The Social Medicine Portal

WHO’s Commission on Social Determinants of Health: Inequities are Killing People on a Grand Scale

On Thursday, August 28^th the WHO’s Commission on the Social Determinants of Health issued its final report: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. The Commission concluded that the “toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible.” The report challenges the world community to achieve global health equity “with a generation” a goal that “is achievable, it is the right thing to do, and now is the right time to do it.” [The report is available on the Commission's website and comes in two versions: an executive summary, and the full 256 report. The website has a variety of other materials including presentations, background papers and pictures.]

The report has received virtually no press coverage in the US. On the morning of its release, Dr. Dennis Raphael searched Google News and found no US reporting on the work of the Commission. We did a similar search on 8/31 and found only 3 US sources about the Commission’s report: WebMD, Time Magazine and Voice of America.

Background to the Commission and its Report

September 2008 will mark the 30^th anniversary of the Alma Ata conference where the call for “Health for All” by the year 2000 was made. The WHO is marking this anniversary, in part, by the publication of the Commission’s report and by focusing its annual World Health Report on Primary Health Care. The Commission was established in 2005 by the late Dr. J.W. Lee, then Director General of the WHO. It was mandated to “investigate and report on evidence to guide action on social determinants of health to reduce health inequities.” The Commission was composed of a diverse group of 20 members, including three from the US (David Sachter, Gail Wilensky and William H. Foege).

The Commission was chaired by Professor Sir Michael Marmot, known for his role as director of the Whitehall Studies. These were two large cohort studies of British Civil Servants. They demonstrated that workers in the lower levels of the Civil Service had worse health and higher mortality than those at higher levels. Only part of this difference was explained by traditional risk factors. One of several implications of these studies was that social differences in health persisted even among people who were not poor and even in a country with a strong national health system. Given this conclusion it was logical that British health researchers began to look outside the health care system for solutions to health inequities.

Organization of the Commission

The Commission adopted a particularly open structure in preparing its report. It worked with four “streams:

Knowledge networks: These were nine international groups charged with producing technical reports on: Early Childhood Development; Employment Conditions; Globalization; Social Exclusion; Health Systems; Measurement and Evidence; Priority Public Health Conditions; Women and Gender Equity; and Urban Settings. Each Network produced a report which is available online.

Country partners: A number of countries subscribed to the Commission’s vision and collaborated with it. These included Brazil, Canada, Chile, Islamic Republic of Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the United Kingdom.

The Commission invited input from Civil Society organizations which conducted consultations in Asia, Africa, Latin America, and the Eastern Mediterranean Region. Their final report is available online and a shortened version was published in our journal Social Medicine. The inclusion of civil society reflected a commitment to democratic governance on the part of the commission; this commitment was also reflected in the report’s recommendations.

The World Health Organization was considered the fourth stream in the Commission’s work.

General Recommendations of the Report.

In support of the goal of eliminating health inequities within a generation, the Commission made three general recommendations:

“Improve Daily Living Conditions

Improve the well-being of girls and women and the circumstances in which their children are born, put major emphasis on early child development and education for girls and boys, improve living and working conditions and create social protection policy supportive of all, and create conditions for a flourishing older life. Policies to achieve these goals will involve civil society, governments, and global institutions.

“Tackle the Inequitable Distribution of Power, Money, and Resources

In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities -such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.

“Measure and Understand the Problem and Assess the Impact of Action

Acknowledging that there is a problem, and ensuring that health inequity is measured – within countries and globally – is a vital platform for action. National governments and international organizations, supported by WHO, should set up national and global health equity surveillance systems for routine monitoring of health inequity and the social determinants of health and should evaluate the health equity impact of policy and action. Creating the organizational space and capacity to act effectively on health inequity requires investment in training of policy-makers and health practitioners and public understanding of social determinants of health. It also requires a stronger focus on social determinants in public health research.”

Commentary:

The Commission’s report (and the extensive preparation for it) clearly represents an important and very rich source of information on global health inequities and their structural bases. The Commission’s comprehensive documentation of how structural changes can quickly lead to improvements in health provides compelling evidence for such structural changes. And the Commission’s overall vision of making health equity and social justice global goals is a needed one in the current political context. We are glad that the WHO is cognizant of its historical mission as the defenders of the public’s health.

Nonetheless it is worth noting that on the 30^th anniversary of Alma Ata we do not have “Health for All.” What we will have are two reports, albeit important, from the WHO.

We are struck by a comment from the Civil Society report:

“As the Commission embarks on its mission to, once again, construct such a strategy [to improve health outcomes globally], we must step back and ponder over two issues. The first, to recapitulate on the global vision that arose from the Alma Ata Declaration of 1978, that explicitly located itself in a social determinants led view of Health. Second, to examine the dominant cause for the failure and virtual abandonment of the vision in the Alma Ata Declaration and the Primary Health Care concept.”

This second comment seems particularly telling. Why did Alma Ata fail? Why does its vision seem so far away? What lessons from this experience might inform current efforts to provide health to all?

These questions raise the issue of what might be called the social determinants of the social determinants of health. In other words, who are the people setting the global health agenda and what are their priorities? How likely are these people to be swayed by the evidence and the arguments for social justice put forth by the Commission? Why are they the ones making the decisions? Why, for example, does the World Bank fund more health programs than the WHO? How could we assure a true participation of civil society in the halls of power?

These are burning issues in the US right now. The Commission’s report comes in the middle of a Presidential campaign and the Commission generously included 3 US members (of a total of 20). And yet the report has been virtually ignored in the US press. The Commission calls for universal access to health care regardless of ability to pay. For us, the simplest, best-evidenced option for this would be a Canadian style national system, an option that has broad public and professional support. And yet, this option is not even up for debate in the United States. The political class in the US has decided that any health reform not based on private insurance is politically unacceptable. This decision is not based on any evidence nor on considerations of social justice. It is based on the economic and political power of the insurance industry.

At least within our local context it does not seem that more evidence is needed. What seems needed are a clearer political analysis, strategy and organization. To develop that strategy we need to answer the question posed by the Civil Society report (speaking of Alma Ata):

“The principal issue, then, that we need to first address is: what prevented us – at a global, national or sub-national level – from harnessing such compelling evidence into a cogent and comprehensive strategy for improving Health outcomes at a global level.”

Here is a summary of the full report:

The Final Report of the Commission on Social Determinants of Health sets out key areas of daily living conditions and of the underlying structural drivers that influence them in which action is needed. It provides analysis of social determinants of health and concrete examples of types of action that have proven effective in improving health and health equity in countries at all levels of socioeconomic development.

Part 1 sets the scene, laying out the rationale for a global movement to advance health equity through action on the social determinants of health. It illustrates the extent of the problem between and within countries, describes what the Commission believes the causes of health inequities are, and points to where solutions may lie.

Part 2 outlines the approach the Commission took to evidence, and to the indispensable value of acknowledging and using the rich diversity of different types of knowledge. It describes the rationale that was applied in selecting social determinants for investigation and suggests, by means of a conceptual framework, how these may interact with one another.

Parts 3, 4, and 5 set out in more detail the Commission s findings and recommendations. The chapters in Part 3 deal with the conditions of daily living the more easily visible aspects of birth, growth, and education; of living and working; and of using health care. The chapters in Part 4 look at more structural conditions social and economic policies that shape growing, living, and working; the relative roles of state and market in providing for good and equitable health; and the wide international and global conditions that can help or hinder national and local action for health equity. Part 5 focuses on the critical importance of data not simply conventional research, but living evidence of progress or deterioration in the quality of people s lives and health that can only be attained through commitment to and capacity in health equity surveillance and monitoring.

Part 6, finally, reprises the global networks the regional connections to civil society worldwide, the growing caucus of country partners taking the social determinants of health agenda forward, the vital research agendas, and the opportunities for change at the level of global governance and global institutions that the Commission has built and on which the future of a global movement for health equity will depend….”

Posted by Matt Anderson, MD