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

Access to health
employment conditions like income, job security, flexibility in
working hours, job and task control, and employment-related
migration.
The effectiveness of regulatory measures, employment and
industrial relations policy, and worker safety legal frameworks
– structural interventions that seek to prevent and mitigate the
effects of employment and working conditions – should be
mapped and analyzed 27 .
The rapidly changing living environment: urban settings
The rapid process of urbanization has seen an explosion of
“slums” worldwide and more generally urban conditions often
not conducive to healthy living, either through the physical,
social or economic environment generated in such settings.
Urban slums are characterized as unplanned informal
settlements where access to services is minimal-tononexistent
and where overcrowding is the norm. Urban
settings and in particular the health challenges of slumdwellers
constitute a vast and growing challenge, particularly
for developing countries.
Urban development has historically been seen as both a
cause and solution for social inequalities in health. However,
social gradients in health within urban areas occur
everywhere and are resistant to change. Urban environments,
and their effect on health, are influenced by the degree and
type of industrialization, availability of sanitary conditions,
quality of housing, accessibility of green spaces and by
transport, an increasing concern. The urban setting is a lens
that magnifies or diminishes other social determinants of
health and exposes different population groups in different
ways to a whole variety of factors conducive or otherwise to
health. Interventions in the urban setting therefore imply the
integration of actions simultaneously addressing a range of
health determinants. Slum upgrading is an often-used
intervention to improve social and environmental
determinants of the urban poor. This usually includes:
physical upgrading of housing, water and sanitation,
infrastructure, and the environment; social upgrading through
improved education; violence reduction programmes; better
access to and improved health services; governance
upgrading through participatory processes; community
leadership and empowering civil society through knowledge
and information 27 .
Globalization in the 21st century
The processes, and nature, of globalization may be regarded
as the underpinning structural social determinant of health
and health equity. Global processes exert a powerful impact
at all levels of the social production of health: on the evolution
of sociopolitical contexts in countries; on the nature and
magnitude of social stratification; and on the configuration of
various specific determinants (e.g. working conditions, food
availability). We see the global influence within countries
operating both formally: multilateral institutions and
processes of engagement, multilateral binding and nonbinding
treaties and agreements; and informally: cultural
production, media and the collapse of “cognitive distance”
between global population groups. Among the most relevant
aspects of globalization on inequalities on health, with
potential for intervention, are: market access, trade barriers
and liberalization, integration of production of goods,
commercialization and privatization of public services, and
changing lifestyle patterns.
While recent years have seen a rapid expansion of interest
in globalization and health, numerous important questions
remain inadequately explored. There is a need to identify and
evaluate policy options through which national policy-makers
can respond to the challenges posed by globalization and also
capitalize on its opportunities in a health-promoting way. It is
necessary to identify and characterize the degree of negative
or positive health impact of globalization in specific cases: not
only to clarify relevant causal processes, but as a contribution
to evaluating the impact of interventions and policies on other
social determinants of health 27 .
In conclusion, if the major determinants of health and
health equity are social, so must be the solutions. Areas
requiring research then should be ones which address the
social factors which influence the global inequities in health.
Each of the nine thematic areas for research and
intervention, identified by the Commission on Social
Determinants of Health, is relevant in all countries. Such
research should seek to highlight the transferability of
knowledge, elucidate the conditions, processes and actors
necessary for effective intervention, and in a systematic
manner compile a knowledge base which will underpin
action to improve health, reduce the health gap and redress
the health gradient. ❏
Sharon Friel is a social and nutritional epidemiologist and has
worked in the area of public health nutrition and inequalities in
health since 1992. She is currently the Principal Research Fellow
for the global Commission on Social Determinants of Health, based
at the International Institute for Society and Health, University
College London. She is also a Fellow at the National Centre for
Epidemiology and Population Health, Australian National
University, Canberra, Australia, where she is currently working as
consultant to the World Cancer Research Fund diet and cancer
policy report. Prior to this Dr Friel worked for many years in the
Department of Health Promotion, National University of Ireland,
Galway, as well as being Chair of the Irish Health Promotion
Association for four years. Much of her work is concerned with the
interface between research, policy and practice in matters relating
to international and national level social determinants of
inequalities in health, in particular those relating to diet.
Ruth Bell is a Senior Research Fellow in the Department of
Epidemiology and Public Health at University College London, working
with the global Commission on Social Determinants of Health. She
has previously worked as a consultant to the Nuffield Foundation and
the King’s Fund. Dr Bell’s early research career at the University of
Freiburg, Germany and the Institute of Cancer Research, Royal
Marsden Hospital, London was in the area of cancer causation.
Tanja AJ Houweling is a social epidemiologist (MSc) and medical
anthropologist/sociologist (MA) and has worked in the area of
social inequalities in health since 2000. Currently, she works as
052 ✜ Global Forum Update on Research for Health Volume 4