Social determinants of health

Commission on Social Determinants of Health

Special Session at the World Health Assembly


Kenyan Minister of Health (and Commissioner) Mrs Charity Ngilu and the UK Chief Health Officer Sir Liam Donaldson at the special session.
Dr Richard Horton (Editor, The Lancet), Dr Tim Evans (ADG, WHO), Dr Jeanette Vega (Head, Commission Secretariat), Dr Patricia Frenz (Ministry of Health, Chile) and Nicole Valentine (Commission Secretariat)

A special session on “Supporting national policy action on social determinants of health” was held at the Palais des Nations on the occasion of the World Health Assembly, attended by some 70 people. Dr Manuel Dayrit (Commissioner and MOH Philippines) was in the chair. Minister Dayrit briefly introduced the Commission, referring to the list of Commissioners contained in the briefing folders provided, introduced the panel, and reviewed the agenda.

A presentation was made on the Commission and its country work, which covered the four streams of work in the Commission (action, learning, advocacy and leadership); the framework for evaluating the point of entry of policies; the spectrum of country actions for creating leadership for integrating social determinants into policies for tackling health inequities; actors and Commission support.

Dr Richard Horton (Editor, The Lancet), Dr Tim Evans (ADG, WHO)

Pedro Garcia, Minister of Health, Chile, described the demographic and health and health inequality trends in Chile; the process of health reform; institutions, policies and programmes put in place since health reform; how Chile is currently tackling social determinants; and topics of mutual interest for collaboration with the Commission.

The UK’s Chief Medical Officer, Sir Liam Donaldson, commented on the lessons learned in the UK on tackling inequalities in health outcomes using a social determinants approach. The main lessons learned were:

  • You need a plan and clear, measurable objectives
  • You need belief. Sometimes, there is a lack of belief that anything can be done: that the problem can be described, but that you can't do anything about it. Action needs to start with the belief that you can do something about it.
  • You need a clear commitment to action.
  • You need a cross-governmental plan to address health inequalities - including the finance ministry. In the UK, the finance ministry was enthusiastic about the topic.
  • The scope of what you are trying to do includes reducing two types of inequalities: in health status and in health care outcomes.
  • Although this work is not about health services alone, the health sector has an important leadership role to play. For example, local health services can convene all the relevant groups in the effort to ensure healthier school meals.
  • “Joined up government” is terribly important, especially at the local level, where planning and funding mechanisms need to be brought into the picture.
  • Recognize the importance of regeneration of local neighbourhoods
  • Social cohesion is important
  • There may be diverse views on the philosophy regarding life styles based on disadvantage from underlying determinants versus personal choice.
  • It has been extraordinarily difficult to get health inequality impact assessment working in government as a routine procedure at all levels.
  • We must have good metrics – without that you don't know how effective your policies have been and could be throwing away money.

Finally, Minister Charity Ngilu (Commissioner and Minister of Health, Kenya) described Kenya's challenges regarding social determinants:

  • There are many health outcomes that the Ministry of Health is forced to deal with, which are created through actions in other sectors. The Ministry of Health ends up bearing the burden of other sector's policies.
  • The Kenyan government is spending less than 5 % of its budget on health and more than 25% on military expenditure and yet the only war Kenya faces is the war on poverty.
  • The Minister cited examples of social determinants issues in Kenya related to a recent outbreak of food poisoning; to the decentralization of over water quality control to villages; and to the enforcement of seatbelt and speed laws control of traffic, resulting in a decrease in trauma. In each case, Actions taken by another sector had an impact on the health sector.
  • Finally, at the global level, ceilings imposed by the international monetary institutions prevent Kenya from hiring further staff to increase the health system's capacity.
  • All these decisions are made outside of the traditional health system, and the Ministry of Health has to be able to influence these decisions if they are to improve health especially for the poorest and most vulnerable.

In the discussion that followed, one speaker felt that Ministers often assumed that their role was exclusively aimed at health care. The real power generally lay with the Ministry of Finance and Planning.

Another speaker noted that social determinants applied to all countries – rich and poor. If you have a multi-sectoral approach, you need to able to apply it differentially to younger and older populations, which had quite different problems. For example, in ageing populations, one of the main problems is loneliness.

Finally, Sir Liam Donaldson encapsulated a key strand of the discussion when he said, “We are in the territory of what makes for effective government and territorial issues. Government has generally accepted that economic and defence issues are ‘corporate’ government issues. Health should also be one of those corporate issues. If health is not corporate in a particular country, a key strategy to do so is to get a public debate going.”

Minister of health, Chile, Dr Pedro Garcia and Commission intern Mette Østergaard at the Commission's World Health Assembly stand.