Combining health and social protection measures to reach the ultra ...

Access to health
A social determinants
approach to health equity
Article by Sharon Friel (pictured), Ruth Bell, Tanja AJ Houweling and Sebastian Taylor
The Commission on Macroeconomics and Health clearly
demonstrated that an investment in health was good for
the national economy 1 . Investing for health arises from
a different paradigmatic base and recognizes the pursuit of
health and social well-being as a human right and a matter
of social justice 2 . Successful investment for health can be
measured not simply by economic improvement but, perhaps
more importantly for sustainable human civilization, by
observable health and social gain.
There is general concurrence internationally that supporting
investment for health requires a shift in policy and practice.
As the 2003/04 “10/90 Report” 3 summarizes, in the past
half century the concept of development has refocused from
human capital to be concerned primarily with the provision of
necessities fundamental to living, including health. However,
not everyone in society has equal opportunity to achieve good
health. Gross differences in health, both between and within
countries, are observed by markers of social stratification
such as income, education, employment, gender and
ethnicity 4,5,6 . In developing countries the emerging double
burden of communicable and noncommunicable disease 7,8,9
combined with pervasive poverty serve to compound the poor
health opportunities for large sections of these populations.
Remedying these inequalities in health between and within
countries requires an approach that gives serious attention to
the social determinants of health.
There is no doubt that poor people suffer from far higher
levels of ill-health and premature mortality than rich people,
and addressing the health of poor people and nations must
be a matter of concern for policy-makers and service
providers 10 . Indeed, the introduction of vertical initiatives to
control major communicable diseases, such as the Global
Fund to Fight Tuberculosis, AIDS and Malaria 11 , the WHO “3
by 5” Initiative 12 and the Roll Back Malaria Partnership 13 , as
well as horizontal initiatives to improve health systems, have
substantially redressed the major infectious disease burden
and improved average population health in developing
countries. The Millennium Development Goals focus attention
on eliminating poverty in the world’s poorest countries and
put health clearly on the international and national
development agendas 14 .
However, poverty and (lack of) health care do not fully
explain the observed inequalities in population health. They
do not explain the variation in life expectancy and health
status among poor people, with different levels of education
or from different ethnic backgrounds 9 , nor why groups along
the social spectrum differ in levels of mortality from, for
example, cardiovascular diseases, cancers and external
causes (violence) 6 , nor why populations with different living
and working conditions have differing health experience 15-18 .
Understanding and tackling the persistent inequalities in
health, in a sustainable manner, therefore requires
recognition and response to not only the poorest in society,
not only the gap between rich and poor, but also the gradient
in health observed across all groups within and between
societies 19,20 . Pursuit of such health equity recognizes
implicitly the need to redress the unequal distribution of
opportunity to be healthy that is associated with membership
of less privileged social groups 21 . This focuses attention not
only on the relief of poverty but also on the structural
determinants of health, including upstream global and
national level social, environmental and economic conditions
within which people live, and more intermediate factors such
as employment, education, housing, quality of living
environments and social relationships 22, 23 .
Background to the Commission on Social
Determinants of Health
At the 2004 World Health Assembly, WHO’s former Director-
General Dr Jong-wook Lee announced the beginning of a
process to act upon the social causes of global health
inequities 24 . As a result the Commission on Social
Determinants of Health, hereafter known as the Commission,
emerged in 2005 to build on previous and current UN efforts
to work towards better health and greater health equity. The
Commission’s vision is a world where all people have the
freedom to lead lives they have reason to value. Working
towards this, the Commission places primary emphasis on
the underlying factors that determine population health and
its distribution within and between societies. It works on the
assumption that healthy populations result, largely, from
action that is often outside the health care sector.
Within the formal lifetime of the Commission (2005–2008)
the aim is to set out solid foundations for its vision: societal
structures, conditions and relations that influence health and
health equity will be visible, understood and recognized as
important. On this basis, the opportunities for policy and
action and the costs of not acting on these social dimensions
will be widely known and debated. Success will be achieved
if institutions, in health and non-health sectors, at local,
050 ✜ Global Forum Update on Research for Health Volume 4