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

Access to healthnational and global level use this knowledge to set andimplement relevant public policy affecting health 23 .The Commission is not only reviewing existing knowledgebut also raising societal debate and promoting uptake ofpolicies that will reduce inequalities in health within andbetween countries. It is doing this through four tracks of work:(1) Learning: organizing, consolidating, disseminating andpromoting the use of existing knowledge thatdemonstrates the causal relationships between socialdeterminants and inequalities in health, and furtherdeveloping the evidence base on interventions andpolicies that focus on key social determinants whichinfluence health and health equity;(2) Advocacy: identifying and promoting opportunities foreffective action on key social determinants and raisingsocietal debate among policy-makers, implementingagencies, civil society organizations and the widercommunity;(3) Action: catalyzing and supporting processes andinstitutions that initiate, inform and strengthen actions tointegrate knowledge on social determinants within publicpolicy and institutional organization and practice; and(4) Leadership: supporting and giving profile to the publicand political leadership for policy and action on thesocial determinants of health, and organizing andprofiling the work of the technical and institutional driversthat support this leadership.Strengthening the knowledge baseThe need for clear, rigorous evidence to inform and supportequity-focused health advocacy, policy, practice andleadership is crucial. Perhaps understanding and addressingthe social determinants of health is one of the morechallenging areas. Research into public health systems andservices and the social determinants of health escalated inthe latter half of the 20th century. Recently, comment is oftenmade along the lines of “we know the problem”, “we knowwhat needs to do done”, “why don’t we just do what isnecessary”. Effective translation of knowledge into policy andpractice which improves people’s health and reducesinequalities in health has however been inconsistent 8,25 .Gwatkin and colleagues describe in “Reaching the Poor” 10 anumber of existing interventions, both policy and practice innature, that are concerned with health issues of impoverishedpeople. However, as the authors highlight, what remainsmissing from the evidence base is the knowledge on how tomake interventions work. A key lesson from this is the needto consider, in a systematic manner, the nature of knowledgeand what is believed to be effective intervention, with thoughtgiven to the contextual relevance of evidence and theadequacy and quality of information 26 . Cognisant of this, thelearning track of the Commission was developed to consistmainly of nine knowledge networks, organized around selectsocial determinants, including early child development,health systems, employment conditions, globalization, prioritypublic health conditions, urban settings, social exclusion, andtwo cross-cutting themes of gender and measurement/evidence. These social factors, some described further below,can be characterized as having strong impact on health andhealth equity, and amenable to action. Indeed theinvestigations by the knowledge networks are focused onidentification of effective intervention and the processes andactors necessary to effect change.A life-course perspective: early child developmentIt is generally believed that the persistence and, in somecases, worsening of health inequalities is transmitted fromgeneration to generation through economic, social anddevelopmental processes, and that the advantages anddisadvantages are reinforced in adult life. A life-courseapproach focuses on the different elements of health, fromthe moment of conception through childhood andadolescence to adulthood and old age. This approach revealscritical points in the transitions from infancy throughchildhood into adult life, where an individual may move inthe direction of advantages or disadvantages in health. Thepatterns are not uniform, varying by social group.There are various routes for the transmission of advantageand disadvantage through early childhood conditions andexperiences. Of note is how poor childhood socialcircumstances relate to poor adult circumstances in severalways. For example, education is still the major route out ofdisadvantage, but poorer children perform educationally lesswell than better-off children. Children dropping out of school,or not entering employment or training after formal schooling,are a particularly high-risk group. Children from poorerbackgrounds are much more likely to get into trouble with thepolice, to be excluded from school, or to become a teenageparent, all of which make moving up the social hierarchymore difficult.Physical, emotional and cognitive development patternshave their roots in early childhood, with beneficial or harmfuleffects on subsequent health. Such findings suggest thatdeveloping robust strategies for promoting health equitythrough social determinants policy requires a specific focuson early child development. Life-course analysis ofmainstream policies in health, education and social welfaresuggest that insufficient protection is currently provided forpeople at these crucial turning points 27 .Exposure and vulnerability: employment conditionsResearch from the past two decades has demonstrated theimportance of the place and content of work and their effectson coronary heart disease, mental health andmusculoskeletal disorders, but many workplaces still haveunacceptable safety risks and exposures.The main foci for improvements in work-related healthhave typically been around the eradication or control ofknown hazards and improvements in the work environment.But even when these “classic” occupational hazards havebeen corrected, inequalities in health remain between higherand lower positions in the workforce. Changes in employmentstatus and unemployment have been shown to be linked tochanges in health. There is a growing evidence base on thehealth effects of factors including: psychological stress;physical and ergonomic risks; toxic chemical exposure; andGlobal Forum Update on Research for Health Volume 4 ✜ 051