives of the Ministries of Health and Social of the community sector (iwi/tribal authorities;
Development. organizations representing urban Māori interests;
Pacific Island communities; Asian communities;
To assess how the Social Reports are affecting people living with a disability); the health sector
other social actors outside the health and social (health service providers; health advocacy agencies;
development arena a brief e-mail survey was public health researchers); the social services
developed (see Annex 3). A 9-item questionnaire sector (social and welfare service providers; social
assessed various dimensions of interest. Two policy researchers); local government (city - and
questionnaire versions were sent via e-mail to regional councils); and the economic sector (The
an overall number of 32 informants in May Treasury; Ministry of Economic Development;
2008. The first questionnaire was tailored to business roundtables; chambers of commerce).
the needs of participants from the community, All participants held senior roles within their
health, social and local/regional government organisations, with the great majority of them
sector (sent to 23 participants); the alternative acting at the chief executive level. The majority of
questionnaire addressed health planners and participants represented national organizations.
funders, The Treasury, The Ministry of Economic However, representatives of regional and local
Development and the business community organisations were selected with a view on
(sent to nine participants). The sending of achieving equal geographical spread throughout
the questionnaire was preceded by an e-mail New Zealand. Twenty-four informants completed
providing introductory information about the the e-mail survey.
purpose of the case study, and the function of
the e-mail survey.

11
4 Findings

4.1 New Zealand’s Social Reports Knowledge Branch carries out the country’s social
[ http://www.socialreport.msd. policy development, research, and evaluation,
govt.nz/] covering the areas of income support, child, youth
and family as well as community development.

N
ew Zealand relies on several public
instruments for health equity monitoring Since 2001, the Ministry of Social Development
in the sense of reporting on trends, has released a series of seven annual reports, the
supported in parallel by the work of Social Reports which assess social well-being and
academics with an interest in health equity (i.e. quality of life along ten discrete social outcomes
the Health Inequalities Research Programme domains, namely Health; Knowledge & Skills;
based at the Wellington School of Medicine, Otago Paid Work; Economic Standard of Living; Civil
University). Centrally, the Ministry of Health has & Political Rights; Cultural Identity; Leisure &
set up an advanced system to monitor health equity Recreation; Physical Environment; Safety; and
outcomes, amongst other means through the Social Connectedness (see Annex 4 for a list
New Zealand Health Monitor (NZHM), placing of the social outcomes domains, their desired
particular emphasis on the disproportionate health outcomes statements and the respective social
burden experienced by the indigenous Māori indicators). The reports now follow a standard
and minority ethnic Pacific Island populations. format: A Foreword from the issuing Minister
The Decades of Disparities reports (Blakely et al., of Social Development is followed by the Chief
2004; Ministry of Health, 2003; Ministry of Health Executive’s Preface. Then follows an Introduction,
& University of Otago, 2006), for instance, have which outlines the purpose of the Social Reports,
fulfilled an important function with respect to conceptually defines social well-being, comments
monitoring disparities in mortality between these on the selection of social indicators, reflects on
ethnic groups of interest as well as socio-economic social disaggregation of the presented data, informs
stratification of mortality. The Social Reports on updates to indicators, describes the structure of
complement this established national monitoring the report, and informs the reader about future
work, adding to their reporting of diverse social, developments of relevance to the report. The next
including health, outcomes disparities a measure section of the Social Reports, which is titled People,
of a range of other sectors of relevance to health, analyses trends of key demographic measures, i.e.
which reflect several of the key SDH. population size and growth, ethnic composition,
migration, age and sex structure of the population,
The lead agency for New Zealand’s social reporting and household information. Forming the core of
scheme is the Ministry of Social Development1, the reports, ten sections (one per social outcomes
one of the country’s largest public departments domain,) follow, reporting on trends as measured
and carrying responsibility for a government through social indicators.
vote of over NZ$16 billion. The service arm of
the ministry administers social services to more Each section of the report covering a social outcome
than one million New Zealanders; the policy arm domain is preceded by a statement summarizing the
embodied in the Social Development Policy and respective domain’s desired overall social outcome,
followed by a definition of the domain’s leading
concepts. After that, each indicator function is
1 See www.msd.govt.nz

12
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

defined, its relevance is explained, the indicator’s 4.2.1 Building momentum


current status and trend over time described, and
New Zealand outcomes compared internationally Following international trends, the 1970s in New
with selected OECD countries. If meaningful, and Zealand were a period of striving interest in and
given that the required data is available, outcome public investigation of conceptually defining, as
measures are presented disaggregated by ethnicity, well as measuring, social well-being. The first
sex, age, disability status and geographic location. national milestone that was achieved in this respect
The Conclusion synthesizes and integrates findings was the 1972 report of the Royal Commission
from the previous sections, reporting changes in on Social Security (also called the “McCarthy
social outcomes for New Zealanders over the longer Commission”), which comprehensively defined
term, sometimes with a thematic focus. The report is what social well-being meant for New Zealanders.
completed by a user-friendly tabulated summary of Following on from and adopting the Commission’s
findings which provides snapshot-type comments approach, the Social Development Council, set
about the essence of changes in social well-being. up in 1971 in the Department of Social Welfare,
developed and published in its 1974 report a set
of eight social objectives centred on the goal of
Disaggregation by social increased social well-being and quality of life,
stratifiers in the 2006 Social but founded in the desire for greater equality in
Report opportunities for all.

The 2006 report, for instance, drew together data sets At the same time, the Council urged the
from the early 1980s in order to provide a picture of Government to establish a social indicator system
how the social conditions of New Zealanders today to fulfil a social outcomes monitoring function.
compare with conditions before the national neo-
The Government responded by setting up as part
liberal economic reforms of the 1980s and 1990s.
It also compares New Zealanders’ social well-
of the national Department of Statistics the Social
being with that of people living in Australia and in Indicator Unit in 1976, which developed an interim
reference to outcomes in the OECD countries and list of social indicators (Department of Statistics,
features changes in social outcomes over time by 1978; updated in 1980) in alignment with the
sex and ethnicity (Maori, Pacific peoples, Asian and social goals defined by the Social Development
Other ethnic groups relative to the New Zealand Council and social indicator sets developed by
European population). Here, short statements, the OECD. In collaboration with the National
visually highlighted, give the reader a quick summary Commission for UNESCO2, which provided a
impression of changes over time for each social link to international social indicator work, the
outcomes domain (i.e. when comparing by sex: ‘Men Department of Statistics convened in 1979 the two-
generally have better Paid Work outcomes than
day Workshop on Social Indicators for Development,
women, though the gap has narrowed’ or ‘Although
female Health outcomes are generally better, the gap
aiming to review progress in the construction and
is closing’). application of social indicators. Informed also by
findings from an unpublished 1974 report from
the Planning Advisory Group on Social Statistics
and the Departments of Statistic’s Social Trends
in New Zealand document (1977), this effort
4.2 The political history of the culminated in the proposal of a collection of key
Social Reports indicators organized in the eight subject domains
put forward by the Social Development Council
The Social Reports as they are today have arisen in 1979 (Cant, Hill & Watson). In 1988, the Royal
from a confluence of changes in New Zealand’s Commission on Social Policy updated definitions
political ideology at the turn of the millennium, of social well-being and re-iterated earlier calls for
associated shifts in the organization of public a thorough national reporting regime.
administration as well as related social science
movements in New Zealand and, to some In parallel to these official movements, geographers
degree, internationally. In order to provide a inspired by a national surge of interest in “social
comprehensive historical overview, we discuss area analysis” showed an interest in social well-
this history in terms of three phases: three building
momentum; establishment; and refinement. 2 This commission acted on behalf of the SDC, the Department of Statistics, the NZ
Planning Council, the National Research Advisory Council and other government
departments and agencies.

13
being indicators for rural and urban geographic of disparities in mortality (Ministry of Health,
areas, calling them “territorial indicators” 2003) and socio-economic resourcing (Ministry
and eventually developing maps and indices of Health & University of Otago, 2006) between
of such indicators from Census New Zealand the indigenous Māori, as well as New Zealand-
data (Crothers, 2006). A parallel stream of based Pacific Island minority populations, and
social indicator work was initiated by the Social non-Māori, non-Pacific New Zealanders during
Monitoring Group of the New Zealand Social the 1980 and 1990s. Some commentators accused
Planning Council (1985; 1989) and, after the the governments during these administrative
council’s abolishment in 1992, upheld by Victoria periods of ‘actively endeavouring to suppress
University’s Institute of Social Policy (Davey, 1993; any systematic information about the social
1998; 2003). Divergent in its approach, this series consequences of its economic policies’ (Crothers,
of social reports titled Tracking Social Change in 2006: 3). At the same time, economic and financing
New Zealand: From Birth to Death organized social monitoring systems were strengthened to the point
outcomes along several life-stages, and critical life that they became anchored in national legislation,
events respectively (for a detailed review of this for example with the passing of the 1994 Fiscal
reporting regime see Davey, 2000). Responsibility Act3, which obliges The Treasury
to publish immediately before an election a full
After this progress had been achieved up to the account of Government finances.
1970s, so argues Corthers (2006), national work
regarding social indicators went into recession 4.2.2 Establishing the Social Reports
due to broader political and international
developments. In the early 1980s a dramatic shift When the Labour Party administration
in economic policy took place in New Zealand. took office in 1999, a Cabinet Committee
Known as “Rogernomics”, a portmanteau of called “Closing the Gaps”, chaired by the Prime
“Roger” for New Zealand’s former Labour Minister Hon Helen Clark and overseen by the
Finance Minister Roger Douglas appointed in Department of the Prime Minister and Cabinet,
1984, and “economics”. This reform shifted the was established to coordinate a whole/all-of-
national economy rapidly from Keynesianism government initiative to address the economic,
to a neo-liberalist paradigm. Centred on the health and social inequities that Māori and Pacific
introduction of free-market policy to the exclusion people experienced. Government departments,
of many regulatory functions of government including the Ministry of Health and The Treasury,
these economic changes, that were introduced were required to report regularly to the Committee
by the Labour Party and strengthened following on initiatives being led by the ministries and work
a change to a National Party government in of the different sectors relating to the “Closing
the 90s, included privatization of public assets, the Gaps” agenda. This led to standard reporting
state-control of inflation, cutting of agricultural of such initiatives in many public reports since
subsidies, and abolishment of former trade 2001 and to sectoral policy alignment with
barriers. As has since been well-documented, such
changes caused an increase in health and social
inequities, indicated for example by a widening 3 While repealed in 2005, the 2004 Public Finance Amendment Act incorporated the same
provision

Supporting the Reducing Inequalities in Health Strategy


Within the Ministry of Health, efforts to level the disparities in mortality and morbidity between Ma-ori, Pacific Islanders
and non-Ma-ori, non-Pacific New Zealanders were jointly led by the directorates of Public Health (including the Pacific
Health Branch) and Ma-ori Health. After public debate about whether the “Closing the Gaps” initiative disadvantaged
non-Ma-ori, non-Pacific New Zealanders, the Cabinet Committee was renamed the “The Social Inequalities Cabinet
Committee” and chairing, as well as reporting (Minister of Social Development and Employment, 2003a; 2003b),
shifted from the Prime Minister to the Minister of Social Development and Employment, Hon Steve Maharey, in 2003.
In line with these changes, the work of the Cabinet Committee was eventually transferred to the Ministry of Social
Development, which has maintained its coordinating role to-date, including convening the Reducing Inequalities
Officials Committee (RIOC)1. Since then, the mandate to set up reducing inequalities initiatives has returned to the
powers of the respective ministries.

1 See http://www.msd.govt.nz/work-areas/cross-sectoral-work/reducing-inequalities.html

14
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

this overarching strategic goal. For example, set up in the form of a task force to directly mirror
looking back on a long tradition of focusing on the Treasury group, the Cross-Sector Strategy
the reduction of health inequities (Matheson, Group, which had previously influenced strategic
2007), the Ministry of Health (2002a) published social policy issues. Supported by the ministry’s
its Reducing Inequalities in Health Strategy in Knowledge Management Branch and a small
2002. This policy document emphasized ministry reference group of social science academics and
understanding that health outcomes disparities other researchers, the Strategic Social Policy task
were caused by the unequal distribution of the force rapidly developed, in collaboration with a
SDH. broad range of 30 government departments, a set
of key outcomes and social indicators. Returning
Alongside this broader government initiative to conceptually to the foundations set by the 1972
achieve a higher degree of economic and social and 1988 Royal Commissions, but in addition
equity, renewed public interest in national social drawing on internationally ratified conventions
indicator development resurfaced again in New (i.e. human rights conventions) and incorporating
Zealand in 2000. Besides the publication of a the most recent national and international research
key article compiling fundamental data sources as to what constitutes social well-being, this work
for social reporting in the New Zealand Journal formed the basis of the first New Zealand Social
of Social Policy (Crothers, 2000), a trip by then Report.
Minister of Social Development and Employment,
Hon Steve Maharey, to the United Kingdom of One major breakthrough was to involve a range
Britain inspired this progress (Crothers, 2006). of other government departments to assist with
During his overseas visit the Minister had the development of those indicators of interest
been impressed by the British government’s to them. This assured not only a greater sense
“Opportunity for All” poverty-reduction scheme, of ownership, and up-take, of the reports across
especially the scheme’s targeted goals and, upon government, but also that the proposed eight
return to New Zealand, instructed his ministry domains were populated with an optimal array of
to, within a very short period of a few months, indicators chosen by experts from the respective
develop a set of social indicators that could monitor sector. Importantly, Te Puni Kōkiri, the Ministry
targets for social achievements desired by the New of Māori Affairs, was also involved throughout
Zealand government (Crothers, 2006). Hence, the all steps of the development of the reporting
Ministry of Social Development, created by the framework.
Government in October 2001, which in its core
strategic function had a broad cross-sectoral social The health domain of the Social
policy role, successfully put forward the proposal Reports
to lead the development of a social reporting The process underpinning the development of the
scheme based on its Social Development Strategy Health domain involved the Ministry of Social
(Pathways to Opportunities; Ministry of Social Development approaching the Ministry of Health
Development, 2001a). to request them to lead the development of the
health indicators. The ministry agreed to take on
Organizing the Social Reports this task and set up an advisory group consisting
The Cabinet, as well as government agencies of representatives mainly from the Public Health
and civil society groups (Ministry of Social and Māori Health Directorates and the Public
Development, 2002a), saw the Ministry of Social Health Intelligence Unit. In alignment with the
Development as the preferable lead agency for the ministry’s overall strategic approach, the advisory
monitoring of social indicators in spite of the fact group developed, and proposed to the Ministry
that the national Statistics Department (Statistics of Social Development, a pyramidal framework
New Zealand) is armed with the constitutional covering the relevant outcomes indicators (see
protection to publish independently from political Figure 1): health expectancy (operationalised as
processes, because Statistics New Zealand, independent life expectancy) was conceptualized as
according to officials from the Ministry of Social the peak summary measure of population health
Development, was reluctant to define social well- as it integrates mortality (fatal or quantity of life
being and to make more normative judgments. dimension) with disability (functional limitation
The Strategic Social Policy function within the or quality of life dimension). This was broken
Ministry of Social Development, the lead agent down into its two components - life expectancy as a
pressing for the social reporting scheme, had been measure of the length of life (premature mortality)

15
Figure 1. Pyramidal framework covering outcomes indicators for the
Social Reports’ Health domain as proposed to the Ministry of
Social Development by the advisory group assembled by the
Ministry of Health

Health
expectancy

Life Disability
expectancy (functional
(mortality) limitation)

Morbid processes
(diseases and injuries)

Risk factors
(behavioural and biological)

SDH
(knowledge & skills, paid work, economic standard of
living, civil & political rights, social connectedness, cultural
identity, leisure & recreation, safety, physical environment)

Source: Dr. Martin Tobias, Ministry of Health

and disability requiring assistance as a measure of Social Development was the limited number of
quality of life (functional limitation). On the next indicators allowed per domain (initially no more
level down were the morbid processes (disease than five indicators; later the number increased
and injury processes, i.e. cancer, cardiac disorders, to six). Two top level indicators (independent
oral disease, mental disease, injury) which produce life expectancy; life expectancy) were undisputed,
the fatal and nonfatal outcomes on the higher and it was decided unanimously that disability
level. On the fourth level of the pyramid were status would be treated as a non-health specific
the behavioral and biological risk and protective variable and reported on throughout all outcomes
factors that are the proximal causes of the morbid domains rather than restricting it exclusively to
processes (operationalized for instance through the Health domain. However, debate was centered
indicators assessing diet, physical activity, obesity, on the selection of measures indicating morbidity
cigarette smoking, and alcohol use). The SDH, and risk factor indicators, eventually settling on
which determine risk exposure, comprised the suicide as a proxy for mental health status and
foundation level of the conceptual framework two indicator measures from the risk level of the
and were covered by the other seven outcomes pyramid, namely cigarette smoking and obesity. In
domains of the Social Report. this debate, the Ministry of Social Development
advocated for behavioral measures, whereas
The indicator model was presented to and health officials had expressed their preference
discussed with the Ministry of Social Development for morbidity indicators, acknowledging that
and external academic expert committees the risks, which deficit-thinking can induce for
specifically called by the Ministry of Health. A instance in the form of victim-blaming, needed to
major constraint imposed by the Ministry of be avoided. This was seen as particularly relevant
16
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

for the reporting of behavioral indicators such as report was virtually universal with those consulted
obesity and cigarette smoking, which was especially commending its cross-sectoral, holistic approach,
problematic when reporting indigenous versus its simplicity and breadth and its ability to be used
non-indigenous inequalities. However, there was by a wide audience.
agreement over the fact that the danger that using
deficit-based, behavioral indicators posed could be
managed, for instance by assuring contextualizing
of outcomes inequities as the result of political and
systemic presses on populations as opposed to “They [the public and stakeholders]
the result of lifestyle choices of individuals. Using liked the fact that the report
positive, visionary and inspiring language in the
collected information from a range
Social Report texts was also seen as counteracting
deficit-model thinking. of sources and on a variety of
topics, and appreciated the report’s
4.2.3 Refining the Social Reports neutrality, its impartial view and its
aim to be politically independent.”
Although the Minister of Social Development
promoted the 2001 Social Report prototype, as a
Ministry of Social Development (2002a), p1.
first step towards the establishment of a regular
national social reporting scheme, the frequency of
the reporting was not determined from the start. Nevertheless, the review paper also identified three
Hence, the launch of the first Social Report, which overarching critiques that had been voiced in
attracted major public and media attention, was relation to the reporting scheme, namely: (1) ‘the
followed by a two-year trial period, in which the need for it to be linked to action and policy; (2)
Ministry of Social Development aimed to assess the need for the report to continue and concern
the feasibility of publishing the Social Reports on over its vulnerability; and (3) the need for it to
an annual basis. The second Social Report was include or be linked to regional information.’
released in 2002(Ministry of Social Development,
2002b), accompanied by the initiation of the Social Maori views in the consultation
Report website4 making the free-access reports process
available on-line. However, no changes were made The consulted Māori groups were generally
to the domains and indicators: the second report positive about the fact that the Social Reports
was a simple online update of the first Social conceptualized well-being in a broad and holistic
Report. way, an approach which aligns well with aspects of
Māori models of health (Durie, 1984; 1985; Pere,
Consultations in compiling the 1984) and associated Māori health development
second Social Report (Durie, 1998) and health promotion approaches
In the course of compiling the second Social Report, (Durie, 1999). On the other hand, Māori voiced
the ministry with the help of an independent a range of concerns. Firstly, they wanted to see
reviewer conducted an extensive nation-wide a strengthening the Social Reports influence in
review seeking to evaluate the usefulness of policy-making to avoid them becoming ‘yet
the initiated social reporting scheme. This another report highlighting poor outcomes for
assessment encompassed several rounds of public Māori without leading to anything being done
and stakeholder consultations, including with about them’ (Ministry of Social Development,
various community groups, non-governmental 2002a: 12). Secondly, pointing towards the (then
organizations, academics, urban Māori groups draft) United Nations Declaration on the Rights
and three iwi/tribes (Kai Tahu, Te Arawa and of Indigenous Peoples as useful reference material
Tainui), Pacific peoples, trade unions and business to inform the Social Reports, several Māori groups
people, as well as consultation with representatives felt concerned about the lacking prominence of the
from central, regional and local government, 1840 Te Tiriti o Waitangi/The Treaty of Waitangi5
including members of parliament. The ministry in the 2001 report prototype. Indeed, they wanted
summarized findings from the consultations in to see the treaty included as an overarching
an official review paper, which pointed out that
‘Support for the existence of a social indicators 5 Te Tiriti o Waitangi/ The Treaty of Waitangi is a treaty signed on 6 February 1840 by
representatives of Māori chiefs from the North Island of New Zealand and the British
Crown. It is considered the founding document of New Zealand. For more information
4 See http://www.socialreport.msd.govt.nz/ see www.treatyofwaitangi.govt.nz and http://www.waitangi-tribunal.govt.nz/treaty/.
17
framework to assure acknowledgement of the Moving ahead following the
treaty-partnership between Māori and the Crown. consultations
Third, Māori expressed the desire for indicators Despite some concerns, the consultations showed
measuring positive aspects of Māori life (i.e. that overall the social reporting scheme was viewed
the strength of whānau/Māori families) to be as a step in the right direction, and had found broad
included in the Social Reports in order to balance support. The decision was made by government
out indicators highlighting poor outcomes. to commit to long-term, annual reporting, even
though annual reporting was opposed by all or
Māori stakeholders also critically questioned why almost all contributing government agencies, who
the reports did excluded Māori-specific health argued that not only was it impossible to update
indicators (Ministry of Social Development, most indicators annually, but that social change
2002a: 47). proceeds slowly and looking at year-on-year changes
could be meaningless, if not actually misleading.
However, with the integration of the obtained
International momentum on indigenous people’s feedback in the 2003 Social Report (Ministry of
health and measurement Social Development, 2003), the reporting scheme
entered into a phase of substantiation and technical
As indigenous people’s health increasingly gains global priority, a conceptual
refinement.
framework for measuring indigenous people’s social and health outcomes has been
proposed (Marks, Cargo & Daniel, 2007). Indigenous scholars, lead by Dr Janet Smylie,
University of Saskatchewan, Canada (co-principal investigators: Dr. Suzanne Crengle, In 2003, the People section, detailing demographic
University of Auckland, New Zealand, and Dr. Ian Anderson, University of Melbourne, trend information, was introduced, and, in
Australia), have joined forces to investigate ‘Action oriented indicators of health and reaction to feedback obtained in the consultation
health systems development for indigenous peoples in Australia, Canada, and New rounds, three of the social outcomes domains
Zealand’. This research has culminated in various topical papers (Anderson, Anderson were renamed to better and unambiguously reflect
et al., 2006; Anderson, Smylie et al., 2006; Smylie et al., 2006), including a background their core meaning (Civil & Political Rights instead
paper on Ma-ori health indicators (Ratima et al., 2006). Ratima et al.’s paper points out of Human Rights; Cultural Identity instead of
that ‘Ma-ori have repeatedly expressed concerns that while universal health indicators Culture & Identity; Physical Environment instead
are important, they are limited in their capacity to capture the state of Ma-ori health
of Environment)7. In addition, certain standard
according to Ma-ori concepts of health (Durie 1994; Pomare, Keefe-Ormsby et al. 1995).
practices were established: firstly to refine and
Others (Smylie et al., 2006) (2006: 2029) acknowledge furthermore that the Ministry
of Health’s (2002b) He Korowai Oranga- Ma-ori Health Strategy framework provides a improve indicators in each report, if new data sets
valuable model for achieving a balance of universal and indigenous-specific health had become available or better measures had been
indicators, given that it ‘can recognise both universal indicators of health such as developed, and secondly to describe in detail all
mortality and disability, and Ma-ori-specific indicators such as social determinants, conceptual changes made in the new report in
secure cultural identity, and control over one’s destiny.’ The authors of the same an appendix, in effect providing a high level of
paper stress also that ‘The development of He Korowai Oranga included consultation transparency of conceptual and technical changes.
meetings and written submission as methods of gaining Ma-ori input’ (Smylie et al., Also, as a result of the 2002 consultations (Ministry
2006: 2029). of Social Development, 2002a), the last major

definitions but recognises the wide diversity of families represented within Māori
communities. It is up to each whānau and each individual to define for themselves who
their whānau is.’ (Ministry of Health, 2002b: 1)
One specific example of the gap that is created Key desired outcomes for the goal of ‘whānau ora’ are that
‘• whānau experience physical, spiritual, mental and emotional health and have control
by the lack of Māori-specific health indicators is over their own destinies
that the Social Reports can, for this reason, not • whānau members live longer and enjoy a better quality of life
• whānau members (including those with disabilities) participate in te ao Māori and
capture the communitarian dimensions of Māori wider New Zealand society.’ (Ministry of Health, 2002b: 1)
constructions of health as prioritized in the He 7 The 2003 (Ministry of Social Development: p. 138) report provides following explanation
for the re-naming of the respective three outcomes domains:
Korowai Oranga- Māori Health Strategy through ‘For The Social Report 2003, civil and political rights replaces human rights as a desired
the overarching aim of achieving “whānau ora” social outcome. The more specific notion of civil and political rights excludes economic,
social, and cultural rights. These were included under the heading of human rights in
(the health of Māori families)6. the earlier report. We have done this because the protection of economic, social and
cultural rights is already covered in the social report by the desired social outcomes
relating to health, paid work, knowledge and skills, economic standard of living, and
6 ‘He Korowai Oranga asks the health and disability sectors to recognise the cultural identity. Including these outcomes again in a human rights domain just creates
interdependence of people, that health and well-being are influenced and affected by unnecessary duplication.
the ‘collective’ as well as the individual, and the importance of working with people in The culture and identity domain from 2001 has been replaced by a cultural identity
their social contexts, not just with their physical symptoms.’ (Ministry of Health, 2002b: domain. We received feedback the 2001 domain was confusing as to whether culture
1). This notion is epitomized in the startegy’s overarching aim of achieving ‘whānau referred to arts and heritage or to identity and belonging. The 2003 desired social
ora’/ the health of Māori families. The strategic document gives the following definition outcome focuses explicitly on the contribution cultural identity and a sense of belonging
of whānau:‘Whānau (kuia, koroua, pakeke, rangatahi and tamariki) is recognised as make to social well-being.
the foundation of Māori society. As a principal source of strength, support, security Physical environment replaces the environment domain for The Social Report 2003. The
and identity, whānau plays a central role in the well-being of Māori individually and new physical environment domain focuses on the contribution to social well-being of
collectively. The use of the term whānau in this document is not limited to traditional both the natural and built environments.’
18
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

change to the overall reporting structure came one of the drafting of a Social Responsibility Act with
year later, when a new outcomes domain (Leisure the function to constitutionally ground social
and Recreation) was added, bringing the number of reporting (Ministry of Social Development,
outcome domains to ten altogether and increasing 2002a), mirroring the provisions made for
the number of indicators from 38 to 43 (Ministry economic reporting under the 1994 Fiscal
of Social Development, 2004). Responsibility Act. However, some interests
claimed that introducing such legislation would
Since these changes were instigated, reports equate to “political correctness” (Crothers, 2006),
(Ministry of Social Development, 2005a; 2006a; and the act was never put before Cabinet. In
2007a) have maintained the 2004 format. Each effect, this means that, given the Social Reports
reporting cycle commences with the Ministry are ministry-based, they could be abolished by
of Social Development holding meetings with future governments.
all contributing agencies (about 40 government
departments), in which the situation and Posing another potential threat for the continued
performance of the previous Social Report is existence of the Social Reports, policy changes
critically discussed and assessed. On top of this have emerged recently which challenge the Social
internal evaluation process, the ministry envisages Reports’ significant interface with broader all-
that every five to ten years an external review is of-government initiatives to reduce inequalities.
commissioned, similar to the comprehensive, Government has navigated toward having four
national consultation meetings held in 2002. overarching themes (“Building national identity”;
Employing this process, the Social Reports are able “Families, young and old”; “Transforming the
to dynamically respond to feedback, and adapt to economy”; and “Sustainable New Zealand”). Health
contemporary national policy needs. policy staff shared the perception that the whole-
of-government agenda on reducing inequalities
One noteworthy addition to the national Social had lost influence and thought that the Ministry of
Reports was the introduction of the Regional Social Development has, to some degree, bundled
Indicators reports since 2005 (Ministry of Social the social inequalities agenda into the Social Reports,
Development, 2005b; 2006b; 2007b). These which still carries on its monitoring. Ironically,
documents disaggregate national data to the this move coincides with the release of official
regional and Territorial Authority-level, visually reports indicating, with regards to health outcomes,
mapping how social well-being varies across New a narrowing of the inequalities between Māori and
Zealand, ranking outcomes by shading regions Pacific people on the one hand and non-Māori
along a color spectrum from best to worst. non-Pacific New Zealanders on the other (Blakely
Individual regional booklets, downloadable et al., 2007) which can be interpreted as providing
from the Social Reports webpage, provide further medium-term evidence for the success of health
geographical break-downs of the regional data, policy initiatives in this arena implemented over
including decomposition by ethnicity, sex and the last nine years.
age. These additions support decision-making at
the regional and local level, responding to local One option for future of the Social Reports was
and regional policy needs that have arisen from to develop a mathematical model, which could
legislative change (e.g. the passing of the 2002 proxy and predict social development in a more
Local Government Act, which, for instance, vests summarized, compressed form, using all the
responsibility for the health and social needs of relevant indicators. However, the challenge is to
communities residing within their boundaries to generate inter-sectoral indicators, for which very
local and regional government, including District few models exist to-date. For this endeavour, a
Health Boards), but also servicing requests from health-centric approach might prove pivotal given
civil society groups for geographic disaggregation the high level of information available about health
of social outcomes. outcomes and how they are influenced by other
sectors through the SDH.
Possible threats to sustainability
Although the reports have now entered a phase
in which, following testing, a firm reporting 4.3 An assessment of the
framework has emerged, a critical issue is that Social Reports’ policy impact
social reporting has not been enshrined in national
legislation. This is despite the Ministry of Social When the Social Report was first mooted, it was
Development having investigated the desirability hoped that its assessment would become as socially
19
relevant as gross domestic product (GDP), i.e. the this approach, the reports were also not
nation would use social indicators in assessing seen to function as an evaluation tool for
“how well we are doing”. the effectiveness of specific public policies,
but instead for broader government
The Social Reports list the following four key policy direction.
functions (reprinted in every Social Report, for
example Ministry of Social Development, 2007a: 5): An additional function, while not explicitly noted
1 ‘to provide and monitor over time in the report, is the role that the Social Reports were
measures of well-being and quality of expected to serve with respect to the monitoring
life that complement existing economic of social equity. Indicative of this function, issuing
and environmental indicators’. Besides Ministers of Social Development, on the basis
providing an account of the level of New of the reports’ findings, commented on equity
Zealanders’ social well-being over time, in social outcomes in their introductions to the
the Social Reports also make apparent reports. In 2002: ‘the disparity between groups
how population groups of particular within the population in terms of their standard of
policy interest (i.e. the indigenous Māori living and their health and educational outcomes
population; ethnic minority populations, remains relatively high’ (Ministry of Social
especially Pacific people; low socio- Development, 2002b: 1); in 2003: ‘a third cross-
economic strata; women; the elderly; the cutting issue is the need to address continuing
disabled) are faring. inequalities and high level of disadvantage in
2 ‘to compare New Zealand with other Māori and Pacific communities’ (Ministry of Social
countries on measures of well-being’. Development, 2003: 7); in 2006: ‘although there
Detailed comparisons with the upper are still disparities between Europeans and other
and lower quintile of OECD countries, ethnicities, the report shows real gains for these
plus neighbouring Australia, were seen as other groups.’ (Ministry of Social Development,
providing important context to national 2006a: 1).
social outcomes and as strengthening the
government’s accountability with respect These various functions were underpinned
to between-country equity. by the government’s overarching vision of an
3 ‘to provide greater transparency in equitable, fair, socially inclusive, prosperous and
government and to contribute to better environmentally sustainable society that embraces
informed public debate’. Given its diversity and is based on the value of equality of
commitment to evidence-based policy- opportunity (Ministry of Social Development,
making and New Zealand’s recent social 2001). An assessment of the currency of the reports
policy renaissance, the ministry also in government, especially also the economic sector,
saw a need for the Social Reports to be and beyond is helpful in considering the usefulness
established as a public record assuring the of developing such reports for policy-makers.
government’s accountability in the social
policy arena. 4.3.1 Currency in government
4 ‘to help identify key issues and areas
where we need to take action, which can The Social Reports have gained some level of
in turn help with planning and decision currency within central and local government,
making’. The Social Reports were envisaged mostly in intersectoral and less so in sectoral
to assist government with the identification public agencies. To bring together a great number
of adverse social trends at an early stage, of government institutions to develop the social
in turn supporting the formulation of reporting framework jointly and then produce
further research needs and the design of annual Social Reports, has been a good strategy
policy solutions. However, the reports were that helped to achieve the report’s current level of
designed with the belief that they would prominence and application.
not always be able to illuminate the drivers
of these trends, because of the multiplicity At the highest level of policy-making, at the
and cross-cutting nature of national and Cabinet, the Social Reports have played the role
international factors impacting on New of bringing social conditions together into one
Zealander’s social well-being. In line with picture and increasing visibility (thereby working

20
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

towards an understanding of social well-being work program for this initiative (Chair of the
in the same way but not to the same extent that Cabinet Social Development Committee, 2004)
economists have made visible economic well- in 2004, which specifically aimed for improved
being). Besides the 43 indicators from the Social coordination of policy across agencies. To fulfill its
Reports, about a dozen or so well-established monitoring mandate within this policy framework,
economic measures (i.e. Gross Domestic Product, the ministry published a document summarizing
Unemployment rates, Cash rates) and maybe trends of social well-being disparities for Māori
another dozen key indicators around sustainability, and Pacific populations, providing absolute and
mainly the environment, have significant currency relative outcomes measures and tabulating them
in today’s policy environment. When all of these together with those respective government policy
indicators need to be considered together is when initiatives expected to reduce the outcomes
the Social Reports become most useful. However, disparities (Strategic Social Policy Group, 2004).
at this level of policy-making the weakness of the This work effectively aligned the whole/all-of-
reports is that the ten outcomes domains are still government initiative with the social monitoring
siloed and that there exists a lack of information regime, even structuring the reporting according
about the explicit, direct conceptual cross-links. to the Social Reports’ well-being domains (see
Strategic Social Policy Group, 2004). However, this
Cabinet ministers reporting has not been repeated since 2004, maybe
Cabinet ministers, above all the Minister of due to a weakening of the reducing inequalities
Social Development, have used the reports as a agenda within government as mentioned earlier
platform to reflect on the causes of improvements with reference to the four overarching themes
in the nation’s social well-being, for instance (“Building national identity”; “Families, young
expressing the opinion in 2004 that ‘recent and old”; “Transforming the economy”; and
government policies have made an important “Sustainable New Zealand”). Although, this trend
contribution to these improvements’ (Ministry of has been observed elsewhere, e.g. South Australia,
Social Development, 2004: 3), but also on behalf and does not necessarily indicate a reduced role for
of the government thanking non-governmental health and SDH. In the South Australia example,
organizations in the latest report for their a health-in-all-policies strategic approach was
contribution to the observed improvements in employed to connect health equity and SDH issues
social outcomes over time (Ministry of Social to the South Australia Development Plan (ref.
Development, 2007a). Similarly, talking about http://www.health.sa.gov.au/pehs/publications/
better support for low-income families through the public-health-bulletin.htm#2008).
introduction of income-related rents, the Minister
of Social Development stated in 2005 that ‘it is Statistics New Zealand
exciting to see these policies beginning to pay The national Statistics Department, Statistics New
dividends’ (Ministry of Social Development, 2005a: Zealand, also made use of the Social Reports in
3). In these instances, the minister used findings a similar way, namely by applying the outcomes
from the Social Reports as an evaluative measure domains and indicators used in the Social Reports
for public policy, although it is questionable for monitoring of the social aspects of New
whether outcomes described in the report can Zealand’s Sustainable Development Program
really be linked to policy, especially specific policy on (Statistics New Zealand, 2002a). Moreover,
initiatives, in the short term. Statistics New Zealand officially acknowledged the
Social Report as a prominent source of national
information on social capital (Statistics New
The Ministry of Social Development Zealand, 2002b).
Within the Ministry of Social Development,
the Social Reports have achieved a good level of The Ministry of Health
currency and application. One key function that Within the Ministry of Health, policy application
they have taken on in this ministry is to serve of the Social Reports was moderate. The health
as an overall guide for the monitoring of New domain indicators reported in the Social Reports
Zealand’s whole/all-of-government “Reducing were of limited use for national health policy-
Inequalities” policy initiative. The responsibility makers, because national health information
for this initiative had shifted to the Ministry of systems provided a much higher level of detail and
Social Development after Cabinet agreed to a analysis, but for some ministry staff the reports

21
acted as reference documents for health-relevant or not.). A third issue raised was that data in the
data across a wide range of sectors (i.e. health, social Social Reports does not cover the same time periods
services, education and justice). Nevertheless, of (sometimes more than 3 years out of date), making
much more importance for ministry staff was it harder to identify overarching trends. For The
the signal function that the reports carried. For Treasury, fourthly, the presented data does not
health policy-makers they confirm a holistic, give the full policy picture in the area of concern
determinants-based, intersectoral approach to (e.g. data on school leavers by ethnicity (Ministry
policy-making, which has been promoted by the of Social Development, 2007: 37) shows increases
health sector for some time. That another agency in all ethnicities achieving the National Certificate
(Ministry of Social Development) took ownership of Educational Achievement (NCEA) level 2; but a
of, and promoted to other government agencies, vital element of the overall picture is missed unless
such a determinants-based approach received the increase in the number of Māori boys leaving
Ministry of Health endorsement. Ministry of with no qualifications is also noted). Finally, The
Health staff also argued in favor of the Social Treasury was concerned about the quality of data
Reports that they increased the understanding of being mixed, arguing that, for instance, the figures
other public agencies with respect to how their for early childhood education participation (Ministry
initiatives impact on other sector’s outcomes (i.e. of Social Development, 2007 : 34) are in no way as
health). The Social Reports were also attributed an robust as for instance NCEA level 2 achievement
important function in terms of raising awareness rates given on the next page.
of the SDH and they were viewed as useful tools
for health officials to influence others sectors In line with one of its earlier official papers (Petrie,
towards also adopting a determinants-approach. 2002), The Treasury expressed strong support for
The report was also seen as an important step to the development of consistent policy indicators and
raising awareness of government officials to the thought that, to that extent, the Social Reports were
root causes of outcomes inequities, disrupting a an important step towards the proper evaluation
sole focus on outcomes disparities alone. of the impact of social policy. In addition, for The
Treasury the Social Reports did not achieve, and
The Treasury are unlikely ever to achieve, the same currency
Whereas the Treasury had participated significantly as gross domestic product (GDP) as a measure
in the development of the Social Reports due to its of overall well-being, arguing that GDP is clearly
general involvement in social policy lead by its defined and has a clear relationship to well-being.
Cross-sector Strategy Group, it has backed off social The measures in the Social Reports, in contrast,
policy issues over the last years, refocusing on its were perceived as more ambiguous: Outside of
core duties after the abolishment of its cross-sectoral the “economic” measures, such as unemployment
policy function. For the Treasury, the Social Reports rate, it was not clear for The Treasury how the
are one of a range of information sources analysts measures in the Social Reports added together
access, but are not part of The Treasury’s strategic to offer more information on the overall well-
planning process. being of New Zealanders. The Treasury expressed
the need for deeper assessment of how policies
The Treasury raised a range of concerns with respect impact on key indicators so judgments on cross-
to the Social Reports, arguing firstly that the data was sector policy can be made. The department saw as
sometimes difficult to interpret and some measures the greatest value of the Social Reports that they
were not specific enough for policy purposes (e.g. create an opportunity for formalizing the use of
The Treasury questioned what information the indicators and developing a more systematic tool
participation in cultural and arts activities indicator for assessing the impact of social policy. In other
provide about quality of life). words, the Treasury saw the Social Reports as a
method of better budget accountability.
The Treasury also argued secondly that where there
are trends in different direction, the diversity of data The Ministry of Economic
makes it difficult to interpret (e.g. in the 2007 report Development
the number of workplace injury claims per 1000 Similarly to The Treasury, a senior official from the
had declined between 2001 and 2005, but over the Ministry of Economic Development confirmed
period 1977 to 2003 the number of people who are that the ministry has made minor to no use of
obese roughly doubled. The Treasury was not sure the reports to-date. However, policy-makers
whether to interpret this overall as an improvement from other ministries saw the Treasury and the

22
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Ministry of Economic Development as in dire District Health Boards


need of broad-level, summarized, cross-sectoral Amongst planners and funders from District
policy information on social development and Health Boards the Social Reports are used, although
believed that the Social Reports should constitute often to a limited extend, as a reference document,
a key document for these government agencies. In to inform service planning and needs assessments,
conclusion, the failed engagement of The Treasury particularly in the context of local partnerships
and the Ministry of Economic Development with and community outcomes. One District Health
the Social Reports needs to be critically highlighted. Board Planning and Funding Division reported
It seems that The Treasury and the Ministry of had integrated the reports as part of a ‘toolkit’ of
Economic Development’s interests in the Social reference resources used on a standard basis for
Report should grow, if these departments were planning and funding, but the division pointed
aware that well distributed economic gain leads out that the Social Reports present a compilation
to improved health outcomes, leads to improved of secondary data source only, while the District
economic performance. Health Board will usually return to the primary
data sources for in-depth analysis.
Local and regional government
Local and regional councils make moderate use
of the Social Reports mostly to support their
Two over-riding concerns
strategic development (i.e. to inform their 10
expressed by policy makers
year Long Term Council Community Plans
were:
(LTCCP)). The publication of the Regional
Indicator Reports, despite failing to provide a 1 the perceived disjunct between what is reported
break-down to local authority-level, found wide on and how this is transferred into decisions
approval and increased the use of the Social and the evaluation of policy development and
Reports amongst these users. One application of interventions (this may be linked to the lack of a
the Social Reports was to brief councilors about clear conceptual framework on social domains,
their communities’ social outcomes by reference cause and effect); and
to these authoritative statistics. The Social Reports 2 there was a sense that a lack of ownership
had here raised awareness to social inequities. and accountability for the different domains
The Chief Executive Officer of a District Council, hindered the reports’ policy impact (in other
for instance, stated that the Social Reports were words, a mapping of social outcomes to
used by the council to focus interventions interventions and ministries responsible for
these interventions needed to take place).
on the biggest outcomes inequalities, both
within New Zealand (by comparing regional
outcomes) and internationally (by reference to
the comparisons of New Zealand social outcomes
with those of other countries). As a result of such 4.3.2 Currency “beyond government”
an approach the council had addressed worse
regional outcomes with respect to roads, water The Social Reports have been used beyond
and sewerage infrastructure and investment. The government, achieving varying degrees of
Chief Executive Officer of a District Council, for currency and up-take either as a strategic planning
instance, stated that the Social Reports were used tool, for advocacy purposes or to provide statistical
by the council to focus interventions on the biggest contexts in grass-roots community organizations,
outcomes inequalities, iwi authorities and other Māori groups, health
advocacy agencies, health and social service
providers, amongst public policy and public
health academics and other researchers, and the
media. But they have not found traction within
“... as a .. result of such an the business sector.
approach the council had addressed
worse regional outcomes with Grass-roots organizations
Many informants shared the opinion that the
respect to roads, water and
Social Reports have been a useful stimulus for
sewerage infrastructure and civil society groups and have generated significant
investment”.

23
public debate and discussion about the causes of report was seen as not assisting the iwi body in
social inequalities. this manner. However, there was overall support
for social reporting.
Many informants identified community-focused
organizations as the sites, where the Social Reports Academia and researchers
had major currency. However, while grass-roots A number of academics and researchers in the
organizations were generally satisfied with the field of public health and public policy have
Social Reports, only some used the reports, mostly supported the development of the Social Reports
to access reference information on social well- first-hand, and, amongst academics working in
being. Some community agencies highlighted this field, there seems to be unanimous support
information needs that they wanted the Social for the existence and role of the Social Reports.
Reports to fill with respect to their particular Many academics working in relevant disciplines
communities. For instance, one community regularly use the Social Reports as resources for
organization assembling disabled people argued their teaching and writing.
that the Social Reports made a derisorily small use
of data on disability, despite data being available One researcher based in a church-affiliated social
for disaggregation for many indicators. According service argued that social statistics always had to be
to the community organization, disabled people fought for and that they, hence, needed continuous
wanted to use data that reflects themselves as airspace in order to generate public will to tackle
part of New Zealand society, and find little use social issues, including equity concerns.
in documents that effectively exclude them in
discussion about it. While stating support for Public health advocacy agencies
systematic monitoring of the use of Te Reo Māori/ Support for the Social Reports was strong amongst
the Māori language, the organization perceived public health advocacy agencies, and the reports
the omission of measures on New Zealand sign have achieved a high level of currency amongst
language (one of three official languages) needed these policy actors. These non-governmental
to also be addressed in future reports. However, organizations reported using the Social Reports
community-run social and health services, if they to inform a range of advocacy activities. A
knew of the reports, often welcomed the Social public health association, for instance, uses the
Reports, but lacked time and staff resource to make Social Reports regularly as a credible source of
significant use of the reports beyond for ad-hoc authoritative, official information on the social
statistical reference. determinants of health. In its advocacy roles,
the association routinely draws on information
Māori organizations, also widely regarded as arising from the Social Reports, i.e. when it seeks
prime audiences and users of the Social Reports, to influence the SDH at the local and central
had made some use of the social reporting, but government level and as a reference source for
proposed improvements be made to enhance the submissions to Parliament, in the first instance
reports’ applicability. One iwi/tribal authority, using information from the Social Reports to
which had utilized the Social Reports to inform argue for health impact assessment of significant
the production of a socio economic and health government policies such as those involved in
profile of its iwi/tribe, argued that opportunities budget commitments. Importantly, the association
for users to request data specific to their needs also utilized the information to inform its position
would increase the currency of the Social Reports statements, which form the basis for their articles,
highly among tribal bodies, explaining that as media releases and media interviews. Given that
an iwi authority they needed iwi-specific data to health advocacy agencies generally grounded their
enable planning and being responsive to the social work in a determinants-approach and endeavored
needs of their tribal members. to improve health equity, they did not use the
Social Reports to inform their strategic planning,
This may be pointing to a different type of service but rather as a solid foundation for their advocacy
rather than a report - it may report to a more live work or, in other words, to raise equity concerns in
question and answer, or on-line, service to respond the wider community as a way to mobilize popular
to information needs on social well-being. The and political support for action on inequities

24
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

documented in the reports. Generally, public as politically fuelled by accompanying media


health advocacy agencies expressed a preference statements released by the ministry or the issuing
for government-sourced information about SDH minister. This mainstream media coverage of the
that, while not necessarily accurate, was seen as Social Reports has an awareness-raising function,
well peer-reviewed and as having the additional facilitating public debate on the pinpointed social
benefit of reducing the disputes about the source issues.
and quality of data, which is often used as an
excuse for action by politicians. Some agencies The business sector
wanted to see more equity and determinants The business sector represented by business
indicators to be included in the Social Reports on roundtables and chambers of commerce was
a standard basis. In summary, Social Reports are generally not aware of the existence of the Social
widely used and are highly valued amongst health Reports and expressed little interest in this
advocacy groups. governmental reporting series due to the business
sector being of the opinion that the reports lacked
The media any application for businesses. This unsuccessful
The release of the Social Reports has received engagement of the business sector in the Social
a high level of media coverage every year, Reports significantly limits the reports’ impact.
reflecting on findings from the reports as much

25
5 Innovative features of the
Social Reports

T
he Social Reports h have a number of actors have insider knowledge about their own
defining features, wwhich reflect some situation and solutions to the challenges they
of the country’s learning
learn in the context face in achieving health equity, but in democratic
o national monitor
of monitoring of the social societies they also have the power to hold
dete
de
determinants
terrmin nants of population health
he and well-being. consecutive governments accountable for strategic
Alth
Al
Although
thou ugh an expression of a na
nationally determined decisions and their effects.
need
ne ed for
f action in this area and, as described
in the
he previous
previous section, a p product of historic The Ministry of Social Development has aimed
deve
de
developments
velo
loppments somewhat uniqunique to New Zealand, to assure civil society participation in the
thes
th
these
esee fe
features carry significan
cant lessons regarding development of the Social Reports through various
in
innovations
nno
novavations and adaptations for countries who means. Conceptually, the Social Reports were
ma
mayay be considering establishing
establish or adapting a grounded in national documents defining how
soci
social
ial reporting scheme. New Zealanders understood social well-being. This
knowledge had resulted from two national Royal
Commissions inquiries (Royal Commission on
Social Security, 1972; Royal Commission on Social
This section identifies eight of
Policy, 1988), which were based on major public
these features in more detail:
consultations held in the early 1970s and late 1980s.
1 Assuring civil society participation, transparency Furthermore, civil society input was sought in a
and accessibility formal round of nation-wide public consultations,
2 Monitoring the SDH including with indigenous stakeholder groups,
3 Monitoring equity in the Social Reports by (1) after the release of the first Social Report in 2002.
socially disaggregating data and (2) using good The consultations were facilitated and findings of
diagrammatic tools it reported by an independent consultant (Ministry
4 Using social reporting to foster intersectoral of Social Development, 2002a). Thematically, these
action public consultations grounded, and re-assessed
5 Broadening understandings of health respectively, the Social Reports’ conceptual make-
6 Highlighting strengths and policy opportunity up, in their core investigating how accurately the
7 Developing social indicators in societies with reports reflected the contemporary values and
indigenous populations aspirations of New Zealanders with regards to
8 Securing on-going, regular social reporting social outcomes. The consultations, however, also
provided a platform for wider public discourse
about the usefulness and function of public social
5.1
5 .1 Assuring civil so
society reporting in New Zealand.
participation,
p articipation, transparency
transp and
accessibility
a ccessibility As part of a broader Government commitment
to ‘making the public service more open to the
Ci society groups, especially
Civil especia disadvantaged public’ (Ministry of Social Development,2003: 7),
populations
po
opu
pulalations and their advocates,
advocate play a significant for the issuing Minister of Social Development
role innp putting
utting health equity concerns on the ‘Social reporting also plays a role in promoting
public
publ
publiic policy agenda; not only do these political an open and transparent government’ (Ministry

26
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

of Social Development, 2003: 3). In consequence, Social Indicator Reports) can be ordered from the
in addition to standard reporting of social Ministry of Social Development free of charge
outcomes, the Social Reports detail both relevant and access to the raw data can also be obtained for
political affairs and motivations (in the Ministerial external analysis without costs.
Foreword of each report) and conceptual and
technical developments of the reports (often However, access could be further improved, so
footnoted throughout the report, but concentrated argue some users of the reports, if all collated data
in the reports’ appendices). The often very was to be made available online for ‘data drill’
detailed technical descriptions target the level (i.e. housing data available online with users able
of information required by statisticians and to search by specific geographic area, ethnicity,
quantitative researchers for expert evaluation of age, socio-economic status and gender). For
the report’s quality and the validity of the measures diverse health outcomes (i.e. communicable and
used, and at the same time help to effectively non-communicable diseases), risk behaviours,
manage the amount of statistical detail provided health systems variables, population groups and
in the main text. various SDH such information is currently already
provided through the Ministry of Health’s Public
This high level of process information about what Health Intelligence PHIOnline internet resource1.
motivates changes to the Social Reports and the This alterative tool for the visualization of health
thorough documentation of the conceptual and and related information makes freely available
technical changes to the reports have created a for users online, interactive atlases with linked
publicly transparent reporting series. Besides tables and charts that allow data to be viewed in
ministerial directive, a couple of other factors, multiple dimensions and broken down to District
have contributed to securing the Social Reports’ Health Board (DHB) and Territorial Authority
transparency: Firstly, given that the reporting (TA) level. It combines national health survey data,
scheme is an attempt to establish a nationally hospitalisations and disease registrations as well as
and internationally unique monitoring system, risk behaviour data and data related to one of the
desired by national social scientists and social ministry’s core strategic approaches, the Healthy
policy-makers for some time, it is not surprising Eating Healthy Action (HEHA)2 framework that
that the writers of the report wanted to document aims for the improvement of nutrition, increase of
the steps taken carefully. In effect, such detailed physical activity and achievement of healthy weight
documentation allows third parties to conduct for all New Zealanders. This health information
independent process evaluations of the tool elegantly highlights health inequities and the
ministry-led reporting. Secondly, the fact that unequal spread of health-relevant socioeconomic
this initiative is located within and spearheaded resources.
by the Ministry of Social Development with
its various responsibilities in the social sector
and its accountabilities to various often highly 5.2 Monitoring the SDH
politicized civil society groups explains a high level
of transparency. Considering that the relatively As described in more detail above, in its pyramidal
recently created ministry is under constant indicator framework developed for the Social
scrutiny by politicians, government departments Reports (see Figure 1), the Ministry of Health
and diverse civil society groups, it is not surprising conceptualised health outcomes (at the level of
that transparency is high. mortality and morbidity) as mediated by risk
behaviours which, in turn, were seen as mediated
In addition, easy public access to official reports by the SDH. For the ministry, the SDH hence
needs to be guaranteed, when civil society mark the most fundamental level of the health
participation in policy-making is desired. Given indicator pyramid. The ministry was of the
that New Zealand is a country with high rates of opinion that the SDH were assessed by the nine
internet use and literacy, public access to the Social other social outcomes domains reported in the
Reports is on a basic level facilitated by assuring Social Reports, in effect conceptually linking health
that reports can be downloaded online and are domain indicators with the other social indicators
open-access from a special homepage hosted by
the Ministry of Social Development’s webpage.
1 See http://www.phionline.moh.govt.nz/
Hard copies of the Social Reports (and the Regional 2 See http://www.moh.govt.nz/healthyeatinghealthyaction

27
assembled in various outcomes domains under a Disaggregating social outcomes
determinants-approach. Disaggregation of social outcomes makes
inequalities between different population groups
However, statistically, the size or level of the evident. Without such social disaggregation, social
relationship has not been attributed, although it reports are unable to facilitate policy attention to
could be in a rough way from the existing literature. the fact that health (and other social) resources
Hence, New Zealand’s Social Reports can be used are generally concentrated amongst the privileged,
to document changes in social outcomes only, while the burden of ill-health disproportionately
but can not describe any cause/effect relationship affects diverse marginalized and disadvantaged
between SDH and diverse health outcomes. Such social groupings. The Social Reports place major
causal links could convincingly be established in emphasis on disaggregation of social outcomes and
social reporting, however, when reports reference since 2005 reports contain a separate section within
research that has provided authoritative evidence the Introduction, which discusses the key issues
for the respective causal link between a health related to data disaggregation in the report. This
outcome (e.g.  obesity) and another social factor information guides readers in their understanding
measured in the social report (e.g. income). of the importance of social disaggregation and
Similarly, looking to the future the indicator report highlights the current data restrictions in this
needs to more closely link the relationship between respect. The 2004 report explains:
individual domains (e.g. the Health and Economic
Standard of Living domains).

5.3 Monitoring social equity in “Ideally, each indicator used in the


the Social Reports report would be able to be broken
down by subpopulations of interest,
Besides standard monitoring of overall social such as age, sex, ethnicity, socio-
outcomes, surveillance of equity in social
outcomes, both within countries and across
economic status, disability status,
countries, is also a key function of many social and region. In the cases of age,
reports. Only such social reports that monitor sex and ethnicity (subject to the
within-country inequities equip policy-makers caveat below), most indicators can
with guidance as to which population groups be disaggregated. The majority of
ought to be prioritized and receive targeted policy the indicators rely on data sources
provision to improve overall outcomes and increase
equity. In order to fulfil this equity monitoring
that do not allow us to disaggregate
function, the Social Reports carefully disaggregate by socio-economic status, disability
social outcomes along various social dimensions status, and region, because either
of interest (e.g. the “Social Determinants of Health they do not collect this type of
Inequities”; see Solar & Irwin, 2010) and, on a information, or because they are
more pragmatic level, use innovative, state-of-the- based on sample sizes too small to
art diagrammatic representations of the findings
that offer easily understandable and interpretable
permit disaggregation”.
policy references.
Ministry of Social Development (2004), p9.
Surveillance of between-country equity is also
not uncommon in national level social reporting While alerting to these data limitations, the
schemes. In the case of New Zealand, the Social report refers to alternative government sources
Reports are closely linked with efforts of the of information about specific disadvantaged sub-
OECD, comparing New Zealand outcomes with populations, effectively directing the interested
the outcomes of the medium and upper quartile audience.
of outcomes of OECD States, and often with
neighboring Australia. This provides policy-makers One strong push to present disaggregated data
with guidance as to which social outcomes New originates from legislative changes. For instance,
Zealand needs to improve on. as postulated by local government and civil society

28
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Measuring ethnicity

Major inequities between different ethnic groups (especially between the indigenous Ma-ori and the non-Ma-ori group),
and state obligations arising from the signing of the 1840 Te Tiriti o Waitangi/The Treaty of Waitangi, has generated
a strong interest in ethnicity as a determinant of health and other social outcomes. In the Social Reports, ethnicity
break-downs of social well-being are presented for three different ethnic groups or clusters of ethnic groups: relative
to New Zealand Europeans; these are the indigenous Ma-ori; Pacific peoples (a conglomerate of populations originating
from diverse Pacific Island States); and members of the ‘Other’ ethnic group (basically anybody who identifies as non-
Ma-ori, non-Pacific and non-New Zealand European). Of course, data disaggregation is only possible, if the required
demographic data is collected reliably.

Certainly, great national effort has gone into improving information systems with respect to the collection of ethnicity
data in New Zealand. For example, the Ministry of Health has taken significant steps to assure that health and
disability service providers collect ethnicity data in a standardized fashion, assuring a high quality of such data. Of
central importance in this context is the chosen definition of ethnicity1, because it requires health service clients to
self-identify their ethnic affiliation or affiliations. The release of the ministry’s protocols about ethnicity data collection
in 2004 has been a further important advance to assure standardized collection across the health and disability
sector (Ministry of Health, 2004). These protocols are grounded in the national Statistics Department’s definition of
ethnicity (Department of Statistics, 1988), assuring consistency (and hence data comparability) across all government
departments with regards to the collection of ethnicity data (Ministry of Health, 2004). This joint effort has made it
possible for government to robustly monitor ethnic inequities. Ma-ori groups, including Ma-ori academics, activists and
government workers, have been a driving force behind the advancement of ethnicity data collection. For instance, Te
Puni Ko-kiri/ The Ministry of Ma-ori Affairs has published a discussion paper that reflects on and provides leadership and
guidance with regards to the measurement of Ma-ori ethnic identity (Kukutai, 2003).

1 According to the Ministry of Health (2004: 5) protocols for the standard collection of ethnicity data for health and people with
disabilities describe ethnicity as follows:
• Ethnicity is self-perceived so the person concerned should identify their ethnic affiliation wherever feasible.
• A person can belong to more than one ethnic group.
• The ethnicities with which a person identifies can change over time.’

groups (Ministry of Social Development, 2002a), operating District Health Boards, by statute
the Social Reports have responded to a growing responsible for the health of the populations
demand for regional and local-authority level residing within their boundaries. These boards
breakdowns of social outcomes necessitated by the often host the regional public health units and
introduction of the 2002 Local Government Act maintain strong links with local and regional
(Ministry of Social Development, 2007). This act Māori and Pacific health service providers and
made local and regional councils responsible and the recently set up Primary Health Organizations.
accountable for previously more centralized issues,
including shared responsibility for the public However, the current disaggregation practices of
health portfolio. In consequence, the Social Reports the Social Reports encounter some limitations,
profile differences at regional and local-authority which are more difficult to address: Firstly, analyses
level since 2006 in annual companion documents by social groupings only highlight differences in
to the Social Reports, the Social Report Regional sub-group averages, but do not sufficiently account
Indicators (Ministry of Social Development, for intra-group variations. A second limitation is
2005b; 2006b; 2007b), for whichever indicator that, while the reports provide break-downs of
sub-national data is available. This secures local indicators by various determinants, they fail to
and regional government agencies and civil monitor outcomes of some socially disadvantaged
society equal access to findings of social well- populations, i.e. Asian populations, refugee
being outcomes catered to their specific planning communities, sexual minorities and transgendered
needs. In terms of the health system, this local and people, likely because these populations are elusive
regional-level information on the distribution of and often not identified in official surveys and
social well-being is well-suited for the regionally due to the difficulty of estimating statistics for

29
Figure 2. Diagrammatic
comparison of selected
indicators of social
well-being for Pacific
Peoples, relative
to New Zealand
Europeans, 2004-2006,
2007 Social Report

Figure 3. Summary
of findings from the
Health domain, 2007
Social Report

30
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

small populations. A third important limitation expert, up-take of social reports. With respect
of the current disaggregation format is that it does to providing equity analysis, two diagrammatic
not provide break-downs by tribal areas. Health features of the Social Reports deserve being
officials were of the opinion that the Social Reports highlighted.
were best placed to measure social outcomes for
Māori against non-Māori which was seen as Firstly, Rae Diagrams are used throughout the
monitoring the government’s commitment to its reports, generally to summarize outcomes of a
citizens. According to the same source, the reports certain social grouping relative to another. An
should not be used to monitor iwi/tribes on the additional is that each diagram is accompanied by
social outcomes of iwi/tribe members, because this a box which guides the reader in the interpretation
could potentially result in comparison of who are of the diagram and, if necessary, alerts to data
good iwi/tribes and who are bad iwi/tribes. Iwi/ limitations and weaknesses of the diagrammatic
tribal authorities, on the other hand, expressed representation. One example is the diagramming
the wish that such information be made available of social well-being outcomes for Pacific peoples
in the Social Reports to inform their strategic relative to New Zealand Europeans between the
planning purposes3. years 2004 and 2006, which is replicated in Figure
2. Overall, these diagrams are good tools for making
Besides disaggregating the outcomes of each social outcomes inequities between two groups
social indicator as appropriate and possible, visible, in a summary form and in a one-page
given data availability, the Social Reports also format. On the other hand, one of the problems with
add in their Conclusions further equity analyses, the Rae Diagrams has been the incomparability of
often exploring trends of social outcomes of a extent of change across indicators, which has led to
particular population of policy interest. A mapping some misinterpretation by stakeholders.
exercise showed that since 2003 Social Reports
have provided Conclusions discussing results for A second noteworthy feature is the tabulated
disaggregated data: for ethnicity (Ministry of summary of findings at the end of each report,
Social Development, 2003, 2004, 2005a, 2006a, which contains not only current outcomes, long
2007a), sex (Ministry of Social Development, 2003, term changes and an international comparison per
2004, 2005a, 2006a, 2007a), age (Ministry of Social indicator, but also explicates trends in health equity
Development, 2003, 2004, 2005a), geographic or, as it is called in the Social Reports, “variations
location (Ministry of Social Development, 2004, within the general population”. This table makes
2005a), and socio-economic status (Ministry of available snapshot-type summary comments
Social Development, 2004). Where historical data about the essence of changes in social well-being
is available, the Social Reports present previously and presents a valuable tool for policy. Figure 3
unavailable time series information, often tracing presents an example for the short summary of
trends over a 30-year period. Stating that time findings in the 2007 report’s health domain.
trend analysis is not possible for all indicators, the
reports also alert the reader at the same time to the Between-country comparisons
fact that definitions and associated measurement The Social Reports compare New Zealand’s social
of some social constructs (i.e. ethnicity) are well-being internationally with Australia and
subject to changes over time, hence challenging the median and upper quartile outcomes of the
comparability of findings and the validity of some OECD countries, hence providing measures of
trend analyses. However, time trend analyses between-country inequities, which allow New
provide most useful medium-term to long- Zealanders to assess how they fare in comparison
term policy evaluation measures, enhancing the to neighbouring Australians and the citizens
applicability and usefulness of the reports. from other high-income countries. As a policy
tool, these international comparisons are of
importance because they allow policy-makers to
Using good diagrammatic tools gain contextual understanding and set priorities to
Presenting data in a visually pleasing and simple, address inequities at the international level. Some
yet succinct form and in a summary format is civil society groups have expressed the wish for
another important step, if the aim is to enhance comparisons with more countries than Australia
policy-makers’, as well as civil society and non- to be made available as part of the Social Reports.
These international comparisons were seen as
3 Statistics New Zealand compiles Iwi Profiles for iwi/tribes upon fulfilling an important facilitation role with respect
request including some social statistics (refer http://www.stats.
govt.nz/census/about-2006-census/iwi-profiles.aspx) to equity advocacy.
31
The usefulness of the Social Reports could be Reports, although still an establishing monitoring
enhanced further if not only overall social framework, have indeed been successful in
outcomes were compared with other countries, fulfilling the Minister’s original intentions; they
but if the reports added standard assessment have started to assist a higher level of coordination
of comparative within-country health equity. amongst social policy initiatives, which interface
This move would facilitate greater, more layered with public policy from several sectors.
understanding with respect to how national health
equity outcomes compare internationally.
5.5 Broadening understandings
5.4 Using social reporting to of health and health
foster intersectoral action determinants
In the first Social Report, the issuing Minister By monitoring various social, including cultural,
of Social Development acknowledged that for dimensions and determinants of health, social
many years governments had generally received reports present the opportunity to contribute
disjointed advice on social policy and that different towards the establishment of broader and
sectors had worked in silo rather than in an more holistic conceptualizations of health in
integrated and collaborative fashion (Ministry public policy. For Ministry of Health staff, the
of Social Development, 2001). In New Zealand Social Reports affirmed and supported national
the Ministry of Social Development has taken population-health based policy-making by taking
on the leading role with regards to intersectoral a determinants-approach focused on the social
social policy advice and intervention. In fact, factors that influence health and other social
the Social Reports have been an intersectoral outcomes, which, in turn, is well-aligned with
endeavour from the start. In strategic terms, inter- health promotion approaches. Especially given
sectoral collaboration on the Social Reports is that it was led by another government agency,
likely to have enhanced a sense of ownership and this approach was seen as counter-acting in-
the application of the report findings amongst house pressures to focus more exclusively on the
participating government agencies. The social reduction of disease.
monitoring system then has the potential to
encourage not only joint intersectoral action, Of particular importance in this respect are
but, on a second impact trajectory, to also gain indigenous conceptions of health, because they
entry into and influence over sectoral policy. The present a compelling case for the necessity to
Minister of Social Development explains social extend western, individualized, medical models
policy as embedded within the policy of other of health to also incorporate spiritual and
public policy arenas as follows: cultural well-being of communities (Awofeso,
2005). Māori health models, e.g. Durie’s 1984
“Te Whare Tapa Wha” and Pere’s 1984 “Te
Wheke” models, conceptualise health in a holistic
fashion by explaining health as influenced by
the spiritual realm, the psychological sphere,
“This means not making an artificial distinction between the physical body and the extended family and
wider community. Such Māori health models, and
economic, social and environmental policy. For policies associated Māori health promotion model (e.g. “Te
in all these areas are about building a better society, Pae Mahutonga”; Durie, 1999), have found wide
for now and into the future. We need to recognise application in New Zealand society and informed
these inter-relationships. A well performing economy the Ministry of Health’s (2001) milestone Māori
and a healthy environment are critical for delivering a health strategy, He Korowai Oranga. They have
fairer society. A fairer society is one of the important entered, or at the very least have broadened out,
the understanding of health for most New Zealand
preconditions for a more prosperous economy and a health practitioners, especially those working in
sustainably used environment”. public health. That the Social Reports holistically
monitor physical and mental health measures
Ministry of Social Development (2005), p5. alongside assessment of various other dimensions
of cultural and community well-being has
As described in the section on the Social Report’s found wide endorsement by Māori stakeholders
policy impact, it can be concluded that the Social (Ministry of Social Development, 2001a).
32
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Māori approaches to health also differ from redefined, shifting them into a more appropriate
western models in that they are communitarian and positive sphere with the potential to empower
in nature. Setting the direction for Māori health disadvantaged groups. When a government is
development in the health and disability sector starting to report on community assets, then
for the next five to 10 years, He Korowai Oranga this can be interpreted as a useful trajectory for
defines as its principal goal ‘whānau ora’4. While empowering communities. And in analysis, it can
these communitarian aspects of Māori health be argued that the underlying policy assumption
have not found entry into social indicators as yet, is that reporting on strength is a valuable strategy
they are an important dimension of health in New to enhance these important community-owned
Zealand and will need to be integrated in the Social resources.
Reports in the future in order to reflect government
direction as set by the Māori Health Directorate of Statements of desired outcomes for all outcome
the Ministry of Health through its Māori-specific domains reported in the 2007 report are listed
health strategies. in Annex 4 of this discussion paper, together
with the respective indicator measures. From
studying these statements, it becomes obvious
5.6 Highlighting strengths that they provide positive visions and objectives
and using language that for the future in each social well-being domain
is responsive to policy instead of exclusively aiming for the reduction of
opportunity specific risks. In effect, the statements highlight
opportunity. The health domain provides a useful
It is not surprising that such innovative New example in this regard. Its statement of desired
Zealand models of health and well-being have outcomes reads as follows:
created a conducive environment for well-being
approaches, within government as within civil
society. In fact, it can be argued that the New
Zealand health and social sectors have shifted
significantly from approaches concerned solely “All people have the opportunity
with the reduction of disease and risk to building of
to enjoy long and healthy lives.
strength and highlighting health (and well-being)
opportunity. This is an important difference. The Avoidable deaths, disease, and
work of several government agencies is proof injuries are prevented. All people
of such a transformed approach. Capturing have the ability to function,
the essence of a strengths-based approach and participate, and live independently
highlighting opportunities, a prime example from or appropriately supported in
the health sector is the 1998 New Zealand Youth
Suicide Prevention Strategy titled Kia Piki te Ora
society”.
o te Taitamariki - Strengthening Youth Wellbeing
(Ministry of Health, 1998). Again, the difference lies in the language used, and
in the case of the Social Reports, the statement
That the Social Reports also at times take a strengths- explicitly talks about ‘opportunity’ and ‘ability’,
based approach is apparent, for instance, in the ‘prevention’ and ‘participation in society’ as the
fact that they report on the social connectedness milestones of health. A re-branding of the current
domain. This domain is closely related to the idea indicators to promote the more positive side of
of social capital, a concept that locates power and New Zealand rather than its deficits was advocated
resource in community activities, inter-individual for by several informants to this study, although,
relationships and exchange of support. Even the at the same time, practical measurement
labelling of indicators is important in this regard. limitations to this endeavor where acknowledged.
For example, in 2003 an indicator which was
initially called dependent disability was renamed
into disability requiring assistance, due to this 5.7 Developing social indicators
being perceived as a less stigmatizing expression in societies with indigenous
(see Ministry of Social Development, 2004: 154- populations
155). Negative, disempowering concepts are here
As increasing attention is being placed on
4 Whānau – Te Reo Māori language term describing the smallest tribal unit, the extended developing measures of indigenous peoples’
family; ora - Te Reo Māori language term, which according to the Ngata Dictionary can 33
be translated as ‘health’ or ‘fitness’. social and health outcomes, international social
reports have commenced reporting on indigenous ethnicity, region or common interests’ (Ministry
social well-being. One striking example is the of Social Development, 2007: 76).
Social Panorama of Latin America report
(Economic Commission of Latin America and The Social Reports also explain why cultural identity
the Caribbean) launched in 2006, which contains should be measured to indicate social well-being
a chapter monitoring indigenous populations’ by referring to trajectories through which a strong
social outcomes (p.141-213) 5. In addition, sense of cultural identity mediates social well-being:
social determinants of health of indigenous A strong cultural identity is seen as granting access
populations are collectively being explored by to social capital by providing a sense of belonging
indigenous peoples at the global level. In 2007, and, as a consequence, a sense of social security.
for instance, the “International Symposium on Sharing social networks accesses support and builds
the Social Determinants of Indigenous Health” collective values and aspirations. Social networks
was held in Adelaide, Australia. As stated in the can function to break down barriers and build a
final report of the symposium prepared for the sense of trust between people. The negative impact
Commission on Social Determinants of Health of social exclusion is juxtaposed, when the Social
(ref. Social determinants and Indigenous health: The Reports also point out that if strong cultural identity
International experience and its policy implications; is expressed in the wrong way, it can contribute
Mowbray, 2007: 3), ‘the papers and Symposium to barriers between groups. The Social Reports
gave examples of instrumental and constitutive highlight the fact that exclusionary practices of the
value attributed by Indigenous Peoples to culture dominant authorities can impinge on the sense
and world views as a determinant of their health of belonging for members of minority cultures.
and well being’. In this context, the Social Reports acknowledge
explicitly that Māori culture including Te Reo
Being a bicultural nation by virtue of Te Tiriti o Māori /the Māori language has been marginalized
Waitangi/The Treaty of Waitangi, New Zealand ‘through much of New Zealand’s history’ (Ministry
can be seen as consisting of Māori whānau/ of Social Development, 2007: 77). The desired
families, hapu/sub-tribes and iwi/tribes on one outcomes for the cultural identity domain mirror
hand and non-Māori settlers represented formally the government’s idea of what optimal expression
by the British Crown or settler governments of cultural identity in New Zealand should look like:
respectively on the other hand. Some argue that
because settlers have arrived to New Zealand
from various parts of the world and given that also
Māori groups and individuals can have multiple
ethnic affiliations, New Zealand society is well
described as multicultural. These political and “New Zealanders share a strong
historic complexities, especially the guarantee national identity, have a sense
of indigenous rights and the systematic settler of belonging and value cultural
colonization of New Zealand, have created a
diversity. Everybody is able to pass
unique cultural environment.
their cultural traditions on to future
Such circumstances are reflected in the Social generations. Maori culture is valued
Reports, above all their Cultural Identity domain. and protected”.
‘Cultural identity’ as per the definition provided
in the Social Reports is a multi-layered construct, Ministry of Social Development (2007), p76.
with culture being understood in its broadest
sense, as expressed through ‘customs, practices, However, measuring cultural identity as a domain
languages, values, and world views that define of social well-being is a recent concern, and in
social groups such as those based on nationality, consequence it is not surprising that indicator
measures in the Social Reports (e.g. people
5 The Commission’s 2007 report includes a chapter reflecting on health programmes identifying as Maori who can speak in Maori) are
and policies for indigenous peoples in Latin America and the Caribbean (Economic still emerging. It needs to be noted that defining
Commission of Latin America and the Caribbean, 2007: 55-59) and comparative
demographic analyses for the indigenous peoples of Latin America as they relate to and monitoring “strong/good” and “weak/bad”
public policy issues. This report refers to the special regime of collective indigenous cultural identity carries significant danger; if
rights based on the principle of self-determination by recognizing equal entitlement
of the indigenes to human rights protection, e.g. marked by the global ratification of the government has the power to defining what
international human rights legislation (i.e. the 2007 United Nations Declaration on the constitutes a “good” and what a “bad” cultural
Rights of Indigenous People). In this context, the report also stresses the increasing
importance of indigenous people as political actors. identity, therefore allowing  inclusion and the
34
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

opposite, then assessments according to these as in other countries by a statistics department),


criteria may further disempower marginalized another important issue is the danger of the
indigenous and ethnic groups. disestablishment of the Social Reports by future
governments, especially if these do not retain the
current emphasis on social policy. To counter
5.8 Securing on-going, regular, this peril, a cementing-in of the Social Reports by
“neutral” social reporting means of statutory obligation to report on social
outcomes has been explored by the Ministry of
As described previously, although the periodicity of Social Development (2002a), but has not been
the Social Reports’ publication was not determined achieved. However, many key-informants to
from the establishment of the regime, the Social this case study, government officials and civil
Reports have been published in annual periodicity society representatives alike, were of the opinion
since first released in 2001. Policy staff from the that the establishment of a Social Responsibility
Ministry of Social Development point out that one Act to directly mirror the existing 1994 Fiscal
of the advantages of publishing the Social Reports Responsibility Act, which requires The Treasury to
on a yearly basis is that the Social Reports have publish their accounts before every election, would
established as a regular commodity, likely creating be a central, desirable step and should include
less political pressure on its annual findings than if government obligation for social reporting.
the report was published less regularly.
In addition, some policy officials and opposition-
According to these ministry staff, an annual party politicians have challenged the Social
publication cycle adds to the consistency of Reports’ appropriateness in reporting positive
reporting and the public transparency of the Social trends (i.e. some objections were raised with
Reports, especially considering that changes in the regards to overly enthusiastic reporting of health
reporting structure (i.e. modifications of indicator improvements for Māori), and attributing these
measures) are explained in great detail in a specific back to recent government policy. The 2002 review
section contained in each report. In terms of of the first Social Report had highlighted some
political impact, setting up a routine, transparency level of confusion amongst stakeholders about the
dynamic was seen as increasing political interest in very issue of whether indicators reports can be
the Social Reports as annual milestone measures, used to assess the impacts of policies (Ministry of
increasing policy debate about social outcomes. Social Development, 2002a). However, although
improvements in social outcomes might have
However, social scientists suggested tri-annual been reported enthusiastically at times, senior
publication as a better mode of operation, wanting policy staff agreed that although ministers have,
to see a social report published just before election in rare occasions, requested changes to be made
time to increase its policy impact. Similarly, to the reports, “neutral” reporting has never been
Ministry of Health staff reported that all or challenged, especially considering that reports
almost all government agencies involved in the simply compile information from previously
development of the Social Reports opposed annual published official statistics.
reporting, arguing that it is impossible to update
most indicators annually and that social change
proceeds slowly. Indeed, the agencies thought
that looking at year-on-year changes might be
meaningless or even misleading.
“Ideally, there should be a cut-out between such
Another point is that the health domain indicators governmental reporting and its exposure to the public:
in the Social Reports (e.g. obesity, smoking), although preferably by constituting an independent advisory board
constituting a strong set of indicators, should be
or perhaps by drawing on the statutory independence
changed periodically. Otherwise, if they were
made into accountability indicators, one would guaranteed to the Government Statistician. Such a
run into the problem of “targets”, i.e. behavioral cut-out would also clip the temptation of the issuing
indicators would skew towards considering them government ministers to gloat over ‘successes’”.
more important and worthy than other indicators.
Crothers (2006), p5.
Given that the Social Reports in New Zealand
are currently published by a ministry (and not
35
6 Key lessons learnt

A
range of implications arise from this Inequity”. Within-country inequities can
country case study which profiled and only be made visible if social outcomes
analyzed the conceptual and technical are disaggregated by various “Social
development, policy impact and some Determinants of Health Inequity” (i.e.
defining features of New Zealand’s Social Reports. ethnicity, gender, geographic residency),
In essence, they could be described as some of often in alignment with a state’s priority
the “lessons learned” with respect to addressing populations for targeted policy attention
the SDH to achieve health equity in national level (i.e. Māori and Pacific Island populations
social reports, and, as such, might inform other in New Zealand). When they socially
countries about the potential of social reports to disaggregate data, social reports can
generate awareness to and, in turn, policy action be used to trace equity for specific
on the SDH. populations.

∏ National level social reports should


LESSON 1: Social reports can be include cross-countries comparisons of
successfully used to make SDH and social (including health) equity in order
health equity visible to account for between-country inequity.
While this aspect is not realized in the New
∏ Social reports can function well to monitor Zealand case, including the monitoring
progress on the SDH. Although sometimes of health equity across diverse countries
not explicitly stated (this is the case in New in social reporting schemes would be
Zealand’s Social Reports), social reports a significant improvement, adding an
effectively monitor a range of SDH, additional dimension of health equity
measuring outcomes from diverse social analysis to inform policy interventions.
domains alongside health outcomes. Some To not only compare social outcomes as
social reports explicitly acknowledge their such, but also the present level of health
function with respect to monitoring SDH, equity internationally would provide
therefore providing leadership in this area. policy-makers and the public with a
The European Union’s social reporting contextualized understanding of how
is a prime example in this respect: In its one country is faring in relation to other
2003 report it features a detailed section countries with respect to within-country
on physical and social determinants of equity. This information could be applied
health as well as an investigation of the to the design of policy interventions
health impact of social capital and social aimed at a reduction of between-country
exclusion across the European Member disparities in health equity.
States (Eurostat & European Commission,
2003: 51-68). ∏ Social reports need to be published
periodically to assure time-series of
∏ To monitor within-country social social outcomes are available for trend
(including health) equity, social reports analyses. Whereas annual publication
ought to present data disaggregated of social reports seems only justifiable if
along the “Social Determinants of Health data becomes available for meaningful up-
36
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

date annually, it is important that social potential to produce political will and,
reports are published periodically. In in turn, action on the SDH to achieve
New Zealand, annual reporting has been health equity, in government and beyond,
criticized by many policy actors from sectorally as intersectorally. Considering
within government and social scientists that social reporting integrates a suitable,
arguing that the reports should rather be standardized set of key indicators that are
released tri-annually or possibly timed to relevant to a broad range of sectors, social
coincide with pre-election. reports are likely to build a more cohesive
administrative force, not only involving
∏ It needs to be ensured that an on-going diverse government departments, but
focus on findings with respect to equity, also civil society actors. However, reports
which have arisen from social reporting, by themselves do not achieve this, but
is maintained. To maximize their policy there has to be an interaction between
impact, issuing ministers and other the information they make visible, and
politicians, the media, and civil society concern for public pressure, or pressure by
actors should freely use the social reports to advocacy groups, as well as participation in
point out social outcomes equity concerns. the policy-making process of these groups.
Coordination in this respect could be One good indication of the impact that
achieved for instance by a systematic social reports have is the level of budgetary
marketing of these results through the implications for government ministries
issuing department, i.e. through employing that they can achieve.
a marketer with the task to keep these area
in the limelight. ∏ Social reports can be used to validate
and strengthen a health sector approach
∏ Social reports can meaningfully be used focused on addressing the SDH, at least
as a platform to raise awareness to the at the strategic level. By compiling in
health outcomes of disadvantaged one report both key health indicators
populations. Sometimes disadvantaged and a range of indicators from other
populations are invisible in social and social sectors such as education
health monitoring, certainly at times due and justice, as well as economic and
to small numbers (small ethnic minorities) environmental indicators, social reports
or due to methodological issues or a lack could theoretically encourage health
of national data. However, if statistical practitioners, especially health planners,
difficulties regarding the measurement of to consider in their activities the factors
these populations could be overcome, social outside the health sector, which impact
reports should be a platform to enhance on health. However, evidence for cases in
the reporting of findings for marginalized, which health practitioners have been able
vulnerable, underreported populations (i.e. to bring this down to the service level could
refugee and other small ethnic communities, not be produced in this case study. On a
sexual and gender minorities). more strategic level on the other hand,
the high-level picture that social reports
provide by monitoring a broad range of
LESSON 2: Social reports can set the social factors aligns well with approaches
basis for policy action on the SDH, concerned with influencing the SDH to
within and outside the health sector, achieve more equitable health outcomes, so
in government and beyond that publication of social reports can work
to strengthen social determinants-based
∏ When exposing social inequalities in policy frameworks. Clearly, intersectorality
a highly visible report that achieves can be strengthened by having a clearer
significant national media coverage, causal framework in evidence.
social reports present a useful policy
tool to produce political will, and action ∏ Social reports can be used to enhance
within government and beyond, with intersectoral coordination in support
respect to addressing the SDH to achieve of policyaction on the SDH. Especially
health equity. The New Zealand case shows when social reports are produced jointly by
that social reporting schemes have the multiple government agencies, they have
37
the potential to be a starting point for the ∏ National social reports are useful for
cultivation of a culture of continued inter- countries with regard to developing
sectoral thinking and action. national agreement on standard social
indicators for national, and international,
∏ For policy actors from civil society benchmarking. While international
concerned with health equity, social standards have been set by international
reports present a good advocacy tool organizations such as the UN, the European
by providing official, authoritative, Union and the OECD and can provide
government-sourced data on the state of some orientation for national decision-
health (and social) equity. In New Zealand, making with respect to the selection of
official social reports have achieved a good the most appropriate set of national social
public profile and are applied for multiple indicators for monitoring, the process of
purposes, not only by government, but putting together national social reports
also by diverse civil society groups. Health fulfills a national benchmarking function.
advocates, important policy actors, are To produce national level social reports,
one of the key audiences for social reports government, academic leaders and civil
if these successfully monitor key issues of society, need to collaboratively agree
interest for these organizations, namely upon standard social indicators, hence
health equity and the SDH. enhancing and standardizing national
thinking with respect to social outcomes.
∏ Extending the healthsector focus on
health and well-being to the notion of ∏ The business sector and its  government
social well-being. The concept of social counterparts need to see themselves and
well-being, extending the healthsector’s their interests clearly in social reports.
understanding of health and well-being Well distributed economic gain leads to
further into the social realm, adds to policy improved health outcomes, and leads
efforts addressing SDH to achieve health to improved economic performance.
equity by further establishing a social In consequence the private and public
model of health as the foundation of health economic sector needs to see themselves
planning. While outcomes in the health and their interests clearly in social reports.
domain might still be assessed according In New Zealand, failure to engage these
to classical medical-model thinking by sectors in the Social Reports has minimized
measuring prevalence and demographic the reports policy impact significantly.
distribution of disease and risk factors,
describing other social domains as
determinants of social well-being increases LESSON 3: Social reports have the
or reinforces an understanding of health potential to inform the evaluation
outcomes as influenced by policy-making and design of public policy and
from both within and outside of the health intervention
sector. This has conceptual implications
for health policy staff involved in the ∏ Social reports can be used to assess the
development of the social reports and their (medium and long-term) impact of
understanding of how other outcomes policy initiatives to reduce social and
domains are interconnected with health health inequity. One further advantage
outcomes, and, in turn, how policy in other of introducing social reporting for
sectors impacts on health outcomes. Health governments interested in reducing
officials valued engaging in a process of inequalities and working with the SDH is
shared meaning-making and language- that such a cross-sectoral and integrated
finding with officials from other sectors, monitoring system has the potential
while involved in the development of the to provide an impact evaluation of
New Zealand Social Reports. Intersectoral governmental policy in this area. While
working and developing a shared inter- short term policy evaluations might be
sectoral approach is likely to aid individual questionable due to the cross-cutting
policy-makers’ understanding of the SDH. nature of social outcomes, medium- to
long-term changes of social outcomes have
successfully been linked to medium- to
38
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

long-term all-of-government initiatives responsive to new social priorities.


(i.e. the Social Reports have successfully Although traditionally health indicators
linked increases in ethnicity-based social often measure the prevalence of disease
outcomes inequity to New Zealand or risk behaviours, social reports also
undergoing gover nment-direc te d incorporate a number of more “positive”
economic policy reform in the 1980s and concepts such as for example social
1990s). However, it is clear that more connectedness as a form of social capital
research and standardized guidance is which rests within communities. For
needed in order to identify how to evaluate civil society, especially marginalized
policy impacts in the short to medium populations, social reports that do not
term. only locate deficits and disparities, but also
at the same time document strengths of the
∏ Preferably, social reports explicitly link respective population are likely to receive
their findings to policy action. Information more attention and endorsement, resulting
generated in social reports ought to be in better currency and application of the
applied to direct or enhance the design and reports.
implementation of policy interventions.
Reports would be strengthened if they ∏ To be able to guide action towards
explained strategic or operational addressing between-country inequities,
improvements that resulted from previous national level social reporting ought
findings. also to share some alignment with
international social reporting, i.e. by
using internationally standardized social
LESSON 4: Social reports need to indicators. Social reports produced for
be developed with a number of core national level reporting ought to utilize,
process, conceptual and technical where possible and in alignment with
considerations in mind national policy needs, social indictors used
in other countries in order to guarantee
∏ If the public, especially diverse international comparability of social
disproportionately burdened populations, outcomes.
have the chance to actively participate
in the conceptual development of social ∏ When social reports do not link their
reports, and the reports are transparent findings to research on the cause/effect
with respect to changes made and easily relationship between SDH and health
available free of charge, an emphasis outcomes, they are unable to make causal
on equity in social reports is likely be statements in this manner. Evidence
strengthened and public debate and up- indicating the pathways through which
take of the reports’ findings increased. social factors impact on health comes
The New Zealand case has shown that from research. These pathways need to
social reports, if easily accessible, user- be made explicit so that the data in the
friendly and transparent, can strengthen social reports can be used to identify
the interface between government causes, or at minimum, associations.
agencies and the public, including various This information needs to be obtained
stakeholder groups as well as the private from well designed studies and, once
and non-governmental organization good research has demonstrated a link
sector. Comprehensive community (preferably a causal link) between a social
consultation and offering civil society, condition (e.g. housing) and health, then
especially marginalized population groups, social reports are very good at showing the
participation in the development process inequities in the SDH. A future challenge
of social reporting regimes can make a for social reports will be to establish
positive contribution in this regard. associations between both the diverse well
being domains (i.e. health and education
∏ If possible, social reports should be based or health and social connectedness) and
on positive, as opposed to deficit-based, between individual social indicators. While
concepts to enhance up-take, especially predictive economic models have been
from civil society. They should also be constructed, taking into account various
39
indicator functions, no equivalent measure to indigenous people for human rights
exists for social outcomes as a whole as abuses inflicted against them by successive
yet. For high-level policy-making the colonial governments, the need for a
Social Report were seen as a good starting distinct set of social indicators catering
point, providing steady, serial updates, for the information needs of indigenous
but critique centered around the reports peoples increases. Besides presenting
lack of explicit predictive potential at this social outcomes carefully disaggregated
point. The reports contain no sense of by the indigenous versus non-indigenous
dynamics and how the different domains categories, a distinct set of social indicators
quantitatively interact with each other- addressing indigenous concerns can be
these are the weak links and the next steps created for inclusion into social reporting
to take for New Zealand. schemes. This is an emerging field of
social reporting, that, while being able to
∏ Social reports ought to closely link the draw on some contemporary conceptual
relationship between individual outcomes frameworks and indicator lists developed
domains. Social Reports increase their by indigenous people, needs to be further
applicability for policy-makers, if they are extended in national-level social reports.
able to statistically capture the relationship
between their diverse outcomes domains. ∏ It is advisable to anchor a responsibility
In the New Zealand report this has to publish social reports in national
not been realized, which leaves doubts legislation. Although social reports
regarding the interconnectedness of the are often published by governmental
various individual outcomes domains. Statistics Departments, which are generally
equipped with statutory independency,
∏ Countries with indigenous populations if social reports are published by other
appear to have the collective need for public departments, their fate often relies
a distinct set of social indicators that, on political good-will to monitor social
developed by indigenous people, have the outcomes, leaving social reports vulnerable
ability to document trends in indigenous to political opposition and changes in
people’s social (including health) government. To counter the threat of
outcomes. With increasing national disestablishment of social reporting
and international acknowledgement of regimes, countries have the option to
indigenous rights (e.g. the 2007 United cement social reporting as a statutory
Nations Declaration on the Rights of responsibility, an option that has been
Indigenous Peoples), paralleled by explored in New Zealand but not as yet
associated progress in many countries with implemented.
political leadership officially apologizing

40
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

List of abbreviations

ECOSOC United Nations Social and Economic Council


MDGs Millennium Development Goals
OECD Organization for Economic Co-operation and Development
SDH Social Determinants of Health
UN United Nations
UNSD United Nations Statistics Division
WHO World Health Organization

41
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48
Monitoring social wellbeing to support policies on the social determinants of health: the case of New Zealand’s “Social Reports/te pūrongo oranga tangata”

Annexes

Annex 1: Selected national social reporting schemes


Selected national social reports
Country Institution Title First Edition Periodicity
Australia
Social Trends 1994 1 year
Australian Bureau of Statistics
Austria
Statistik Austria (before 2000 Statistisches Sozialstatistische Daten 1977 4/5 years
Zentralamt)
Canada Quarterly (since
Canadian Social Trends 1990
Statistics Canada 2006 triennially)
Denmark 4/5 years (last
Levevilkår I Danmark 1976
Danmarks Statistics/ Statistics Denmark published 1997)
Federal Republic of Germany
Datenreport 1983 2 years
Statistisches Bundesamt
France
Institut Nationale de la Statistique et des Données Sociales 1973 3 years
Economique
United Kingdom of Great Britain
Social Trends 1970 1 year
National Statistics
Hungary
1990
TÁRKI Social Research Institute Social Report 2 years
(non-governmental)
Israel Society in Israel 1976, 1980 1 year
Israel Central Bureau
of Statistics2 Israel Social Report 1995-2002 ?

ADVA Centre: Information on Equality Israel: A Social Report 2005 —


and Social Justice in Israel (non-
governmental)
Italy
Instituto Nationale di Statistica/ Sintesi della Vita Sociale
1990 ?
Statistics It