Social determinants of health

Taking action to improve health equity

© Zoltan Balogh
Portuguese fisherman in Torreira, Portugal, 2009

Governments are committed to taking action against health inequities – in collaboration with civil society, United Nations and development organizations, academia, donors and the private sector – in five priority areas (as specified by the Rio Political Declaration on Social Determinants of Health): enhancing health policies and decision-making, widening participation in policy-making and implementation, improving health care and services, strengthening international cooperation, and monitoring impact and progress. This section describes the action being taken to address SDH.


Global Plan of Action on Social Determinants of Health

WHO Secretariat has developed a Global Plan of Action on Social Determinants of Health (the Global Plan) that identifies and defines how the Secretariat will assist Member States and partners in the implementation of the Rio Political Declaration and thus improve health equity. WHO is supporting implementation in five Action Areas of the Rio Declaration

WHO is supporting implementation in five Action Areas of the Rio Political Declaration:

1. Adopt improved governance for health and development

WHO is assisting Member States to enhance health policies and strengthen decision-making processes that give voice to all groups involved, to address SDH and health inequities.

Taking a social determinants approach requires governments to coordinate and align different sectors and different types of organizations in the pursuit of health and development — for all countries, rich and poor — as a collective goal. Building governance, whereby all sectors take responsibility for reducing health inequities, is essential to achieve this goal. Intersectoral action — that is, effectively implementing integrated work between different sectors — is a key component of this process.

WHO assists Member States to further develop and strengthen understanding on working with other sectors, promote ‘Health in all Policies’ (HiaP), develop effective policies with clear and measurable outcomes, that build accountability for social determinants of health and related health inequities.

2. Promote participation in policy-making and implementation

WHO will support Member States in widening participation in health policy-making and implementation to include civil society and communities.

The governance required to act on social determinants is not possible without a new culture of participation that ensures accountability and equity. Facilitating participation can help safeguard equity as a principle and ensure its inclusion in public policies.

Besides participation in governance, other aspects of participation, such as individual participation in taking up services or participation of communities in service delivery, are also important for reducing health inequities. However, the participation of communities and civil society groups in the design of public policies, in the monitoring of their implementation, and in their evaluation is essential to action on social determinants.

3. Further reorient the health sector towards promoting health and reducing health inequities

WHO will support Member States in improving access to, and affordability and quality of health care and services, and assist their health sectors to act to reduce health inequities.

Poorly performing health systems can be a major barrier to health care and a critical social determinant of health. Moreover, there are high level of inequalities in the distribution of health services, access to health services and in the burden of ill-health, according to socio-economic status or geographical status, including unfair burden of out-of-pocket expenses and high proportion of catastrophic household spending on health.

Well performing health system can help improving health outcomes, and improve health equity. To improve performance of health systems in many low and middle income countries require continuous support and concerted efforts from several actors- including the international organizations, Governments, civil society organizations and academia.

WHO provides support to Member States in making their health care and services more accessible, available, affordable, and of higher quality to reduce health inequities, and make social determinants of health and health equity a priority in all its programmes, policies, and strategies.

Reorienting public health programmes in Chile

Chile has recently embarked on a reorientation of its public health programmes to reduce health inequities. In 2008, equity assessments using a Tanahashi-based framework were initiated for six major public health programmes: child Health, reproductive Health, cardiovascular Health, oral Health, Health of Workers, and red Tide (algal blooms). The aims of these assessments were to identify differential barriers and facilitators to prevention, case detection, and treatment success and to provide guidelines to reorient each programme so as to improve equity in access to care.

Multidisciplinary teams undertook the assessments, with participation of health workers from all levels of the health system, communities, health bureaucrats, and decision-makers from other sectors. in 2010, all programmes applied the resulting recommendations, using intersectoral and participatory strategies. For example, the cardiovascular Health programme implemented 67 good-practice interventions identified by its assessment and assisted all regional health teams in developing specific action plans to put these interventions into practice. In the red Tide programme, strategies were developed for improved handling of the issue, with reduction of negative effects on fishermen through temporary diversification and restructuring of working conditions. This process resulted in the development of a set of indicators and methodologies for assessing equity of access to public health programmes.

4. Strengthen global governance and collaboration

WHO will provide support to Member States to access financial resources and technical cooperation, and coordinate and strengthen international cooperation in promoting health equity globally.

Increasing the ability of global actors (including bilateral cooperation agencies, regional agencies, philanthropic groups, and international organizations) to contribute to national and local action on social determinants requires improvements in global governance. Coherent global policies are also essential, in order to mutually contribute to development. Like national governance mechanisms, global governance mechanisms are currently inadequate to address multifaceted problems like health inequities along with other global priorities. This situation challenges global institutions to reform in order to accommodate the changing realities of the 21st century.

In response to this, WHO provides support to Member States to access financial resources and technical cooperation, and coordinate and improve international cooperation, including the work with other UN agencies on social determinants of health in promoting health equity.

UN Platform on social determinants of health

Following the World Conference on Social Determinants of Health, 19-21 October 2011, in Rio de Janeiro, Brazil, ILO, UNAIDS, UNDP, UNFPA, UNICEF and WHO have agreed to work together on social determinants of health to reduce health inequities and promote development, supporting countries to implement the Rio Political Declaration.

The agencies agreed to work on the four themes, which are interlinked: Advocacy; Capacity strengthening; Monitoring; and, Country work. Proposed action is divided into:

  • Those activities which will be done by one lead agency and for which funding has been made available, but where other UN agencies are invited to give input;
  • Those activities which are already in the work plan of the lead agency, but would benefit from a collaboration with other UN agency; and
  • Those activities which are not in the work plan of any Organization, but which are felt to be important and would be implemented together, under the leadership of one UN agency;

Priorities identified

Those activities which will be done by one lead agency and for which funding has been made available, but where other UN agencies are invited to give input

• Advocacy: WHO will take the lead in work in Health in All Policies and produce a Health in all Policies manual. UNAIDS will take the lead in sharing a briefing resource on HIV and SDH for UNAIDS staff and will pass an SDH briefing to the UNAIDS Coordinators and social mobilization officers.

• Capacity Strengthening: ILO will lead and disseminate to the other UN Agencies a costing tool on the social protection floor and WHO will finalize the development and dissemination, of a data base on Intersectoral Action for Health (ISA).

• Monitoring: WHO will take the lead in the development of country health equity profiles which will be disseminated to all agencies.

Those activities which are already in the work plan of the lead agency, but would benefit from a collaboration with other UN agency

• Economic rationale/Investment case: WHO Department of Ethics and Social Determinants of Health is currently involved in developing economic rationale to work on social determinants of Health. UNAIDS, ILO and UNICEF are interested in this area of work, and will contribute.

• Monitoring of inequities in health outcomes and access to health services: WHO, UNICEF, UNAIDS and UNFPA have all identified this activity as a priority in their respective work plans. They will share their set of indicators and reports and work together in order to harmonize them across the UN Agencies.

• Country work: WHO, UNICEF, UNAIDS, UNDP and UNFPA have identified it as a priority in their work plans. They will ensure country work to be properly coordinated wherever possible through their respective country representatives. Priority will be given to “One UN Countries” (Armenia, Cape Verde, Mozambique, Pakistan, Rwanda, Tanzania, Uruguay and Vietnam)

Those activities which are not in the work plan of any Organization, but which are felt to be important and would be implemented together, under the leadership of one UN agency

Advocacy:

• Social Determinants of Health in Post-2015: All the UN agencies participated in this process identified social determinants of health in Post-MDG 2015 as a key priority. This could be done by using an agreed position to advocate based on a common position paper/statement to be developed. UNDP is the lead agency for this work.

• ICPD +20, 2012: While UNFPA is the lead agency for this work, WHO, UNICEF, UNAIDS and ILO have identified this as another priority. Including social determinants of health in ICPD beyond 2014 operational review is the key activity identified.

• Exploring opportunities with BRICS: Exploring opportunities to mobilise resources to work on social determinants of health with BRICS countries is a priority for many UN agencies. WHO will be the lead agency on this (UNICEF, UNDP, UNAIDS and ILO have also identified it as a priority).

Capacity Strengthening

• Integrating social determinants of health in to public health programmes: Joint tool to work in health programmes is identified as one of the key priorities by the UN agencies. While WHO and UNICEF will lead this process, UNDP, UNAIDS and UNFPA will also join this initiative. Tuberculosis, HIV, Maternal and child health are some of the potential areas. The scope and the focus needs to be identified.

• Review of capacity building programs supported by partners of SDH: Take stock of what capacity building programs are available in various agencies. WHO will be the lead agency for this work. UNICEF, UNFPA,, UNAIDS and ILO also have identified as a priority.

Monitoring:

• A Review of methodologies, evidence, gaps and evidence on effective equity in access to health care: ILO will lead this process, whereas UNICEF, WHO, UNFPA and UNAIDS have also identified this as a priority. Specific activities include: workshop on reviewing methodologies, developing a plan, and develop targets and outcome indicators

Country work:

• Support SDH Mainstreaming at Country Level: UNDP will lead this process, potentially through a few of the eight “one UN countries” Armenia, Cape Verde, Mozambique, Pakistan, Rwanda, Tanzania, Uruguay and Vietnam. Defining priority countries for mainstreaming SDH approach, briefing country teams and RCs, joint missions and strengthening capacities are some of the key steps identified. UNDP will be the lead agency for this work. All others have also identified this as a key priority.

• Share lessons in assessing potential entry points in the UNCT and theme groups including JUNTA: This involves review of UNDAF entry points and planning cycle, and ensure that SDH is included. UNDP will lead the process, and all others have also identified this as a key priority.

• Best practices on Social Participation and Empowerment in the Context of SDH: UNICEF will be the lead agency for this work, and all others have also identified this as a priority.

5. Monitor progress and increase accountability.

WHO will assist Member States in tracking trends in health inequities, and monitoring impacts of policies and actions, and in making policies more accountable to citizens.

Effective governance for social determinants requires monitoring and measurement to inform policy-making, evaluate implementation, and build accountability. Inequities in health outcomes, social determinants, and the implementation and impact of policies must be monitored. This information needs to be institutionalized as part of accountability mechanisms to guide policy-making in all sectors.

Monitoring of social determinants requires the collection of data and the dissemination and application of these data in the policy process. Measurement of inequities in health outcomes is generally more developed than measurement of the social production of health and disease. Moreover, less information is routinely collected about the distribution of social and environmental risks for ill health than about biological risk factors. This dearth of information is a barrier to monitoring the effects of policy and to developing and evaluating evidence-based interventions on social determinants to reduce inequities.

Hence, WHO assists Member States in tracking trends in health inequities, and impacts of policies and actions, and in making policies more accountable to citizens.