Social determinants of health: time to act for health equity

Social determinants have extremely powerful influences on health. The World Health Organization’s Commission on the Social Determinants of Health worked for several years to explore the global situation further. Ruth Bell, from University College London, talks about the work of the Commission and urges health workers at community level to call for action.

Health workers, more than anyone else, see the dramatic effects of the social determinants of health in their daily work. There is no biological reason why a girl born in Zambia should have a life expectancy of 43 years, while her counterpart born in Japan should have a life expectancy twice as long at 86 years. In a deprived part of Glasgow, Scotland life expectancy for men, at 54 years, is less than the average for men in India (62 years) where nearly 80 per cent of the population live on less than two dollars a day. Social determinants are linked to ill health and premature death witnessed by health workers wherever they are around the world.

The social determinants of health are the conditions in which people are born, grow, live, work and age, and the structural drivers of those conditions, that is the distribution of power, money and resources. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization in 2005 to support action on the social determinants of health to improve overall population health, improve the distribution of health, and to reduce disadvantage due to poor health. It published its Final Report and recommendations in 2008.

The CSDH’s aim was to stimulate action to reduce the health inequalities that exist between countries and within countries. According to the CSDH, in situations where health inequalities are preventable and avoidable, but are not avoided, they are inequitable, and taking action to reduce them is a matter of social justice.

The CSDH recommendations are based on three principles for action:

1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness
about the social determinants of health.

What kind of action has the CSDH stimulated and what will be the effects on health?

It can seem a long way from a high-level policy review to action that makes a difference on the ground. Three points are important here. First, health inequities are associated with social inequalities. Health outcomes are linked to position in social hierarchies, described by income, occupation and education, by ethnic group or by gender and to geographic location, for example, rural or urban. In particular, poor health outcomes are likely where social inequalities intersect, for example, for children of women with no education in poor households in rural areas. Studies in low and middle income countries in Africa and Asia show a stepwise increase in under-five mortality across households by wealth, with children from the poorest fifth of households more likely to die before their fifth birthday than the next poorest and so on across the distribution. This pattern is seen for a number of health outcomes and is known as the social gradient in health, meaning that health outcomes are associated with people’s position in the social hierarchy. The social gradient has important implications for policy as it means that policies and programmes must not only target the worst off in society, but must also address the conditions of the whole of society in order to tackle the gradient in health.

Second, and crucial to the social determinants of health approach, is that where differential health outcomes are linked to social inequalities, then action to improve health outcomes must include action to reduce social inequalities. Seen in this light, every sector is, in effect, a health sector, because every sector, including finance, business, agriculture, trade, energy, education, employment, and welfare, impacts on health and health equity.

Thirdly, action needs to happen at global, national and local levels. The national level policy environment needs to empower grass roots community participation in identifying what needs to happen, in developing interventions and programmes and in evaluating their effects. The Commission’s report is optimistic. The global movement for health equity is growing. Progress may be patchy but progress can be made and the report contains examples of successful action including work in Sri Lanka and India (see articles in this issue of Health Exchange). But there needs to be more innovation and more evaluation so that promising approaches can be developed and extended to reach more people. Health workers at the heart of communities have a pivotal role to play in raising awareness and calling for action on social determinants and in the process of developing and evaluating action at local and national level.

The Commission on Social Determinants of Health’s Final Report and recommendations are published in: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, 2008, World Health Organization, available at:

Ruth Bell, University College London

Innovations in Health Research

Cardiovascular disease: combining research and action

Over 700 people living in Korogocho and Viwandani slums in Nairobi, Kenya have benefited from free drugs, regular screening and check-ups for heart disease, hypertension and other chronic conditions. Not what you might expect from a research institute, but this is how the African Population and Health Research Center (APHRC) is combining research and action. Elizabeth Kahurani and Rose Oronje tell the story.

The African Population and Health Research Center (APHRC) is spearheading efforts to ease the growing burden of chronic disease, especially among the urban poor. “Diseases that affect the heart and the blood circulation system, also known as cardiovascular diseases (CVD), are a leading cause of death and ill health in sub-Saharan Africa among adults aged 30 years and above,” said Dr Catherine Kyobutungi, an Associate Research Scientist at APHRC.

Projections from WHO’s Global Burden of Disease indicate that from 1990 to 2020, the burden of CVD faced by African countries will double. The increase in the number of people diagnosed with CVD is alarming. Africa’s weak health systems, which are already collapsing under the yoke of infectious diseases, now have to contend with this glaring epidemic.

“Our health systems are ill prepared to handle the increasing burden of chronic diseases, mainly due to lack of data and poor health information systems,” explained Dr Kyobutungi, underscoring the need for research. Early diagnosis of these conditions could help prevent complications and prolong life. Regular screening could help individuals lead healthier lives as they will have more access to better information and be able to make different choices.

These diseases greatly affect the quality of life of individuals who have them. They are chronic and expensive to manage and they often strain the resources of families. In urban slums, the high stress environment, risky behaviours and limited access to health care mean poor marginalised populations in these slums are adversely affected. For this reason APHRC is combining research and action. APHRC is collaborating with the City Council of Nairobi, Provide International and The Kenya Diabetes Management and Information Center to provide free medical services to residents of Korogocho and Viwandani slums in Nairobi, Kenya. Over 700 people in these two communities have now benefited from free drugs, regular screening/check-ups, counselling and other services offered at the CVD medical clinics.

Before the project started, many of the beneficiaries carried out their day-to-day routines unaware that they suffered from diabetes or hypertension. When some people experienced constant headaches or fatigue, they thought it was normal. “I often would feel fatigued even without having engaged in any chores,” said Beatrice Wakeeni, who was among the first people to be screened. “I got a visit from two of APHRC’s field staff who I allowed to conduct a hypertension and diabetes screening. After the procedure, one of them paused and politely asked me, ‘Cucu (grandmother), have you been thinking a lot lately?’ Then they slowly explained that I was hypertensive.” The same story goes for 48-year-old John Mburu, who experienced frequent headaches but did not think that it was anything serious. When he was screened, he discovered that he had hypertension.

Previously, no-one informed the slum population of the need for regular screening. Even if they had been informed, the fee charged for screening is way beyond their means. The majority of the population survives on under a dollar a day and many take care of large families. “All of us here thank APHRC for bringing these health services close to us. Many people here suffer and die because they even do not know where to go for help,” John Mburu said.
The clinics are part of a wider research project whose main objective is to assess CVD risk factors and risk perception among the adult population in Nairobi slums. For a long time, CVD have been associated with the rich as a lifestyle disease, but current trends are proving otherwise. This research study will examine linkages between socio-economic and socio-cultural factors, as well as health behaviour that put the urban poor at risk. If taken up, this evidence-based information will no doubt inform strategies for developing sustainable health systems and other interventions that target this population effectively.

Being an international research organisation, APHRC has over the years continued to generate credible scientific evidence with an aim to promote the wellbeing of Africans through policy relevant research on population and health. The organisation runs a continuous survey that monitors households within the Korogocho and Viwandani slum areas on a regular basis. Data from this survey serves to inform policies and programmes that aim to address the challenges of an ever growing urban population, particularly now in the context of a huge economic downturn. Besides health, APHRC has conducted further research on education, poverty, and sexual and reproductive health and continues to engage actively and work with policy makers as well as other key stakeholders who use this research to bring about the much needed change.

APHRC is a partner in Realising Rights