Improving Equity in Health by Addressing Social Determinants

319 Pages·2012·1.5 MB·English

Improving Equity in Health by
Addressing Social Determinants
Edited by: The Commission on Social Determinants of Health Knowledge Networks,
Jennifer H. Lee and Ritu Sadana

Improving Equity in Health by
Addressing Social Determinants
Edited by: The Commission on Social Determinants of Health Knowledge Networks,
Jennifer H. Lee and Ritu Sadana
Acknowledgements
We are grateful to the authors and members of the Knowledge Networks created to inform the work of the
CommissiononSocialDeterminantsofHealth(2005-2008)fortheircontributionstothisbook.Weareequallygratefulto
FinnDiderichsenandJoséCarvalhodeNoronhafortheirextensivereview,insightfulcommentsandsuggestionsandto
LindseyMartinez-Mackeyfortechnicaleditingthechapterstoprovidebalancedcontentgiventherangeofperspectives
contained.TheDepartmentofHealth,UnitedKingdom,providedfinancialsupportintheeditingandproductionofthis
volume.WeappreciatethetechnicalandmanagerialsupportthatDanielAlbrecht(WHO)providedinthepreparation
andeditionofearlierdraftsofthisbook.
Thebookwascopy-editedbyLinaTuckerReinders.
DesignandLayout:AnilKumar,InditeGlobal
WHO Library Cataloguing-in-Publication Data
Improving equity in health by addressing social determinants / edited by the Commission
on Social Determinants of Health Knowledge Networks, Jennifer H. Lee and Ritu Sadana.
1.Socioeconomic factors. 2. Health care rationing. 3. Health services accessibility.
4. Health status disparities. 5. Social change. 6.Internationality. 7. Child welfare - trends. 8. Sex
factors. 9. Urban health. 10. National health programs - ethics. I. Commission on Social
Determinants of Health. II. Lee, Jennifer H. III. Sadana, Ritu.
ISBN 978 92 4 150303 7 (NLM classification: WA 525)
© World Health Organization 2011
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Contents
Preface 6
1. Strengthening efforts to improve health equity 7
RituSadana,SarahSimpson,JenniePopay,DanielAlbrecht,AhmadRezaHosseinpoorand
TordKjellstrom
2. Globalization: the global marketplace and social determinants of health 23
TedSchreckerandRonaldLabonté
3. Gender inequity in health 59
GitaSenandPiroskaÖstlin
4. Social exclusion and health inequalities: definitions, policies and actions 88
JenniePopay,SarahEscorel,MarioHernández,HeidiB.Johnston,JaneMathiesonand
LaetitiaRispel
5. Early child development: a powerful equilizer 115
ArjumandSiddiqi,EmilyHertzman,LoriG.IrwinandClydeHertzman
6. Urban settings: our cities, our health, our future 142
JostacioLapitan,JenniferH.LeeandTordKjellstrom
7. Employment and working conditions as health determinants 165
JoanBenachandCarlesMuntanerwiththeEMCONET
8. Challenging inequity through health systems 196
LucyGilson,JaneDohertyandReneLoewenson
9. Reducing health inequities through public health programmes 231
ErikBlasandAnandSivasankaraKurup
10. Measuring the social determinants of health: theoretical and empirical challenges 263
JosianeBonnefoy,AntonyMorgan,EmmaDoohan,JenniePopay,JohanMackenbachand
MichaelP.Kelly
11. The way forward: acting on the evidence and filling knowledge gaps 294
JenniferH.LeeandRituSadana
Preface
During its tenure, the Commission on Social Determinants of Health focused on nine broad
areasthatcontainwithinthemmajordeterminantsofhealth.Tosupportthiswork,theWorldHealth
Organization (WHO) invited leading academics, practitioners and advocates from a variety of
disciplines and sectors to participate in Knowledge Networks (KN): early child development,
employment conditions, globalization, women and gender equity, urban settings, priority public
health conditions, measurement and evidence, social exclusion, and health systems. More than 350
individuals from around the world contributed to a tremendous body of literature for the
Commission.
The idea for this book originated during a symposium on the findings of the KNs held in
September 2007 in Rio de Janeiro, Brazil. This single volume offers the only in-depth effort to date
thatpresentsthecollectiveworkofthenineKnowledgeNetworks.Thechaptersofthisbookprovide
asummaryofglobalevidenceonthesocialdeterminantsofhealth.
InSeptember2011,WHOorganizedtheWorldConferenceonSocialDeterminantsofHealth,
hosted by the Government of Brazil. Participating Member States adopted the Rio Political
DeclarationonSocialDeterminantsofHealthpledgingtoworktowardsreducinghealthinequitiesby
takingactiononfivecoreareas:
(cid:2) adoptbettergovernanceforhealthanddevelopment
(cid:2) promoteparticipationinpolicy-makingandimplementation
(cid:2) reorientthehealthsectortowardsreducinghealthinequities
(cid:2) strengthenglobalgovernanceandcollaboration
(cid:2) monitorprogressandincreaseaccountability.
Actions to reduce health inequities using methods consistent with these principles are synthesized
acrossthisbook.Thereisarenewedcommitmenttoachievehealthequityandnowistheopportunity
toact.
The Commission on Jennifer H. Lee Ritu Sadana
Social Determinants of Health
Knowledge Networks
Strengtheningeffortstoimprovehealthequity 7
Introduction
Strengthening efforts to
1
improve health equity
Ritu Sadana, Sarah Simpson, Jennie Popay, Daniel Albrecht,
Ahmad Reza Hosseinpoor and Tord Kjellstrom
1. Healthequityfromasocialdeterminants'perspective
In the late 1940s, two very important documents were published: The Constitution of the
World HealthOrganization (1946) and TheUniversal Declarationof HumanRights(1948). Together,
these recognize that health as a fundamental human right cannot be separated from other human
rights. The path to “the highest attainable standard of health” reflects inputs that are neither
confinedtomedicaltreatmentnoronlyunderthejurisdictionofhealthsystems.
It is worthwhile to reiterate that the Constitution of the World Health Organization sets out
nine basic principles in its preamble. The first is that “Health is a state of complete physical, mental
and social well-being and not merely the absence of disease or infirmity.” The second is that “The
enjoyment of the highest attainable standard of health is one of the fundamental rights of every
human being without distinction of race, religion, political belief, economic or social condition.”
Given these and other principles, the constitution sets out 22 functions (a-v) for the organization,
with function (i) setting the stage explicitly for a social determinants' perspective as a means to
achieve its objective, namely, “to promote, in co-operation with other specialized agencies where
necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working
conditionsandotheraspectsofenvironmentalhygiene”(WHO,1948).
8 Improvingequityinhealthbyaddressingsocialdeterminants
Thepreambleand30articlesoftheUniversalDeclarationofHumanRightsalso
establishesthefoundationforasocialdeterminants'perspective.Article25states:
Everyonehastherighttoastandardoflivingadequateforthehealthandwell-
being of himself (sic) and of his family, including food, clothing,housingand medical
care and necessary social services, and the right to security in the event of
unemployment,sickness,disability,widowhood,oldageorotherlackoflivelihoodin
circumstancesbeyondhiscontrol(UN,1948).
Moreover,Article28pointsoutthat“Everyoneisentitledtoasocialandinternationalorderin
whichtherightsandfreedomssetforthinthisDeclarationcanbefullyrealized”(UN,1948).
Together,thesetwodocumentssetoutaglobalagendaforimprovingboththeaveragelevel
of health and its distribution, based on shared principles and the right to health. In recent decades
global health efforts have led to improvements in population health around the world.
Unfortunately, the result has not benefitted all people equally (WHO, 2003). Empirical evidence
documentsthathealthinequities theunfairdistributionofhealthoutcomes aregrowingbetween
the rich and poor, privileged and marginalized, and across different countries and global regions.
Inequities within all countries exist as a social gradient. The relationship between socioeconomic
standingandhealthisonacontinuousgradientatallincomelevelsratherthanagapsimplybetween
the rich and poor. This phenomenon occurs whether health differences are measured by income,
employment, education, or other markers of social stratification. The greater the differences in
health between social groups within a society the steeper the gradient or the greater the inequity
(Dahl, 2002). Numerous studies discussed in this book and elsewhere conclude that most of these
differences in health across different social groups are inequities: they are not due to biologic or
genetic factors, but to social factors that are unjust and amenable to policy. Therefore, the terms
inequality and inequity are used with intentionthroughoutthe book; they are not interchangeable.
Inequalityreferstodifferencesbetweenpeople,whileinequitiesarethosedifferencesthatareunjust
and largely determined by one's place in society and ability to access the services and systems that
contributetohealthandwell-being.
The global health architecture and ways of working have evolved dramatically over the past
six decades. The number of global, national and local entities working towards improving health,
socialandeconomicdevelopment,andhumanrightshasincreasedinallspheres:government,non-
government, private and public. Yet, despite this, the responsibility and competency to implement
shared global objectives and ensure rights is uneven. A large and growing body of evidence
summarized in this book and elsewhere underlines that the path towards improving health for all
people requires action to address the underlying causes of health inequities as well as action by
health systems. These underlying causes are complex, often reflecting systematic social, political,
historical, economic and environmental factors that accumulate across people's lifetimes and are
transferredacrossgenerations.Healthsystemsandpublichealthalsohavethepotentialtoimprove
equity, such as through progressive financing of health services or other approaches towards
universal coverage. Conversely, health policies can also reduce equity, for example, through
inadequateprovisionofcareordiscriminatorypractices.
Strengtheningeffortstoimprovehealthequity 9
Theterm"socialdeterminants”isusedasshorthandforallofthesefactors,andwasthebasis
forthenameoftheWHOCommissiononSocialDeterminantsofHealth(CSDH),theworkofwhichis
described in Box 1. This book reports the work of nine global Knowledge Networks (KNs) that
collated evidence on key social determinants of health inequities to inform the work of the
Commission.Theiroverarchingargumentisthatasocialdeterminants'perspectiveisessentialifwe
are to understand the root causes of health inequities between and within countries and develop
effectivesolutionstoreducethem.
Box1: WHOCommissiononSocialDeterminants of Health
In2005,theWorldHealthOrganizationestablishedanindependentCommissiononSocial
Determinants of Health (“the Commission” or CSDH) as a global strategic mechanism to
strengthen health equity by widening knowledge and encouraging debate on the opportunities
for policy and action on the social determinants of health. (Irwin et al., 2006) The Commission's
focus was on socially-determined health inequalities that are preventable, avoidable and unfair.
Itsgoalswereto:
(cid:2) support health policy change in countries by assembling and promoting effective,
evidence-basedmodelsandpracticesthataddressthesocialdeterminantsofhealth;
(cid:2) supportcountriesinplacinghealthequityasasharedgoaltowhichmanygovernment
departmentsandothersectorsofsocietycontribute;and
(cid:2) help to build a sustainable global movement for action on health equity and social
determinants, linking governments, international organizations, research institutions,
civilsocietyandcommunities.
(CSDH,2006)
The Commission was led by 20 commissioners from political, advocacy and academic
backgrounds,furtherinvolvedresearchers,policymakersandleadersfromcivilsociety,andwas
supported by a joint secretariat in WHO and University College London (Valentine et al., 2007).
Theirworkcomprisedfourareas:
Countryaction-TheCommissionworkedcollaborativelywithcountriestosupportthem
inadvancingactiononthesocialdeterminantsofhealthandimprovinghealthequity.The
learningfromtheseexperienceswasincorporatedintotheotherareasofwork;
Knowledgenetworks(KNs)-ninespecifictopicalthemeswerechosenforin-depthstudy
bymultidisciplinarynetworksofinternationaltopicexperts;
Civil society - Civil society representatives across the world were consulted to gather
knowledgeondifferentlevelsofactionoutsidetheformalsectors;
Leadership for global action - The Commissioners engaged leading voices on health
inequities to build support for the work and establish a global movement for continued
action.
10 Improvingequityinhealthbyaddressingsocialdeterminants
From the outset WHO recognized that there was already a strong body of work and
knowledge supporting the cause of social determinants of health (WHO, 2005). Therefore the
Commission was designed to marshal this existing knowledge about what can be done to promote
healthequityandbysodoingtofocusglobalattentiononthechallengesofachievinggreaterhealth
equitywithinandbetweencountries.
Thereareatleastthreereasonswhyequityisimportanttohealthanditssocialdeterminants.
First,equityisavaluethatunderpinssocialjusticeandhasalonghistorywithinpublichealth.Recent
historyprovidesampleexamplesofcountriescommittingthemselvestoworktogetherinthepursuit
ofgreaterhealthequity.In1978,TheDeclarationofAlma-Atabroughtcountriestogethertoconsider
waystooffercomprehensiveprimaryhealthcarethatcombinedandofferedawiderangeofsocial,
health and development services (WHO, 1978). Fast forwarding to 2000, the World Health
Organizationreiteratedthattheobjectiveofgoodhealth andhealthsystems istwo-fold:“thebest
attainable average level goodness and the smallest feasible differences among individuals and
groups fairness” (WHO, 2000). In contemporary context, social justice is typically taken to mean
distributive justice. The report of the International Forum for Social Development (UN, 2006)
identifiesthreecriticaldomainsofequalityandequityascentraltofairdistribution:equalityofrights,
equalityofopportunities,andequityinlivingconditions.
Second,progresstowardsequityasanobjectiverequiresthatthedistributionofhealthisnot
only described as an average value for a population. Quantitative and qualitative data sources are
now more readily available allowing links to be made between people's social characteristics and
health outcomes thus enabling more effective monitoring and analyses of health inequities. These
data have generated a vast body of research that describe the unfair distribution of health,
demonstratingthatsocialfactors,whichareshapedbyone'srelativepositioninsociety,accountfor
the bulk of differences between social groups and therefore are inequities (Braveman & Gruskin,
2003;Marmot&Wilkinson,1999;Acheson,1998;Momas, Caillard&Lesaffre,2004).Inotherwords,
thepoorerpeopleareandthemoresociallydisadvantagedthemorelikelytheyaretogetsickand/or
dieyoungercomparedtopeopleinmoreprivilegedsocialpositions(Labonté,2003).Thisisthecase
inlow-,middle-andhigh-incomecountries.
Progress towards equity is also measured in other social determinants that matter to health.
Forexample,accountabilitytowardsnarrowinginequitiesineducationandliteracyhasbeendirectly
linked to good governance involving countries, donors and others from international agencies to
localcommunities(UNESCO,2009).Importantly,societiesthathavenarrowedhealthinequitiesalso
have much higher overall levels of health: this suggests that further gains in average population
health require that health equity is also improved (Wilkinson & Pickett, 2009). Thus, equity as an
accountability mechanism is gaining increasing currency across global health and development
efforts.Thisapproachrecognizesthatinformationisneededtodocumentandaddresstheprocesses
driving unfair differences in health across and within countries impacting particularly severely on
groups who are often not visible in national statistics, such as migrants, indigenous peoples and
statelesspeople.