The summer 2009 issue of Health Exchange focuses on the social determinants of health, what they mean for health workers and how we put this into practice. To mark the issue Healthlink Worldwide, Merlin and RedR hosted a lunchtime discussion in London, UK. Participants, mainly from NGOs working in health and development, discussed social justice, equity and the social determinants of health. They talked about what it looks like for development NGOs to be involved in the social determinants of health approach; and don’t NGOs always put equity at the forefront of their work? What is different now?
Alison Dunn, of Healthlink Worldwide writes about the discussion.
Can we do more to improve health equity? In May 2009, 193 member states of the World Health Organization (WHO) approved a resolution calling for action to achieve health equity at the 62nd World Health Assembly.
The resolution was based on the recommendations of a 2008 report by WHO’s Commission on the Social Determinants of Health- Closing the gap in a generation: health equity through action on the social determinants of health.
Ruth Bell, Senior Research Fellow from University College London, who wrote an article for this issue of Health Exchange, presented the work of the WHO Commission on the Social Determinants of Health. Ruth was a researcher on the secretariat of the Commission, compiling and synthesising data about social determinants of health from all over the world. She presented how the Commission worked, and why it focused on health equity. There is no biological reason why life expectancy is 40 in some places and 80 in others and why there is huge discrepancy in health and well-being within and between countries.
Looking at the social determinants of health raises some serious questions for health systems and health workers. It can be very frustrating to treat people’s illnesses and then send them back to the conditions that made them sick in the first place. Ruth highlighted an example from Rene Loewenson’s article in Health Exchange on social empowerment as a determinant of health, where a mother took her five-year-old-daughter to a clinic to be treated for diarrhoea. The clinicians said to give her food and lots of water, but the mother only had access to water twice a week. Daily living conditions prevented her daughter from receiving the treatment she needed and she died.
The Commission calls for three principal areas of action: tackle the daily living conditions in which people are born, grow, live, work and age; tackle the structural drivers of those conditions at global, national and local levels; and carry out more research to measure the problem, evaluate action and increase awareness. In trying to address structural drivers of conditions, the Commission queried the efficacy and power of the market to solve all the problems.
Ruth pointed out that while the social determinants of health approach is having a resurgence, it is not new. The concept was first on the global agenda at Alma Ata in 1978, where the Declaration stated that wider determinants are very important. She talked about how colleagues working with the Commission started calling it, unofficially, the ‘Equity’ commission and saw it as an opportunity to re-introduce equity and fairness onto the global health agenda.
Part of the approach is to bring sectors together to work to address health at global, national and local levels., “It is the job of people working in health to say to others, working in education or employment for example, that what you are doing is also very important for health,” Ruth said.
One participant posed the problem that if health is everything to do with development, and everything we do is health, it can lead to a cul-de-sac. Another asked whether the Commission felt it was ideologically linked with left wing politics because of its findings and how did it deal with this. Ruth responded that the social determinants of health approach is about equity and social justice and has not been perceived to be about political ideology. She cited Michael Marmot, Chair of the Commission, who said that social justice and equity seem to be having a resurgence in influence globally. WHO’s work has been very high profile and UNESCO’s recent work on education has a strong focus on equity.
The WHO Commission’s report makes recommendations for action by a diverse range of stakeholders. As some participants at the discussion said, data can be ammunition. Dr Lee Jong-Wook, the late Director General of WHO, said in 2004, at the start of the Commission’s work, “The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change — aiming toward practical uptake among policymakers and stakeholders in countries”.
Participants at the lunchtime discussion recognised the increased opportunities to work differently because of the high profile nature of the report and the resolution. One participant from Action Against Hunger International, working on nutrition, was very excited about the potential that the social determinants approach could have as a tool or a lever for change. She argued that nutrition policies are very limiting and have cut-off levels for certain age-groups, for example the under-fives, or the most malnourished. However there are many malnourished children who should not be overlooked simply because they do not fall into a certain category. She suggested, with the social determinants of health or ‘equity’ lens, there is more leverage to challenge these policies. If a global body such as WHO is saying, with authority and legitimacy, that equity matters, they will be able to use this to advocate for better, more comprehensive, nutrition policies. Ruth Bell agreed and said, “It changes the debate. If you look at policies from the perspective of health equity, it can be transformational.”
During the discussion, it was apparent that participants felt they should, in their work, do ‘more of the same’, but some key areas on which to work further also emerged.
The World Health Assembly resolution on social determinants of health urges member states to promote awareness and increase the capacity of health workers to address the social determinants of health when they are delivering health care. It was an important theme that came up during the discussions. How do we empower health workers to feed into policy? If a nurse, or a doctor, or a midwife sees patterns of ill-health and sees patients returning with similar complaints caused by their environment or living conditions, what can they do about this? Where are the mechanisms for them to feed their observations and experience back to policy and decision-making levels? How do we strengthen those connections between frontline realities and policy?
Other suggestions were that we should form coalitions between organisations and networks in education, sanitation, employment, tax and trade, and many more, to address the social determinants of health in our work. The Commission’s report calls for evaluation and measurement of the problem. Could NGOs get involved in monitoring and evaluation, and advocate for better multi-sectoral linkages?
Another challenge raised was to look for new actors to influence about social determinants. The big donors know about social determinants, social justice and equity. There are still others who are not working in this way. Who do we need to tell about this approach?
The report is called ‘Closing the gap in a generation’ for a reason. This is a long term process and one that creates opportunities to do things a bit differently than before. Many NGOs already take into account social determinants of health and have an equity focus, trying to work across sectors and with other departments or fields but there is still room for progress. There is now a stronger tool available to advocate for equity in health and development policies. There is also a greater challenge, to work to empower health workers to feed into health policy decisions and advocate for better mechanisms to allow them to do so.
Alison Dunn
Healthlink Worldwide and Editor of Health Exchange
healthexchange@healthlink.org.uk
Filed under: social determinants of health
