© The Policy Press, 2009 • ISSN 0305 5736 463

Health inequalities, social determinants and

public health policy
Hilary Graham

Over the past decade, new public health policies have been launched in a number of
high-income countries. The policies are distinguished by an emphasis on tackling ‘health
inequalities’ and ‘social determinants’. This article considers how the two concepts are
configured in national strategy documents. Noting that both concepts have a spectrum
of meanings, it develops a schematic matrix through which to depict public health policies
claiming an equity and determinants focus. Examples are given to illustrate how this analytical
tool can be used to develop critical readings of public health policies.

Introduction

High-income countries have experienced sustained improvements in living standards

and life expectancy over the last 100 years. However, greater national wealth and
improved population health have failed to level up opportunities for good health
across their populations. Instead, in a pattern repeated across Europe, the US, Canada,
Australia and New Zealand, socioeconomic inequalities in health have persisted;
moreover, evidence for recent decades points to widening inequalities (Acheson,
1998; NHC, 1998; Perrson et al, 2001; Mackenbach, 2005). Behind the trend towards
widening health inequalities lies the differential rate of improvement in health, with
more advantaged groups experiencing a faster rate of health gain than less advantaged
groups (Schalick et al, 2000; Mackenbach, 2005; DH, 2008).
Over the last decade, governments in high-income countries have begun to
engage with inequalities in the health of their populations. In an increasing number
of countries, the goals of public health policy have been widened beyond their
traditional focus on improving population health to include an explicit commitment
to addressing the unequal distribution of health. In the US, policy documents refer
to ‘health disparities’, a term used particularly with reference to health differences
between African-American, white and Hispanic groups (Adler, 2006). In New
Zealand, ethnic differences are also a primary focus of national policy, with the
concept of health inequalities used to describe health differences between Mãori
and non-Mãori communities as well as between socioeconomic groups (NHC,
1998). In Northern Europe, ‘health inequalities’ typically refer to socioeconomic
differentials. The broadening of policy goals has been accompanied by a widening
of policy boundaries. National and regional governments have launched new public
health strategies, which claim to move public health beyond a focus on individual
behaviour and secondary prevention to include the physical and social environments
in which lifestyles are embedded and health services are accessed.

Key words: health inequalities • social determinants • public health policy

Final submission January 2009 • Acceptance March 2009

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 464 Hilary Graham

Broader goals and wider remits are summed up as ‘tackling health inequalities’ and
‘tackling social determinants’. National strategy documents – ministerial strategies,
White Papers and reports to Parliament – have heralded the new approach. Like
other political texts, these documents are rhetorical devices: they are ways of
communicating how governments would like policy challenges and policy solutions
to be seen by the constituencies to which governments aim to appeal (Humpage
and Fleras, 2001).The documents can therefore shed light on ‘what ideas, values and
interests dominate the policy arena’ (Iannantuono and Eyles, 1997) and, specifically,
how concepts like health inequalities and social determinants are being deployed
in the presentation of government policy.
Researchers have begun to interrogate policy texts to uncover the meanings of
health inequalities and social determinants on which the texts draw. To date, these
critiques have typically focused either on single national examples or on a small
number of countries. In addition, they have tended to consider either discourses
of health inequalities (eg Graham, 2004a; Exworthy et al, 2006;Vållgarda, 2008) or
social determinants (eg Graham, 2004b; Raphael and Bryant, 2006). This article
builds on and advances this critical seam of work. It does so by combining a focus
on both health inequalities and social determinants, and an examination of how these
concepts are configured in policy documents that have launched national strategies
to tackle health inequalities. Drawing on this examination, the article suggests a
schematic matrix through which to map policies claiming an engagement with
health equity and social determinants.
To set boundaries around the analysis, the article includes public health strategies
published between 1997 and 2007 where translations and/or synopses are available
in English. It is therefore inevitably weighted towards countries that, by 2007, were
positioned at the advanced end of Whitehead’s (1998) ‘action spectrum on inequalities
in health’: where governments had moved beyond general awareness and statements
of intent to the development of explicit policies. It therefore excludes countries with
legislative commitments to promoting the health of poorer groups and making a
contribution to greater health equity – for example the 2005 law governing public
health services in Greece and the 2000 law relating to the operation of the healthcare
system in Germany – but where explicit policies are not in place (Judge et al, 2005;
Costongs et al, 2007). Similarly the review does not include countries like France
and the Netherlands where, while reducing socioeconomic inequalities in health
is among its stated objectives, the government has not developed and published a
national strategy to take forward the goal (Costongs et al, 2007). Also excluded is
Finland: its 2001 public health strategy included a target to reduce socioeconomic
inequalities in mortality but, by 2007, its national action plan had not been published
(MSAH, 2008). It should additionally be noted that the inclusion criteria favour
English-speaking countries: among these, England is widely regarded to be at the
leading edge of policy development (Mackenbach and Bakker, 2003).
As these provisos indicate, this article is not seeking to provide a comparative
review of policies to tackle health inequalities in high-income countries. Its aims
are more modest. It examines national policy texts to develop an analytical tool
through which policy researchers can map the concepts of health inequalities and
social determinants in play in public health policy.To this end, the two sections below
consider how health inequalities and social determinants are conceptualised in new

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 Health inequalities, social determinants and public health policy 465

strategies published across a decade of major change for public health policy.The third
section brings the concepts together in a schematic matrix through which policies
claiming an equity and determinants focus can be categorised. Examples are given
to illustrate how such a matrix can be used to develop critical readings of national
policies. However, the matrix has been designed for broader use, with the capacity
for refinement to enable readers to adapt it to the contexts of its application: for
example, to capture differences in orientation at national/local level and between
policy sectors or to identify how specific interventions contribute to (or are in
tension with) national policy goals.
The importance of critical engagement in policy analysis and development has
been underlined by the recently published report of the Commission on Social
Determinants of Health (CSDH). The Commission was established by the World
Health Organization (WHO) to catalyse action to tackle the unequal distribution
of health within and between countries, an unequal distribution that, it argues, is
the consequence of the unequal distribution of the social determinants of health
(WHO CSDH, 2008a).The article is designed as a contribution to the cause of social
justice that the WHO is championing. As the CSDH argues, the development of a
society can be judged by ‘how fairly health is distributed across the social spectrum’
(WHO CSDH, 2008b: 1).

Health inequalities and public health policy

Since the mid-1990s, reducing health inequalities and disparities have been made a
core goal of public health policy in a number of high-income countries. It has been
placed alongside overall health gain in policies launched in England and the devolved
governments of Northern Ireland, Scotland and Wales, as well as in Canada, New
Zealand, Sweden and the US. Illustrative examples are given in Box 1. Norway’s new
strategy goes further, removing the goal of health improvement for those in good
health in favour of a single focus on reducing health inequalities. Addressing the
unequal distribution of health is also given prominence in Danish policy documents
as well as in Australia in states like New South Wales, which are pursuing an equity
agenda (Government of Denmark, 2002; Newman et al, 2006).

Box 1:Tackling health inequalities

England: ‘Improving health for all and tackling health inequality is a challenging objective
– a crusade for health on a scale never undertaken by Government before’ (SSH,
1999:5).

Scotland: ‘The Government’s vision … is about making a difference to the health and
life of the whole population and about tackling the health inequalities which currently
exist … tackling inequalities will be the overarching aim’ (SSS, 1999: 2,vii).

New Zealand: ‘The combined goals must be the improvement in the health of our
community (and) reduced disparities in health outcomes for all New Zealanders,
including Mãori and Pacific peoples … addressing health inequalities is a major priority
requiring ongoing commitment’ (MH, 2000: 3-4).

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 466 Hilary Graham

The US:‘Healthy People 2010 is designed to achieve two overarching goals: increase quality
and years of healthy life (and) eliminate health disparities’ (USDHHS, 2000: 2).

Sweden: ‘The vision proposed is to achieve good health on equal terms’ (MSAH, 2000:
11).

Denmark: ‘Social inequality in health should be minimised’ (Government of Denmark,

2002: 8).

Canada:‘The vision of the Healthy Living Strategy is a healthy nation in which all Canadians
experience the conditions that support the attainment of good health. To achieve this
vision, the goals of the Strategy are to improve overall health outcomes and reduce
health disparities’ (ACPHHS, 2005: 10).

Norway: ‘The primary goal of future health work is not to further improve the health
of the people that already enjoy good health. The challenge now is to bring the rest of
the population up to the same level as the people who have the best health – levelling
up’ (NMHCS, 2007: 5)

Changes in government – and specifically the election of a centre-left government

– have been a catalyst for the new health policies in New Zealand (Humpage and
Fleras, 2001), the UK and the US (Exworthy et al, 2006) and Norway (Torgersen
et al, 2007). In these countries, the incoming government sought to establish its
political credentials by signalling that the old regime had been replaced by one
willing to make an explicit commitment to tackling health inequalities. Behind the
commitment lie international charter obligations, including those enshrined in the
WHO’s constitution, reaffirmed in the WHO Global strategy for health for all by the
year 2000 (HFA), and carried forward into the successor HFA strategy for the 21st
century (WHO, 1981;WHA, 1998).These enshrine the right ‘without distinction of
race, religion, political belief, economic or social condition’ to achieve ‘the highest
attainable standard of health’ (WHO, 1946: I).
In her analysis of public health policy in England, Graham (2004a) described how
the goal of tackling health inequalities was represented in government documents
spanning the period 1997 to 2003. Pointing to multiple and shifting meanings of
the new goal, she identified a spectrum ranging from remedying health disadvantages
(captured in the government’s commitment ‘to improve the health of the worst
off in society’; SSH, 1998: 5) through narrowing health gaps (‘to narrow the health
gap’; SSH, 1998: 5) to reducing health gradients (‘our vision is of a country in which
everyone has the same chance of good health, regardless of where they live or their
social circumstances’; DH, 2002: v).While developed initially to capture ambiguities
and tensions within England’s new public health strategy, the typology has been
applied to a range of other countries (see, for example, Judge et al, 2005;Vällgarda,
2007, 2008; Whitehead and Dahlgren, 2007).
The first goal commits governments to maintain what is already a longrunning
trend in high-income countries: namely to secure the contiunuing improvement
in the health of disadvantaged groups. An example of this approach is the goal set

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 Health inequalities, social determinants and public health policy 467

by the Scottish government in 2004 ‘to increase the rate of improvement of the
health status of people living in the most deprived communities’, with targets set
to reduce mortality under the age of 75 from coronary heart disease and cancer for
the most deprived communities by 2008 (Scottish Executive, 2006).
The second goal – to narrow health gaps – is more challenging as it requires a
reversal of the trend towards widening health inequalities (Acheson, 1998; NHC,
1998; Perrson et al, 2001; Mackenbach, 2005). To achieve it, the rate of health gain
among the poorest groups needs to outstrip that achieved by the comparator group
(typically defined as either the most advantaged group or the population as a whole).
As the Welsh strategy document puts it, the goal of the health inequalities strategy
is ‘to improve … mortality in all groups and at the same time aim for a more rapid
improvement in the most deprived groups’ (WAG, 2006). It is the goal most widely
used when targets are set, both by national governments (eg in England, the target is
to lift standards of health in poorer communities closer to the population average)
and international agencies (eg the target of the WHO’s HFA strategy for Europe is
to reduce ‘the health gap between socioeconomic groups within countries … by
substantially improving the level of health in disadvantaged groups’;WHO Europe,
1999: 180).
However, while more ambitious, the goal of narrowing health gaps, like remedying
health disadvantages, casts health inequalities as a condition to which only those in
disadvantaged circumstances are exposed. Strategies can therefore focus solely on
disadvantaged groups, seeking to improve their health in absolute terms (the more
limited variant of the goal) and in relative terms. In contrast, the goal of reducing
health gradients makes clear that health is unequally distributed not only between
the poorest groups and the better-off majority but also across all socioeconomic
groups. As an example of this broader concept of health inequalities, the English
government’s review of policies to tackle health inequalities noted that ‘health
inequalities follow a social gradient, with the health gap increasing steadily with
poorer social class…. [Therefore] interventions must reach more than the most
deprived, socially excluded populations’ (DH, 2002: v2). As a second example,
Norway’s new public health strategy is grounded in an appreciation that ‘the link
between social position and health forms a gradient and affects all levels of society’
(NMHCS, 2007: 8); therefore ‘the primary objective of this strategy is to reduce
social inequalities in health by leveling up (NMHCS, 2007: 6).This broader framing
of health inequalities demands a broader framing of policy goals. Lifting levels of
health across the population requires a rate of health gain that is greatest for the
poorest, progressively lower for better-off groups and lowest for those in the most
advantaged circumstances. Differential rates of health improvement in turn require
differential rates of improvement in the factors that promote good health: in what
are called the ‘social determinants of health’.

Social determinants and public health policy

For most of the last century, public health was an adjunct to health policies concerned
with the funding and delivery of healthcare (Lewis, 1986, 1991).As governments were
confronted by rising rates of chronic disease and increasing healthcare costs, public

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 468 Hilary Graham

health policy became increasingly focused on tackling what the UK government

called ‘unwise behaviour and over-indulgence’ (DHSS, 1976: 31).
It was against this background that a set of powerful critiques of health policy was
published (Illich, 1975; McKinlay, 1975; Navorro, 1976; Crawford, 1977; Doyal, 1979;
McKeown, 1979). While the analyses differed in important ways, they concurred
that health policies placed too little emphasis on the social conditions that promote
people’s health and too much emphasis on personal responsibility and medical care
for those at risk of disease. McKeown (1979) drew on his historical analysis of the
causes of declining mortality in England and Wales to highlight the primary role
of environmental improvements, and improved living and nutritional standards
in particular. Meanwhile, Crawford (1977: 663) pointed to ‘the emergence of an
ideology which blames the individual for her or his illness and proposes that the
individual should take more responsibility for her or his health’. He argued that this
ideology serves to ‘divert attention from the social causation of diseases … [and]
to obscure the reality of class and the impact of social inequality on health’ (1977:
663, 672).
The critics therefore concluded that there was ‘a case for refocusing upstream
… away from those individuals and groups who are mistakenly held responsible
for their condition, toward a range of broader upstream political and economic
forces’ (McKinlay, 1975: 7). These upstream factors were referred to as the ‘social
determinants of health’, a concept designed to highlight ‘the impact of living and
working conditions, and patterns of social and economic relationships, on the
health of individuals and groups’ (Doyal, 1979: 296).The perspective gained further
momentum in the early 1980s with the publication of the Black Report on the
causes of health inequalities (Townsend and Davidson, 1982), instigated by the British
government in the late 1970s but having wide international impact (Whitehead,
1998). While noting the contribution of health behaviour and healthcare, it
concluded that health inequalities ‘can only be understood in terms of the more
diffuse consequences of the class structure’ (Townsend and Davidson, 1982: 134).
Reducing health inequalities therefore required ‘measures to reduce differences in
material standards of living at work, at home and in everyday social and community
life’ (Townsend and Davidson, 1982: 173).
These critical reassessments provided the context in which Dahlgren and
Whitehead (1991, 1993) developed their model of the main determinants of
health. Designed to inform the WHO’s HFA agenda, the model provides a visual
representation of the major factors influencing population health. It makes clear
that these factors are social in origin: overarching societal factors operate through
people’s living and working conditions to influence health both directly and through
health behaviour (Figure 1).The iconic model has served to embed the concept of
determinants in both national and international policy discourses. Box 2 illustrates
how the concept of ‘determinants’ – and its popular variants of ‘underlying causes’
and ‘root causes’ – has figured in policy blueprints for tackling health inequalities
published from the late 1990s.

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 Health inequalities, social determinants and public health policy 469

Figure 1:The main determinants of health

, cu l t u r a l a n d e nv i
ron
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n nt
e co Living and working
conditions a
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Work Unemployment

on
so

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an a l life s t y l e t
Water and
Education

io n s
sanitation
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Health
Soc

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care
In di

services
Agriculture
and food
production
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Age, sex and
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Source: Dahlgren and Whitehead (1993); accessible in Dahlgren and Whitehead (2007); reproduced with
permission

Box 2:Tackling determinants

Wales:‘The Government wishes to tackle the underlying causes of ill-health….A person’s

social and economic circumstances are probably the strongest influence on health,
avoidable sickness and preventable death’ (SSW, 1998: 1,10).

New Zealand: ‘Improving the population’s health means focusing on those factors that
most influence health….Tackling broader determinants requires action across sectors’
(MH, 2000: 5).

Northern Ireland: ‘The Government is committed to attacking the root causes of ill
health and poor social wellbeing.… It is clear that many of the major inequalities in
heath are associated with disadvantage, whether this is measured by income, level of
educational achievement or occupation’ (DHSSPS, 2000: 18, 26).

The US: ‘Communities, States, and national organisations will need to take a
multidisciplinary approach to achieving health equity – an approach that involves
improving health, education, housing, labor, justice, transportation, agriculture, and the
environment’ (USDHHS, 2000: 6).

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 470 Hilary Graham

Sweden: ‘Sweden now has a new national public health policy…. Where objectives had
previously been based on diseases or health problems, health determinants are now
chosen instead’ (Ågren, 2003: 3, 5).

England: ‘[We are] addressing the underlying determinants of health – dealing with the
underlying causes of health inequalities.… The Government’s aim is to reduce health
inequalities by tackling the wider determinants of health inequalities’ (DH, 2003: 5, 7).

Behind the common language, however, the concept of social determinants is

employed in variable ways in national policy texts, with multiple reference points
and malleable boundaries. Policy documents talk of wider determinants and root
causes when referring both to the major influences on overall health and to the social
factors that underlie its unequal distribution (Graham, 2004b). Thus, for example,
the Canadian strategy notes that ‘taking action on a wide spectrum of factors known
to influence health is essential to reducing health disparities’ (ACPHHS, 2005: 12).
The US programme advocates a ‘systematic approach’ to ‘determinants of health’
(USDHHS, 2000: 7), with the goals of improving health and eliminating health
disparities to be met through overall improvements in determinants (for example,
increasing the proportion of the adult population who are physically active and
reducing national rates of cigarette smoking). However, evidence across the last
30 years suggests that there is no necessary association between population-level
improvements in health determinants and reductions in their unequal distribution.
Instead, a common trend is for positive trends in health determinants at population
level – for example, overall increases in overall living standards and reductions
in the overall prevalence of cigarette smoking – to be associated with widening
socioeconomic inequalities in determinants – for example, increasing inequalities
in the incomes of richer and poorer households and steepening socioeconomic
gradients in smoking (Giskes et al, 2005; Hill et al, 2005; Graham, 2007). As this
suggests, it is social inequalities in health determinants that underlie social inequalities
in health.
The documents announcing the new public health strategies also employ a concept
of social determinants with flexible boundaries: one that can give variable weight
to the arcs in Dahlgren and Whitehead’s rainbow. For example, the concept can
be defined inclusively to encompass the spectrum of determinants, from societal
to individual (examples are given in Box 3a). Or the concept can be used more
narrowly to give greater emphasis to environmental influences or individual risk
factors (Box 3b and 3c).

Box 3:Tackling social determinants

(a) Emphasising a spectrum of determinants

US: ‘Determinants of health: Topics covered by the objectives in Healthy People 2010
reflect the array of critical influences that determine the health of individuals and
communities…. Individual biology and behaviors influence health through their interaction
with each other and with the individual’s social and physical environments. In addition,

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 Health inequalities, social determinants and public health policy 471

policies and interventions can improve health by targeting factors related to individuals
and their environments’ (USDHHS, 2000: 18; italics in original).

Sweden: ‘The health of the population is affected by a range of what are known as
determinants. These are factors that in part relate to the structure of society and in
part to people’s lifestyles and habits’ (MSAH, 2001: 8).

(b) Emphasising wider determinants

Northern Ireland: ‘The determinants of health. Health is mainly determined by people’s

social, economic and cultural environment and any strategy must address these factors’
(FMDFM, 2000: 12).

Canada: ‘[Our] approach focuses on the living and working environments that affect
people’s health, the conditions that enable and support people in making healthy choices,
and the services which promote and maintain health’ (ACPHHS, 2005: 10).

c) Emphasising individual risk factors

England: ‘[T]he wider determinants of infant mortality include breast feeding, obesity
and smoking’ (DH, 2007a: 15).

Shifting meanings are apparent within as well as between policy documents. A

recurrent slippage occurs as the policy statements move from overarching principles
to strategic objectives, with a broad concept of determinants giving way to a
narrower focus on individual risk factors. For example, the New Zealand health
strategy makes clear that ‘social factors outside the immediate control of the health
sector, such as income, housing, employment and education, play a major role in
the health status of people throughout their lifetime’ (MH, 2006: 101); however,
its ‘priority population health objectives’ are to change individual behaviour
(smoking, physical activity, alcohol consumption) (MH, 2000: 5). Similarly, the US
strategy document appears to adopt an inclusive definition of determinants as ‘the
individual behaviours, physical and social environmental factors and important
health system issues that greatly affect the health of individuals and communities’
(USDHHS, 2000: 24; see also Box 3a). But when it identifies indictors through
which the success of the strategy is to measured, the concept narrows. These are
heavily weighted towards behavioural factors (physical activity, tobacco use, substance
abuse, sexual behaviour, immunisation), and only one – air quality to be measured
by exposure to ozone and environmental tobacco smoke – covers factors related
to the physical and social environment (USDHHS, 2000: 40). As a third instance of
this broader pattern, Canada’s policy blueprint initially embraces a broad concept
of determinants. Determinants are defined primarily in terms of people’s living
and working conditions (Box 3b), with the document noting that the public health
strategy ‘strives to address some of the root causes that lead to poor health outcomes’
(ACPHHS, 2005: 10). But the boundaries of the concept shrink when it comes to

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 472 Hilary Graham

setting targets to carry forward the strategy: these are focused on ‘healthy eating,
physical activity and healthy weights’ (ACPHHS, 2005: 3).

Health inequalities and social determinants: a policy

framework
The overview of national policy documents presented in the previous two sections
suggests that the concepts of health inequalities and social determinants are being
mobilised to lend legitimacy to a range of different approaches. Under the banner
of tackling health inequalities, policy blueprints can focus on achieving absolute
improvements in the health of the poorest groups, narrowing the gap between
their health and the wider population and/or on tackling the broader relationship
between social position and health. Under the banner of addressing root causes, the
concept of determinants can be used to legitimate action across all the arcs in the
Dahlgren and Whitehead model; alternatively, it can focus attention on upstream
societal influences or downstream risk factors.
It is possible to combine at least some of the meanings of health inequalities and
social determinants into a schematic outline of determinants-oriented approaches
to tackling health inequalities (Figure 2). The vertical axis captures the spectrum
of health inequalities goals, from securing absolute improvements in the health of
poor groups to reducing the population-wide health gradient. The horizontal axis
captures approaches to tackling social determinants. In line with national policy
documents, it characterises these as focusing on broader determinants or proximal
risk factors.
As a tool for policy analysis, the matrix can be refined and developed in different
ways. For example, it can be used to position strategies at national, state and
community level or to classify specific interventions (for instance, the introduction
of an early child development programme targeted at low-income families or a
more progressive taxation policy) to capture their potential contribution to reducing
inequalities in access to the determinants of good health.Additional subdivisions can
also be included. For example, ‘broader determinants’ can be further differentiated
to distinguish between approaches that define these in terms of people’s living and
working conditions and those that emphasise the deeper societal structures that shape
them (what the WHO CSDH calls ‘the fundamental global and national structures
of the social hierarchy’; WHO CSDH, 2008a: 42). Similarly, subdivisions can be
introduced into the category of ‘individual risk factors’ to separate behavioural
factors (smoking, poor diet) and physiological factors (obesity, high blood pressure)
or to distinguish between approaches favouring drug-based interventions (nicotine
replacement therapy, anti-hypertensives, statins) and behavioural interventions
(weight reduction and exercise programmes). As an analytical tool, the matrix could
also serve as a stimulus for debate, for example by inviting groups drawn from the
research and policy communities to apply the matrix to specific policies to tease
out divergences in perceptions of whether and how they were tackling inequalities
in social determinants and in health.
Here, the simple version of the matrix presented in Figure 2 is used to illustrate
one of its potential applications. Taking three examples, the matrix is applied to
national policy documents to identify the discourses that frame them.

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 Health inequalities, social determinants and public health policy 473

Figure 2: Determinants-oriented approaches to tackling health inequalities

Tackling inequalities in social determinants

in broader determinants in individual risk factors

Tackling reducing health (1) increase in level of (2) reduction in prevalence
health gradients determinants in all groups in all groups to match that in
inequalities to match that in most most advantaged group
advantaged group
narrowing health (3) faster rate of (4) faster rate of reduction in
gaps improvement in risk factors in poorest group
determinants in poorest than comparator group
group than comparator
group
improving health (5) improvement in (6) reduction in risk factors
of poorest groups determinants in poorest in poorest group
group

Norway’s new national strategy was launched in 2007 in a policy blueprint that
conceptualises health inequalities as health gradients: as it notes, while ‘inequalities
in health are most noticeable in groups with low income and little education
… social inequalities affect all social classes, not only the most disadvantaged’
(NMHCS, 2007: 7). Determinants are conceptualised in the document as covering
the spectrum of social factors in Dahlgren and Whitehead’s rainbow model. There
is an explicit commitment to policies and interventions to ‘reduce social inequalities
that contribute to inequalities in health’ like inequalities in income and in health
behaviour (NMHCS, 2007: 7), with emphasis given to the need to promote equitable
access to the social determinants of good health, including income, employment
and housing (NMHCS, 2007). As this suggests, the approach advocated by the
national strategy is located in cells 1 and 2 of the matrix, with interventions to
reduce inequalities in broader social determinants (eg income inequalities) seen as
providing the context for effective interventions to tackle inequalities in individual
risk factors. As the strategy document puts it,‘the Government is going to take steps
to reduce economic inequalities in the population … because people’s personal
economy affects their ability to take advantage of health-promoting products and
services’ (NMHCS, 2007: 34).
In contrast, Denmark’s public health strategy document suggests that more restricted
concepts of health inequalities and social determinants are in play (Government of
Denmark, 2002).Vallgärda’s (2007, 2008) analysis indicates that policy is located in
cell 6, with the predominant focus on the poorer health of disadvantaged groups
and on individual-level risk factors and health behaviour in particular. It is the
culture of disadvantaged groups rather than the structure of the wider society that
is seen to lie behind their higher rates of health-damaging behaviours. As the policy
document puts it,‘the concepts of quality of life and a good life among vulnerable and
distressed groups may challenge the usual norms and values of society’ (Government
of Denmark, 2002, quoted in Vallgärda, 2008: 78).
The documents that have marked the development of England’s health inequalities
strategy suggest that the meanings of health inequalities and social determinants have

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 474 Hilary Graham

both shifted and narrowed over time. The early documents – published in the late
1990s and early 2000s – signalled a broad understanding of health inequalities (see
SSH, 1998, 1999; DH, 2001, 2002).Thus, attention was paid to improving the health
of the poorest (bottom row in the matrix), the inequality goal was framed in terms
of narrowing health gaps (middle row) and gaps were seen, in turn, to be part of a
wider social gradient (top row). As an early strategic review noted, ‘interventions
must reach more than the most deprived areas and the most socially disadvantaged,
socially excluded populations to … make progress on health inequalities’ (DH, 2002:
2). In line with the recommendations of the government-commissioned inquiry
into health inequalities (Independent Inquiry, 1998), early policy documents also
indicated that the government would take a broad approach to social determinants.
Thus, ‘the Government’s main task …is to tackle the root causes of ill health. Most
of these are social, economic and environmental’ (SSH, 1999: 39). The perspective
therefore appeared to be one that straddled cells 1, 3 and 5.
In more recent documents, this broad perspective has given way to a narrower
conceptualisation, with policy discourse consolidating around narrowing health gaps
and tackling individual risk factors (cells 4 and 6). As a number of commentators
have argued, the setting of targets to reduce health inequalities has contributed
to this narrowing of focus (Blackman et al, 2006; Bauld et al, 2007, Blackman,
2007). In 2001, two targets were set to narrow the health gap in life expectancy
and infant mortality between disadvantaged groups and the population average
by 2010. To date, life expectancy has risen and infant mortality rates have fallen in
the target groups from the baseline period, but the rate of improvement has been
greater in the population as a whole. As a result, rather than narrowing, the relative
gap in both indicators has widened over the last decade (DH, 2008). In response,
strategy documents have retreated from the broader vision of policy intimated in
the early policy blueprints, with tackling health inequalities increasingly equated
with tackling individual risk factors in the small and tightly-defined subgroups on
which monitoring is based (DH, 2007a, 2007b, 2007c). For example, the 2007 policy
advice on how to achieve the life expectancy target emphasises the importance
of smoking cessation and pharmacological interventions (anti-hypertensives and
statins) in the target groups; in consequence,‘successful delivery [of the 2010 national
target] will be primarily through NHS actions, rather than actions to tackle wider
determinants’ (DH, 2007c: 12). In a similar vein, policy guidance for achieving the
infant mortality target notes that progress towards the target depends on changing
maternal behaviour.‘Actions to reduce the gap in infant mortality’ (DH, 2007c: 36)
give emphasis to reducing teenage pregnancies, smoking and obesity in the target
group and to cutting death rates from sudden unexpected deaths by ‘persuading
women in this group to avoid sharing a bed with their baby or putting it to sleep
prone’ (DH, 2007c: 7).

Conclusion
Over the last three decades, economic and social policies in high-income societies
have delivered greater national wealth and better population health. But marked
inequalities in health remain and show little sign of narrowing. Between 1997 and
2007, a number of governments responded to these trends by launching new public

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 Health inequalities, social determinants and public health policy 475

health policies. An examination of these documents suggests that their defining

feature is a dual engagement with health inequalities and social determinants. Both
concepts are grounded in research: in studies detailing the systematic association
between social position and health and in evidence highlighting the primary causal
role of social conditions in influencing individual and population health.This article
has explored how these foundational concepts are configured in the texts that present
the new public health policies.
It has pointed to the plasticity of both concepts. In pursuit of the health equity
goal, policy documents can advocate an exclusive focus on the poorest groups or
an inclusive strategy for the whole population. Tackling the unequal distribution
of determinants can be represented either as a comprehensive strategy to moderate
inequalities at the macro, meso and micro level or as selective action at particular
points along the causal pathway. Combining these dimensions, a matrix has been
constructed through which to capture determinants-oriented approaches to tackling
health inequalities.The article used the matrix to illustrate its potential as a tool for
policy analysis by mapping a range of policy responses to health inequalities. In the
English case, the setting of health inequalities targets appears to have consolidated an
approach to public health that was the focus of the 1970s critiques: ie an approach
that is risk-factor oriented and health-service led. The stronger social-democratic
traditions in countries like Norway may enable them to maintain their current
emphasis on levelling up access to broader social determinants (Lundberg et al,
2007;Torgensen et al, 2007), a position in accord with the recommendations of the
WHO CSDH (2008a). Alternatively, as in the UK, mounting political pressure for
evidence of short-term progress may shift the policy emphasis from reducing health
gradients across the population to improving the health of the poorest – and from
upstream social policies to downstream health service interventions.
Set in a broader historical context, the last decade may turn out to be less of a
new dawn for public health policy and more a period of episodic re-engagement
with the public health consequences of rapid economic and social change. Political
commitment to greater health equity may quickly wane, particularly if the policy
changes instituted in the name of health equity prove insufficient to secure a
narrowing of inequalities in social determinants and health outcomes within the
short time periods that governments typically set for their policy goals: for example,
those of England’s health inequalities were set in 2002 for achievement by 2010.
It should be anticipated, too, that economic recession will lessen the chances of
sustained governmental action, with governments stripping out broader welfare goals
to target their declining tax revenues on policies to stimulate the economy. But while
political commitment may falter, socioeconomic gradients in health determinants
and health outcomes are set to persist. These persisting gradients mean that the
public health community – researchers, practitioners and the wider public – have
a vital role to play in continuing to make the case for policies to equalise access to
the social determinants of health across socioeconomic groups.

Acknowledgements
I would like to thank the anonymous referees of Policy & Politics for their helpful
comments on an earlier version of this article.

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 476 Hilary Graham

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Hilary Graham, Department of Health Sciences, University of York, UK,

hmg501@york.ac.uk

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