Social determinants of health

5 key questions and answers

1. How can country actors catalyze action at the national level?

Country Partners’ experience shows that driving SDH action requires managing several processes, which have tended to unfold through three overlapping phases:

  • increasing the visibility of SDH and HE issues, for example by using data on existing health inequities to stir public concern and generate political will for action;
  • creating an institutional structure to take the SDH agenda forward, for example a national commission on SDH or a national reference group; for best results, such structures should incorporate spaces for dialogue between government and civil society on SDH/HE issues;
  • developing a national action plan—which need not be exhaustive, but can usefully highlight specific opportunities for action in a relatively short time frame (e.g., one year).

Country Partners’ action plans have given attention to short-term deliverables and potential ‘quick wins’, while also looking towards more ambitious horizons of structural change to reduce social inequities. The perspective has generally been incremental and additive, based on the idea that smaller initiatives now will build momentum for systemic change.

2. What can the health sector do to promote an SDH and HE agenda internally?

For countries embarking on SDH work, the health sector is a good place to start, even if their ultimate goal is to employ an approach that involves the whole of government. Country Partners found that ‘getting the health sector right’ requires priority action in the following areas:

  • presenting information on the health equity situation strategically, to reinforce political commitment and highlight opportunities for intervention, for example by using statistical decomposition analysis to pinpoint the roots of specific health inequities, as has been done for under-five mortality in Iran;
  • ensuring that the health system's design and management contribute to reducing socially determined health inequities, and that health sector programmes are equity-sensitive;
  • establishing national health equity goals and plans to achieve them, as Chile and England did prior to beginning Country Work, and as Kenya and Mozambique are now intending;
  • strengthening the national health information system to improve ‘health intelligence’ and routine monitoring of social health inequities, as Sri Lanka is now doing through improvements to its national vital registration system and key survey tools, in collaboration with CSDH and WHO.

3. What should the health sector be doing about intersectoral/cross-sectoral action on socially determined health inequalities?

The health sector has responsibility to identify an appropriate role in intersectoral/cross-sectoral action towards health equity goals. Intersectoral action has long been recognized as an essential facet of primary health care (PHC). Historically, however, intersectoral work has been among the most challenging dimensions of PHC to implement.

As part of its work with the CSDH, Canada has sponsored a series of more than 20 country case studies on intersectoral action. These constitute a substantial new body of evidence to inform policy approaches in countries at all income levels. There are several levels of integration within intersectoral activities, ranging from cooperation to avoid overt programming and policy conflicts among sectors, to coordination, to integrated policy-making. Countries have found that beginning with relatively limited forms of cooperation can be a useful way to build skills, trust and a culture of collaboration, laying groundwork for more ambitious efforts. Many CSDH Country Partners have recognized the goal of moving from a traditional model of intersectoral action towards more comprehensive, cross-sectoral strategies and ultimately a whole-of-government approach.

Country Partners’ experiences point to a series of key steps in advancing intersectoral agendas, including:

  • clearly define the role the Ministry of Health will play;
  • engage communication with other Ministries to identify shared concerns and potential areas of action; if ambitious collaborations involving multiple sectors are not immediately feasible, work can begin on priority objectives that may engage only one other ministry, as in Mozambique, where the Ministry of Health plans to develop water and sanitation interventions with the Ministry of Public Works to reduce infant mortality;
  • to expand intersectoral buy-in, consider incorporating ‘social determinants of health’ into a broader, more accessible vocabulary of social justice and wellbeing, as Chile is doing with its national social protection system;
  • use tools such as Health Equity Impact Analysis to evaluate policies outside the health sector and show why and how health concerns should be incorporated in these areas;
  • support innovative government management models and incentive structures that can encourage intersectoral cooperation, such as Chile’s new public-sector Management Control System;
  • line up the support of government and administrative actors with broad mandates: for example the Office of the President, as in the case of Brazil’s National Commission, or legislative actors, as when action by Canada’s CSDH Reference Group led to a Senate Sub-Committee agreeing to study SDH policy options and report its findings to Parliament.

4. How can Ministries of Health improve social participation on SDH/HE?

Civil society participation can strengthen political will around SDH and HE agendas. Social participation involving vulnerable and excluded groups should seek the empowerment of those groups, increasing their effective control over decisions that influence their health and life quality. All CSDH Country Partners explored ways to build social participation into SDH processes. However, political structures and institutional cultures often hamper substantive participation. Brazil’s model of institutionalizing participatory management in health policy holds promise.

Civil society organizations themselves have suggested strategies to strengthen social participation in the Primary Health Care agenda, including SDH and HE. These recommendations should be implemented.

As part of their collaboration with the Commission, WHO Regional Offices, in particular AMRO/PAHO and EMRO, supported work to strengthen regional civil society capacities on SDH. If the work is followed up and existing momentum reinforced, these processes will continue to build informed demand and civil society action on SDH/HE.

5. What kinds of capacities and skills need development to strengthen SDH/HE action, and how can the health sector build capacity?

Workforces in many countries lack training in areas that are important for addressing SDH/HE. While basic skills can be taught relatively quickly, countries need mechanisms to institutionalize ongoing learning and foster the development of new skills. The aim must be to build a cadre of trained experts able not only to adopt and implement an SDH approach but also to develop new techniques and strategies.

Capacity building may be especially urgent in the following areas: SDH monitoring and data analysis; capacity to plan and implement health sector programmes that take on board how the health system itself functions as a social determinant; capacities and mechanisms for cross-government action and social participation; and translating/ communicating evidence to influence policy processes.

Several Country Partners provided or received forms of training during their CSDH work, including Brazil, Chile, Iran, Mozambique, and Sri Lanka. WHO is exploring the possibility of developing a training course to build SDH-related capacities in Ministries of Health.