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A conceptual framework for action on the social determinants of health

Reproduced from: http://www.who.int/social_determinants/corner/en/ 


A CONCEPTUAL FRAMEWORK FOR ACTION ON THE SOCIAL DETERMINANTS OF HEALTH

Social Determinants of Health Discussion Paper 2

World Health Organization

Geneva

2010


The Series:

The Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the social determinants of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, and capacity building. They aim to review country experiences with an eye to understanding practice, innovations, and encouraging frank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed.

Background:

A first draft of this paper was prepared for the May 2005 meeting of the Commission on Social Determinants of Health held in Cairo. In the course of discussions the members and the Chair of the CSDH contributed substantive insights and recommended the preparation of a revised draft, which was completed and submitted to the CSDH in 2007. The authors of this paper are Orielle Solar and Alec Irwin.

Acknowledgments:

Valuable input to the first draft of this document was provided by members of the CSDH Secretariat based at the former Department of Equity, Poverty and Social Determinants of Health at WHO Headquarters in Geneva, in particular Jeanette Vega. In addition to the Chair and Commissioners of the CSDH, many colleagues offered valuable comments and suggestions in the course of the revision process. Thanks are due in particular to Joan Benach, Sharon Friel, Tanja Houweling, Ron Labonte, Carles Muntaner, Ted Schrecker, and Sarah Simpson. Any errors are responsibility of the principal writers. Nicole Valentine edited the paper and coordinated production.

Suggested Citation:

Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva, World Health Organization, 2010.

WHO Library Cataloguing-in- Publication Data

A conceptual framework for action on the social determinants of health. (Discussion Paper Series on Social Determinants of Health, 2)

1.Socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. I.World Health Organization. ISBN 978 92 4 150085 2   (NLM classification: WA 525)

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Contents

Foreword

Executive Summary

1. Introduction

2. Historical trajectory

3. Defining core values: health equity, human rights, and distribution of power

4. Previous theories and models

4.1 Current directions in SDH theory

4.2 Pathways and mechanisms through which SDH influence health

4.2.1 Social selection perspective

4.2.2 Social causation perspective

4.2.3 Life course perspective

5. CSDH conceptual framework

5.1 Purpose of constructing a framework for the CSDH

5.2 Theories of power to guide action on social determinants

5.3 Relevance of the Diderichsen model for the CSDH framework

5.4 First element of the CSDH framework: socio-economic and political context

5.5 Second element: structural determinants and socioeconomic position

5.5.1 Income

5.5.2 Education

5.5.3 Occupation

5.5.4 Social Class

5.5.5 Gender

5.5.6 Race/ethnicity

5.5.7 Links and influence amid socio-political context and structural determinants

5.5.8 Diagram synthesizing the major aspects of the framework shown thus far

5.6 Third element of the framework: intermediary determinants

5.6.1 Material circumstances

5.6.2 Social-environmental or psychosocial circumstances

5.6.3 Behavioral and biological factors.

5.6.4 The health system as a social determinant of health.

5.6.5 Summarizing the section on intermediary determinants

5.6.6 A crosscutting determinant: social cohesion / social capital

5.7 Impact on equity in health and well-being

5.7.1 Impact along the gradient

5.7.2 Life course perspective on the impact

5.7.3 Selection processes and health-related mobility

5.7.4 Impact on the socioeconomic and political context

5.8 Summary of the mechanisms and pathways represented in the framework

5.9 Final form of the CSDH conceptual framework

6. Policies and interventions

6.1 Gaps and gradients

6.2 Frameworks for policy analysis and decision-making

6.3 Key dimensions and directions for policy

6.3.1 Context strategies tackling structural and intermediary determinants

6.3.2 Intersectoral action

6.3.3 Social participation and empowerment

6.3.4 Diagram summarizing key policy directions and entry points

7. Conclusion

List of abbreviations

References

LIST OF FIGURES

Figure A: Final form of the CSDH conceptual framework

Figure B: Framework for tackling SDH inequities

Figure 1: Model of the social production of disease

Figure 2. Structural determinants: the social determinants of health inequities

Figure 3: Intermediary determinants of health

Figure 4: Summary of the mechanisms and pathways represented in the framework

Figure 5: Final form of the CSDH conceptual framework

Figure 6: Typology of entry points for policy action on SDH

Figure 7: Framework for tackling SDH inequities

LIST OF TABLES

Table 1: Explanations for the relationship between income inequality and health

Table 2: Social inequalities affecting disadvantaged people

Table 3: Examples of SDH interventions


Foreword

Conceptual frameworks in a public health context shall in the best of worlds serve two equally important purposes: guide empirical work to enhance our understanding of determinants and mechanisms and guide policy-making to illuminate entry points for interventions and policies.

Effects of social determinants on population health and on health inequalities are characterized by working through long causal chains of mediating factors. Many of these factors tend to cluster among individuals living in underprivileged conditions and to interact with each other. Epidemiology and biostatistics are therefore facing several new challenges of how to estimate these mechanisms. The Commission on Social Determinants of Health made it perfectly clear that policies for health equity involve very different sectors with very different core tasks and very different scientific traditions. Policies for education, labour market, traffic and agriculture are not primarily put in place for health purposes. Conceptual frameworks shall not only make it clear which types of actions are needed to enhance their “side effects” on health, but also do it in such a way that these sectors with different scientific traditions find it relevant and useful.

This paper pursues an excellent and comprehensive discussion of conceptual frameworks for science and policy for health equity, and in so doing, takes the issue a long way further.

Finn Diderichsen MD, PhD Professor, University of Copenhagen October, 2010


Executive summary

Complexity defines health. Now, more than ever, in the age of globalization, is this so. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization (WHO) to get to the heart of this complexity. They were tasked with summarizing the evidence on how the structure of societies, through myriad social interactions, norms and institutions, are affecting population health, and what governments and public health can do about   it. To guide the Commission in its mammoth task, the WHO Secretariat conducted a review and summary of different frameworks for understanding the social determinants of health. This review was summarized and synthesized into a single conceptual framework for action on the social determinants of health which was proposed to and, largely, accepted by, the CSDH for orienting their work. A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result. This paper describes the review, how the proposed conceptual framework was developed, and identifies elements of policy directions for action implied by the proposed conceptual framework and analysis of policy approaches.

A key lesson from history (including results from the previous “historical” paper – see Discussion Paper 1 in this Series), is that international health agendas have tended to oscillate between: a focus on technology-based medical care and public health interventions, and an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action. In this context, the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutional commitments to health equity and social justice.

Having health framed as a social phenomenon emphasizes health as a topic of social justice more broadly. Consequently, health equity (described by the absence of unfair and avoidable or remediable differences in health among social groups) becomes a guiding criterion or principle. Moreover, the framing of social justice and health equity, points towards the adoption of related human rights frameworks as vehicles for enabling the realization of health equity, wherein the state is the primary responsible duty bearer. In spite of human rights having been interpreted in individualistic terms in some intellectual and legal traditions, notably the Anglo-Saxon, the frameworks and instruments associated with human rights guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having been associated with historical struggles for solidarity and the empowerment of the deprived they form a powerful operational framework for articulating the principle of health equity.

Theories on the social production of health and disease

With this general framing in mind, developing a conceptual framework on social determinants of health (SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three main theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social frameworks.

All three of these theoretical traditions, use the following main pathways and mechanisms to explain causation: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives. Each of these theories and associated pathways and mechanisms strongly emphasize the concept of “social position”, which is found to play a central role in the social determinants of health inequities.

A very persuasive account of how differences in social position account for health inequities is found in the Diderichsen’s model of “the mechanisms of health inequality”. Didierichsen’s work identifies how the following mechanisms stratify health outcomes:

  • Social contexts, which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions.
  • Social stratification in turn engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability.
  • Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes per se).

The role of social position in generating health inequities necessitates a central role for a further two conceptual clarifications. First, the central role of power. While classical conceptualizations of power equate power with domination, these can also be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action as embodied in legal system class suits. In this context, human rights embody a demand on the part of oppressed and marginalized communities for the expression of their collective social power. The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. Second, it is important to clarify the conceptual and practical distinction between the social causes of health and the social factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework makes a point of making clear this distinction.

On this second point of clarification, conflating the social determinants of health and the social processes that shape these determinants’ unequal distribution can seriously mislead policy. Over recent decades, social and economic policies that have been associated with positive aggregate trends in health- determining social factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups. Furthermore, policy objectives are defined quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities.

The CSDH Conceptual Framework

Bringing these various elements together, the CSDH framework, summarized in Figure A, shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. Illness can “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions.

“Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market; the educational system, political institutions and other cultural and societal values. Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies). In the CSDH framework, structural mechanisms are those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and processes of the socioeconomic and political context.

The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity.

Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” The underlying social determinants of health inequities operate through a set    of intermediary determinants of health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors. The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant.

  • Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment.
  • Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof).
  • Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.

The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people’s lives.

Figure A. Final form of the CSDH conceptual framework

figa

The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both. Yet focus on social capital, depending on interpretation, risks reinforcing depoliticized approaches to public health and the SDH, when the political nature of the endeavour needs to be an explicit part of any strategy to tackle the SDH. Certain interpretations have not depoliticized social capital, notably the notion of “linking social capital”, which have spurred new thinking on the role of the state in promoting equity, wherein a key task for health politics is nurturing cooperative relationships between citizens and institutions. According to this literature, the state should take responsibility for developing flexible systems that facilitate access and participation on the part of the citizens.

Policy action 

Finally, in turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified. These may be based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population. A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other.

Policy development frameworks can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. The review showed the framework that Diderichsen and colleagues proposed- a typology or mapping of entry points for policy action on SDH inequities – to be very useful in the way it is very closely aligned to theories of causation. They identify actions related to: social stratification; differential exposure/ differential vulnerability; differential consequences and macro social conditions.

Considerations of these policy action frameworks lead to discussion of three key strategic directions for policy work to tackle the SDH, with a particular emphasis on tackling health inequities: (1) the need for strategies to address context; (2) intersectoral action; and (3) social participation and empowerment.

Policy action challenges for the CSDH

Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups (see Figure B). To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.

Figure B. Framework for tackling SDH inequities

figb

A key task for the CSDH will be:

  • to identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and to characterize in detail the political and management mechanisms that have enabled effective intersectoral programmes to function
  • to demonstrate how participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward after the Commission has completed its
  • Finally, SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science.

1  Introduction

On announcing his intention to create the Commission on Social  Determinants of Health (CSDH), World Health Organization  (WHO) Director-General Lee Jong-wook identified the Commission as part of a comprehensive effort to promote greater equity in global health in a spirit of social justice 1. The Commission’s goal, then, is to advance health equity, driving action to reduce health differences among social groups, within and between countries. Getting to grips with this mission requires finding answers to three fundamental problems:

  • Where do health differences among social groups originate, if we trace them back to their deepest roots?
  • What pathways lead from root causes to the stark differences in health status observed at the population level?
  • In light of the answers to the first two questions, where and how should we intervene to reduce health inequities?

This paper seeks to make explicit a shared understanding of these issues to orient the work of the CSDH. We recall the historical trajectory of which the CSDH forms a part; and then we make explicit the Commission’s fundamental values, in particular the concept of health equity and the commitment to human rights. We describe the broad outlines of current major theories on the social determinants of health, and we review perspectives on the causal pathways that lead from social conditions to differential health outcomes. Afterwards a new framework for analysis and action on social determinants is presented as a potential contribution of the CSDH to public health – the “CSDH framework”.

The CSDH conceptual framework synthesizes many elements from previous models, yet we believe it represents a meaningful advance. We ground the framework in a theorization of social power and make clear our debt to the work of Diderichsen and colleagues. We present the core  components  of  the  framework, including:

(1) socioeconomic and political context; (2) structural determinants of health inequities;  and (3) intermediary determinants of health. Our answers to the first two questions above will be articulated by way of these concepts. In the last section of the paper, we deduce key directions for pro-equity policy action based on the framework, providing broad elements of a response to the third question.

An important definitional issue must be clarified in advance. The CSDH has purposely adopted a broad initial definition of the social determinants of health (SDH). The concept encompasses the full set of social conditions in which people live and work, summarized in Tarlov’s phrase as “the social characteristics within which living takes place” 2. A broad initial definition of SDH is important in order not to foreclose fruitful avenues of investigation; however, within the field encompassed by this concept, not all factors have equal importance. Causal hierarchies will be ascertained, leading to crucial distinctions 3. Much of this paper will be concerned with clarifying these distinctions and making explicit the relationships between underlying  determinants of health inequities and the more immediate determinants of individual health.


2 Historical trajectory

Health is a complex phenomenon, and it can be approached from many angles. Over recent decades, international health agendas have tended to  oscillate between: (1) approaches relying on narrowly defined, technology-based medical and public health interventions; and (2) an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action, and sometimes linked to a broader social justice agenda.

WHO’s 1948 Constitution clearly acknowledges the impact of social and  political  conditions on health, and the need for collaboration with sectors such as agriculture, education, housing and social welfare to achieve health gains. During the 1950s and 1960s, however, WHO and other global health actors emphasized technology- driven, ‘vertical’ campaigns targeting specific diseases, with little regard for social contexts 4. A social model of health was revived by the 1978 Alma-Ata Declaration on Primary Health Care and the ensuing Health for All movement, which reasserted the need to strengthen health equity by addressing social conditions through intersectoral programmes 5.

Many governments embraced the principle of intersectoral action on SDH, under the banner of Health for All; however, the neoliberal economic models that gained global ascendancy during the 1980s created obstacles to policy action. In the health sector, neoliberal approaches mandated market-oriented reforms that emphasized efficiency over equity as a system goal and often reduced disadvantaged social groups’ access to health care services 6. On the level of macroeconomic policy, the structural adjustment programmes (SAPs) imposed on many developing countries by the international financial institutions mandated sharp reductions in governments’ social sector spending, constraining policy-makers’ capacity to address SDH 7.

Even as these market-oriented reforms were being applied in both developing and developed countries, new and more systematic analyses of the powerful impact of social conditions on health began to emerge. A series of prominent studies, including those of McKeown and Illich, challenged the dominant biomedical paradigm and debunked the idea that better medical care alone can generate major gains in population health 8,9,10,11,12. The UK’s Black Report on Inequalities in Health (1980) marked a milestone in understanding how social conditions shape health inequities. Black and his colleagues argued that reducing health gaps between privileged and disadvantaged social groups in Britain would require ambitious interventions in sectors such as education, housing and social welfare, in addition to improved clinical care 13.

Throughout the 1980s and early 1990s, the Black Report sparked debates and inspired a  series  of national inquiries into health inequities in other countries, e.g. the Netherlands, Spain and Sweden. The pervasive effects of social gradients on health were progressively clarified, in particular by the Whitehall Studies of Comparative Health Outcomes among British civil servants 14, 15. Important work at WHO’s European Office in the early 1990s laid conceptual foundations for a new health equity agenda, and the vocabulary of SDH began to achieve wider dissemination 16, 17.

By the late 1990s and early 2000s, in response to mounting documentation of the scope of inequities, and evidence that existing health and social policies had failed to reduce equity gaps 3, 16, 18, 19, health equity and the social determinants of health had been embraced as explicit policy concerns by a growing number of  countries, particularly but not exclusively in Europe. In the UK, the arrival in 1997 of a Labour government explicitly committed to reducing health inequalities focused fresh attention on SDH. Australia and New Zealand explored options for addressing health determinants, with New Zealand’s 2000 health strategy reflecting a strong SDH focus 20. In 2002, Sweden approved a new, determinants- oriented national public health strategy, arguably the most comprehensive model of national policy action on SDH. New policies focused on tackling health inequities were passed in England, Ireland, Italy, the Netherlands, Northern Ireland, Scotland and Wales during this period 3. Meanwhile, in developing regions, including sub-Saharan Africa, Asia, the Eastern Mediterranean and Latin America, resurgent critical traditions allying health and social justice agendas, such as the Latin American social medicine movement, refined their critiques of market-based, technology-driven neoliberal health care models and called for action to tackle the social roots of ill-health 21, 22, 23.

In 2003, Lee Jong-wook took office as Director- General  of  WHO,  on  a  platform  marked by commitments to health equity, social justice and a reinvigoration of the values of Health For All. Lee’s first announcement of his intention to create a Commission on Social Determinants of Health, at the 2004 World Health Assembly, positioned the CSDH as a key component of his equity agenda. Lee welcomed rising global investments in health, but affirmed that “interventions aimed at reducing disease and saving lives succeed only when they take the social determinants of health adequately into account” 24. Lee charged the Commission to mobilize emerging knowledge on social determinants in a form that could be turned swiftly into policy action in the low- and middle-income countries where needs are greatest. In his speech at the launch of the CSDH in Chile in March 2005, Lee noted that the Commission would deliver its report in 2008 for the thirtieth anniversary of the Alma-Ata conference and sixty years after the formal entry into force of the WHO Constitution. He urged the Commission to carry forward the values that had informed global public health in its most visionary moments, translating them into practical action for a new era.

Key messages from this section:

  • Over recent decades, international health agendas have tended to oscillate between: (1) a focus on technology-based medical care and public health interventions; and (2) an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action.
  • The 1978 Declaration of Alma-Ata and the subsequent Health for All movement gave prominence to health equity and intersectoral action on SDH; however, neoliberal economic models dominant during the 1980s and 1990s impeded the translation of these ideals into effective policies in many settings.
  • The late 1990s and early 2000s witnessed mounting evidence on the failure of existing health policies to reduce inequities, and momentum for new, equity- focused approaches grew, primarily in wealthy countries. The CSDH can ensure that developing countries are able to translate emerging knowledge on SDH and practical approaches into effective policy action.
  • In his speech at the launch of the CSDH, WHO Director-General Lee Jong-wook noted that the Commission will deliver its report in 2008 for the thirtieth anniversary of the Alma-Ata conference and sixty years after the WHO Constitution. He instructed the Commission to carry forward the values that have informed global public health in its most visionary moments, translating them into practical action.
  • The CSDH revives WHO constitutional commitments to health equity and social justice and reinvigorates the values of Health for All.

3  Defining core values: health equity, human rights, and distribution of power

Policy choices are guided by values, which may be implicit or explicit. The concept of health equity is the explicit ethical foundation of the Commission’s work, while human rights provide the framework for social mobilization and political leverage to advance the equity agenda. Realizing health equity requires empowering people, particularly socially disadvantaged groups, to exercise increased collective control over the factors that shape their health.

WHO’s Secretariat (the (then) Department of Equity, Poverty and Social Determinants of Health) defined health equity (also referred to as socioeconomic health equity) as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” 25. In essence, health inequities are health differences that are socially produced, systematic in their distribution across the population, and unfair 26. Identifying a health difference as inequitable is not an objective description, but necessarily implies an appeal to ethical norms 27.

Primary responsibility for protecting and enhancing health equity rests in the first instance with national governments. An important strand of contemporary moral and political philosophy was built on the work of Amartya Sen to link the concepts of health equity and agency and to make explicit the implications for just governance 28. Joining Sen, Anand stresses that health is a “special good” whose equitable distribution merits the particular concern of political authorities. There are two principal reasons for regarding health as a special good: (1) health is directly constitutive of a person’s well-being; and (2) health enables a person to function as an agent 29. Inequalities in health are thus recognized as “inequalities in people’s capability to function” which profoundly compromise freedom. When such inequalities arise systematically as a consequence of an individual’s social position, governance has failed in one of its prime responsibilities, i.e. ensuring fair access to basic goods and opportunities that condition people’s freedom to choose among life- plans they have reason to value 30. Ruger argues similarly for the importance of health equity as a goal of public policy, based on “the importance of health for individual agency” 31. Nonetheless, the causal linkages between health and agency are not uni-directional. Health is a prerequisite for full individual agency and freedom; yet at the same time, social conditions that provide people with greater agency and control over their work and lives are associated with better health outcomes 32. One can say that health enables agency, but greater agency and freedom also yield better health. The mutually reinforcing nature of this relationship has important consequences  for policy-making.

The international human rights framework is the appropriate conceptual structure within which to advance towards health equity through action on SDH. The framework is based on the 1948 Universal Declaration of Human Rights (UDHR). The UDHR holds that ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services’ (Art. 25) 33, and additionally that ‘Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized’ (Art. 28). The human rights aspects of health, and in particular connections between the right to health and social and economic conditions, were clarified in the 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR). In ICESCR Article 12, States signatories acknowledge “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”; and they commit themselves to specific measures to pursue this goal, including improved medical care and also health-enabling measures outside the medical realm per se like the “improvement of all aspects of environmental and industrial hygiene” 34.

The General Comment onthe Human Right to Health released in 2000 by the UN Committee on Economic, Social and Cultural Rights explicitly affirms that the right to health must be interpreted broadly to embrace key health determinants including (but not limited to) “food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment” 35. The General Comment echoes WHO’s Constitution and the 1978 Declaration of Alma-Ata in asserting a government’s responsibility to address social and environmental determinants in order to fulfil citizens’ rights to the highest attainable standard of health.

Human rights offer more than a conceptual armature connecting health, social conditions and broad governance principles. Rights concepts and standards provide an instrument for turning diffuse social demand into focused legal and political claims, as well as a set of criteria by which to evaluate the performance of political authorities in promoting people’s well-being and creating conditions for equitable enjoyment of the fruits of development 36. As Braveman and Gruskin argue,

“A  human rights perspective removes actions to relieve poverty and ensure equity from the voluntary realm of charity … to the domain of law”. The health sector can use the “internationally recognized human rights mechanisms for legal accountability” to push for aggressive social policies to tackle health inequities, since international human rights instruments “provide not only a framework but also a legal obligation for policies towards achieving equal opportunity to be healthy, an obligation that necessarily requires consideration of poverty and social disadvantage”37.

Over recent years, the work of the United Nations Special Rapporteur on the Right to Health has been instrumental in advancing the political agenda around the right to health at national and global levels 38.

While human rights have often been interpreted in individualistic terms in some intellectual and legal traditions, notably the Anglo-Saxon, human rights guarantees also concern the collective well-being of social groups and thus can serve to articulate and focus shared claims and an assertion of collective dignity on the part of marginalized communities. In this sense, human rights principles are intimately bound up with values  of solidarity and with historical struggles for the empowerment of the disadvantaged 21, 39.

Alicia Yamin and others have shown that empowerment is central to operationalizing the right to health and making it relevant to people’s lives. “A right to health based upon empowerment” implies fundamentally that “the locus of decision- making about health shifts to the people whose health status is at issue”. For Yamin, echoing Sen, the full expression of empowerment is people’s effective freedom to “decide what the meaning  of their life will be”. In this light, the right to health aims at the creation of social conditions under which previously disadvantaged and disempowered groups are enabled to “achieve the greatest possible control over … their health”. Increased control over the major factors that influence their health is an indispensable component of individuals’ and communities’ broader capacity to make decisions about how they wish to live 40.

Key messages of this section:

  • The guiding ethical principle for the CSDH is health equity, defined as the absence of unfair and avoidable or remediable differences in health among social groups.
  • Primary responsibility for protecting health equity rests with governments.
  • The international human rights framework is the appropriate conceptual and legal structure within which to advance towards health equity through action on SDH.
  • The realization of the human right to health implies the empowerment of deprived communities to exercise the greatest possible control over the factors that determine their health.

Previous theories and models

The CSDH does not begin in its conceptual work in a vacuum. The concepts presented here build on the contributions of many prior and contemporary analysts. In  this section, we first cite three important directions emerging recently in social epidemiology theory. Then we review a number of perspectives on the pathways through which social conditions influence health outcomes. These discussions uncover important elements to be included in a framework for action for the CSDH. Finally we highlight areas that previous theories have left insufficiently clarified, and upon which, the proposed CSDH framework can shed new light.

4.1      Current directions in SDH theory

The three main theoretical directions invoked by current social epidemiologists, which are not mutually exclusive, can be designated as follows: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) ecosocial theory and related multi-level frameworks. All three approaches seek to elucidate principles capable of explaining social inequalities in health, and all represent what Krieger has called theories of disease distribution that cannot be reduced to mechanism–oriented theories of disease causation. Where they differ is in their respective emphasis on different aspects of social and biological conditions in shaping population health, how they integrate social and biological explanations, and thus their recommendations for action 41, 42, 43.

  • The first school places primary emphasis  on psychosocial factors, and is associated with the view that people’s “perception and experience of personal status in unequal societies lead to stress and poor health” 44, 45. This school traces its origins to a classic study by Cassel 46, in which he argued that stress from the ‘social environment’ alters host susceptibility, affecting neuroendocrine function in ways that increase the organism’s vulnerability to disease. More recent researchers, most prominently Richard Wilkinson, have sought to link altered neuroendocrine patterns and compromised health capability to people’s perception and experience of their place in social hierarchies. According to these theorists, the experience of living in social settings of inequality forces people constantly to compare their status, possessions and life circumstances with those of others, engendering feelings of shame and worthlessness in the disadvantaged, along with chronic stress that undermines health. At the level of society as a whole, meanwhile, steep hierarchies in income and social status weaken social cohesion, with this disintegration of social bonds also seen as negative for health. This research has generated a substantial literature on the relationship between (perceptions of) social inequality, psychobiological mechanisms, and health status 47, 48, 49, 50, 51, 52.
  • A social production of disease/political economy of health framework explicitly addresses economic and political determinants of health and disease. Researchers adopting this theoretical approach also sometimes described as a materialist or neo-materialist position, do not deny negative psychosocial consequences of income inequality. However, they argue that interpretation of links between income inequality and health must begin with the structural causes of inequalities, and not just focus on perceptions of that inequality. Under this interpretation, the effect of income inequality on health reflects both lack of resources held by individuals and systematic under-investments across a wide range of community infrastructure 53, 54, 55. Economic processes and political decisions condition the private resources available to individuals and shape the nature of public infrastructure—education, health services, transportation, environmental controls, availability of food, quality of housing, occupational health regulations—that forms the “neomaterial” matrix of contemporary life. Thus income inequality per se is but one manifestation of a cluster of material conditions that affect population health.
  • Recently, Krieger’s “ecosocial” approach and other emerging multi-level frameworks have sought to integrate social and biological factors and a dynamic, historical and ecological perspective to develop new insights into determinants of population distribution of disease and social inequities in health 41, 42, 43. According to Krieger, multi- level theories seek to “develop analysis of current and changing population patterns of health, disease and well-being in relation to each level of biological, ecological and social organization”, all the way from the cell to human social groupings at all levels of complexity, through the ecosystem as a whole. In this context, Krieger’s notion of “embodiment” describes how “we literally incorporate biological influences from the material and social world” and that “no aspect of our biology can be understood divorced from knowledge of history and individual and societal ways of living” 41.

4.2 Pathways and mechanisms through which SDH influence health

Having canvassed major theoretical approaches to SDH, we now proceed to review specific models, and the supporting evidence, that purport to explain health inequities. We characterize these models as “perspectives”, adopting Mackenbach’s classification. This term underscores that the hypotheses examined have a potentially complementary character and, like the theoretical “directions” described in section 4.1, should not be regarded as necessarily mutually exclusive.

4.2.1         Social selection perspective

The social selection perspective implies that health determines socioeconomic position, instead of socioeconomic position determining health.

The basis of this selection is that health exerts a strong effect on the attainment of social position, resulting in a pattern of social mobility through which unhealthy individuals drift down the social gradient and the healthy move up. Social mobility refers to the notion that an individual’s social position can change within a lifetime, compared either with his or her parents’ social status (inter- generational mobility) or with himself/herself at an earlier point in time (intra-generational mobility). It is important to distinguish between inter- and intra- generational health selection, although few studies are available that examine selection in both ways. The literature on health and social mobility suggests that, in general, health status influences subsequent social mobility 56, 57, but evidence is patchy and not entirely consistent across different life stages. Also, there has been limited and inconclusive evidence on the effect that this could have on health gradients 58, 59, 60. Recently, it was proposed that health-related social mobility does not widen health inequalities 61. On this interpretation, people who are downwardly mobile because of their health still have better health than the people in the class of destination, upgrading this class. Similarly, upwardly mobile people will nonetheless lower the mean health in the higher socio-economic classes into which they become incorporated 62, 57. Again, the evidence for this is inconsistent, with some studies suggesting that health selection acts to reduce the magnitude of inequalities 63, 64, 65, 66, 67, whereas others do not 68. Some studies conclude that health selection cannot be regarded as the predominant explanation for health inequalities 69, 70.

Approaches to studying health selection

Several approaches have been used to study the role and magnitude of health selection on the social gradient. One approach focuses on the effect of social mobility, that is all social mobility and not just that related to health status, on health or health gradients 71, 72. A second approach focuses on the effect of health status at an earlier life stage in relation to health gradients later on 73. A third approach has been suggested to overcome these difficulties by focusing on both prior health status and social mobility 74, 75. It has been argued that health selection would have a stronger effect around the time of labour market entry, when the likelihood of social mobility is greatest 57.

It may be fruitful to distinguish between when illness influences the allocation of individuals to socioeconomic positions (“direct selection”) and when ill-health has economic  consequences owing to varying eligibility for and coverage by social insurance or similar mechanisms (example of “indirect selection”). Blane and Manor argue that the effect of the “direct selection” mechanism on the social gradient is small, and, therefore, direct social mobility cannot be regarded as a main explanation for inequalities in health. More commonly social mobility is considered selective on determinants of health (hence “indirect selection”), not on health itself 58. It is also important to take into account that the health determinants on which indirect selection takes place could themselves arise from living circumstances of earlier stages of life. Indirect selection would then be part of a mechanism of accumulation of disadvantage over the life course. The process of health selection may, therefore, contribute to the cumulative effects of social disadvantage across the life span, but, to date, the inclusion of health selection into studies of life course relationships is scarce.

4.2.2         Social causation perspective

From this perspective, social position determines health through intermediary factors. Longitudinal studies in which socioeconomic status has been measured before health problems are present, and in which the incidence of health problems has been measured during follow-up, show higher risk of developing health problem in the lower socioeconomic groups, and suggest “social causation” as the main explanation for socioeconomic inequalities in health 15. This causal effect of socioeconomic status on health is likely to be mainly indirect, through a number of more specific health determinants that are differently distributed across socioeconomic groups. Socioeconomic health differences occur when the quality of these intermediary factors are unevenly distributed between the different socioeconomic classes: socioeconomic status determines a person’s behavior, life conditions, etc., and these determinants induce higher or lower prevalence of health problems. The main groups of factors that have been identified as playing an important part in the explanation of health inequalities are material, psychosocial, and behavioral and/or biological factors.

Material factors are linked  to  conditions of economic hardship, as well as to health- damaging conditions in the physical environment, e.g. housing, physical working conditions, etc. For researchers who emphasize this aspect, health  inequalities  result  from  the differential accumulation  of  exposures  and experiences that have their sources in the material world. Meanwhile, material factors and social (dis) advantages predictably intertwine, such that “people who have more resources in terms of knowledge, money, power, prestige, and social connections are better able to avoid risk … and to adopt the protective strategies that are available at a given time and a given place” 76.

Psychosocial factors are highlighted by the psychosocial theory described above. Relevant factors include stressors (e.g. negative life events), stressful living circumstances, lack of social support, etc. Researchers emphasizing this approach argue that socioeconomic inequalities in morbidity and  mortality  cannot be entirely explained by well-known behavioral or material risk factors of disease. For example, in cardiovascular disease outcomes, risk factors such as smoking, high serum cholesterol and blood pressure can explain less than half of the socioeconomic gradient in mortality. Marmot, Shipley and Rose 142 have argued that the similarity of the risk gradient for a range of diseases could indicate the operation of factors affecting general susceptibility. Meanwhile, the inverse relation between height and mortality suggests that factors operating from early life may influence adult death rates 77.

Behavioral factors, such as smoking, diet, alcohol consumption and physical exercise, are certainly important determinants of health. Moreover, since they can be unevenly distributed between different socioeconomic positions, they may appear to have important weight as determinants of health inequalities. Yet this hypothesis is controversial in light of the available evidence. Patterns differ significantly from one country to another. For example, smoking is generally more prevalent among lower socioeconomic groups; however, in Southern Europe, smoking rates are higher among higher income groups, and in particular among women. The contribution of diet, alcohol consumption and physical activities to inequalities in health is less clear and not always consistent. However, there is higher prevalence of obesity and excessive alcohol consumption in lower socioeconomic groups, particularly in richer countries 19, 78, 79.

The health system itself constitutes an additional relevant intermediary factor, though one which has often not received adequate attention in the literature. We will discuss this topic in detail in subsequent sections of the paper.

4.2.3         Life course perspective

A life course perspective explicitly recognizes the importance of time and timing in understanding causal links between exposures and outcomes within an individual life course, across generations, and in population-level diseases trends. Adopting a life course perspective directs attention to how social determinants of health operate at every level of development—early childhood, childhood, adolescence and adulthood—both to immediately influence health and to provide the basis for health or illness later in life. The life course perspective attempts to understand how such temporal processes across the life course of one cohort are related to previous and subsequent cohorts and are manifested in disease trends observed over time at the population level. Time lags between exposure, disease initiation and clinical recognition (latency period) suggest that exposures early in life are involved in initiating disease processes prior to clinical manifestations; however, the recognition of early-life influences on chronic diseases does not imply deterministic processes that negate the utility of later-life intervention.

In a table produced by Ben-Shlomo and Kuh 80 the authors propose a simply classification of potential life course models of health. Two main mechanisms are identified.

The “critical periods” model is when an exposure acting during a specific period has lasting or lifelong effects on the structure or function of organs, tissues and body systems that are not modified in any dramatic way by later experiences. This is also known as “biological programming”, and it is sometimes referred to as a “latency” model. This conception is the basis of hypotheses on the fetal origins of adult diseases. This approach does recognize the importance of later life effect modifiers (e.g. in the linkage of coronary heart disease, high blood pressure and insulin resistance with low birth weight) 81.

The “accumulation of risk” model suggests that factors that raise disease risk or promote good health may accumulate gradually over the life course, although there may be developmental periods when their effects have greater impact on later health than factors operating at other times. This idea is complementary to the notion that as the intensity, number and/or duration of exposures increase, there is increasing cumulative damage to biological systems. Understanding the  health effects of childhood social class by identifying specific aspects of the early physical or psychosocial environment (such as exposure to air pollution or family conflict) or possible mechanisms (such as nutrition, infection or stress) that are associated with adult disease will provide further etiological insights. Circumstances in early life are seen as the initial stage in the pathway to adult health but with an indirect effect, influencing adult health through social trajectories, such as restricting educational opportunities, thus influencing socioeconomic circumstances and health in later life. Risk factors tend to cluster in socially patterned ways, for example, those living in adverse childhood social circumstances are more likely to be of low birth weight, and be exposed to poor diet, childhood infections and passive smoking. These exposures may raise the risk of adult respiratory disease, perhaps through chains of risk or pathways over time where one adverse (or protective) experience will tend to lead to another adverse (protective) experience in a cumulative way.

Ben-Shlomo and Kuh 80 argue that the life course approach is not limited to individuals within a single generation but should intertwine biological and social transmission of risk across generations. It must contextualize any exposure both within a hierarchical structure as well as in relation to geographical and secular differences, which may be unique to that cohort of individuals. Recently the potential for a life course approach to aid understanding of variations in the health and disease of populations over time, across countries and between social groups has been given more attention. Davey Smith 70 and his colleagues suggest that explanations for social inequalities in cause- specific adult mortality lie in socially-patterned exposures at different stages of the life course.

Key messages of this section:

  • In contemporary social epidemiology, three main theoretical explanations of disease distribution are: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social and other emerging multi-level frameworks. All represent theories which presume but cannot be reduced to mechanism–oriented theories of disease causation.
  • The main social pathways and mechanisms through which social determinants affect people’s health can usefully be seen through three perspectives: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives.
  • These frameworks/directions and perspectives are not mutually exclusive. On the contrary, they are complementary.
  • Certain of these frameworks have paid insufficient attention to political variables. The CSDH framework will systematically incorporate these  factors.

CSDH conceptual framework

5.1       Purpose of constructing a framework for the CSDH

We now proceed to present in detail the specific conceptual framework developed for the CSDH. This is an action-oriented framework, whose primary purpose is to support the CSDH in identifying where CSDH recommendations will seek to promote change in tackling SDH through policies. A comprehensive SDH framework should achieve the following:

  • Identify the social determinants of health and the social determinants of inequities in health;
  • Show how major determinants relate to each other;
  • Clarify the mechanisms by which social determinants generate health inequities;
  • Provide a framework for evaluating which SDH are the most important to address; and
  • Map specific levels of intervention and policy entry points for action on SDH.

To include all these aspects in one framework is difficult and may complicate understanding. In an earlier version of the CSDH conceptual framework, drafted in 2005, we attempted to include all of these elements in a single synthetic diagram; however, this approach was not necessarily the most helpful. In the current elaboration of the framework, we separate out the various major components.

We begin by sketching additional important background elements not covered in the previous theoretical frameworks and perspectives as follows:

  1. insights from the theorization of social power, which can help to clarify the dynamics of social stratification; and
  2. an existing model of the social production of disease developed by Diderichsen and colleagues, from which the CSDH framework draws significantly.

With these background elements in place, we proceed to examine the key components of the CSDH framework in turn, including:

  1. the socio-political context;
  2. structural determinants and socioeconomic position; and
  3. intermediary

We conclude the presentation with a synthetic review of the framework as a whole. The issue  of entry points for policy action will be taken up explicitly in the next chapter.

5.2     Theories of power to guide action on social determinants

Health inequities flow from patterns of social stratification—that is, from the systematically unequal distribution of power, prestige and resources among groups in society. As a critical factor shaping social hierarchies and thus conditioning health differences among groups, “power” demands careful analysis from researchers concerned with health equity and SDH. Understanding the causal processes that underlie health inequities, and assessing realistically what may be done to alter them, requires understanding how power operates in multiple dimensions of economic, social and political relationships.

The theory of power is an active domain of inquiry in philosophy and the social sciences. While developing a full-fledged theory of power lies beyond the mandate of the CSDH, the Commission can draw on philosophical  and political analyses of power to guide its framing of the relationships among health determinants and its recommendations for interventions .

Power is “arguably the single most important organizing concept in social and political theory” 82, yet this central concept remains contested and subject to diverse and often contradictory interpretations. We review several approaches to conceptualizing power.

First, classic treatments of the concept of power have emphasized two fundamental (and largely negative) aspects: (1) “power to”, i.e. what Giddens has termed “the transformative capacity of human agency”, in the broadest sense “the capability of the actor to intervene in a series of events so as to alter their course”; and (2) “power over”, which characterizes a relationship in which an actor or group achieves its strategic ends by determining the behavior of another actor or group. Power in this second, more limited but politically crucial sense may be understood as the capability to secure outcomes where the realization of these outcomes depends upon the agency of others. “Power over” is closely linked to notions of coercion, domination and oppression; it is this aspect of power which has been at the heart of most influential modern theories of power 83.

It is important to observe, meanwhile, that “domination” and “oppression” in the relevant senses need not involve the exercise of brute physical violence nor even its overt threat. In a classic study, Steven Lukes showed that coercive power can take covert forms. For example, power expresses itself in the ability of advantaged groups to shape the agenda of public debate and decision-making in such a way that disadvantaged constituencies are denied a voice. At a still deeper level, dominant groups can mold people’s perceptions and preferences, for example through control of the mass media, in such a way that the oppressed are convinced they do not have any serious grievances. “The power to shape people’s thoughts and desires is the most effective kind of power, since it pre-empts conflict and even pre- empts an awareness of possible conflicts” 84. Iris Marion Young develops related insights on the presence of coercive power even where overt force is absent. She notes that “oppression” can designate, not only “brutal tyranny over a whole people by a few rulers”, but also “the disadvantage and injustice some people suffer … because of the everyday practices of  a  well-intentioned  liberal society”.

Young terms this “structural oppression”, whose forms are “systematically reproduced in major economic, political and cultural institutions” 85. For all their explanatory value, power theories which tend to equate power with domination leave key dimensions of power insufficiently clarified. As Angus Stewart argues, such theories must be complemented by alternative readings that emphasize more positive, creative aspects of power.

A crucial source for such alternative more positive models is the work of philosopher Hannah Arendt. Arendt challenged fundamental aspects of conventional western political theory by stressing the inter-subjective character of power in collective action. In Arendt’s philosophy, “power is conceptually and above all politically distinguished, not by its implication in agency, but above all by its character as collective action 83. “Power corresponds to the human ability not just to act, but to act in concert. Power is never the property of an individual; it belongs to a group and remains in existence only so long as the group keeps together” 86. From this vantage point, power can be understood as:

“a relation in which people are not dominated but empowered through critical reflection leading to shared action” 87.

Recent feminist theory has further enriched these perspectives. Luttrell and colleagues 88 follow Rowlands 89 in distinguishing four fundamental types of power:

  • Power over (ability to influence or coerce)
  • Power to (organize and change existing hierarchies)
  • Power with (power from collective action)
  • Power within (power from individual consciousness).

They note that these different interpretations of power have important operational consequences for development actors’ efforts to facilitate the empowerment of women and other traditionally dominated groups. An approach based on “power over” emphasizes greater participation of previously excluded groups within existing economic  and  political  structures.  In contrast, models based on “power to” and “power with”, emphasizing new forms of collective action, push towards a transformation of existing structures and the creation of alternative modes of power- sharing: “not a bigger piece of the cake, but a different cake” 90.

This emphasis on power as collective action connects suggestively with a model of social ethics based on human rights. As one analyst has argued: “Throughout its history, the struggle for human rights has a constant: in very different forms and with very different contents, this struggle has consisted of one basic reality: a demand by oppressed and marginalized social groups and classes for the exercise of their social power91. Understood in this way, a human rights agenda means supporting the collective action of historically dominated communities to analyze, resist and overcome oppression, asserting their shared power and altering social hierarchies in the direction of greater equity.

The theories of power we have reviewed are relevant to analysis and action on the social determinants of health in a number of ways. First, and most fundamentally, they remind us that any serious effort to reduce health inequities will involve changing the distribution of power within society to the benefit of disadvantaged groups. Changes in power relationships can take place at various levels, from the “micro-level” of individual households or workplaces to the “macro-sphere” of structural relations among social constituencies, mediated through economic, social and political institutions. Power analysis makes clear, however, that micro-level modifications will be insufficient to reduce health inequities unless micro-level action is supported and reinforced through structural changes.

By definition, then, action on the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. This political process is likely to be contentious in most contexts, since it will be seen as pitting the interests of social groups against each other in a struggle for power and control of resources. Theories of power rooted in collective action, such as Arendt’s, open the perspective of a less antagonistic model of equity-focused politics, emphasizing  the  creative  self-empowerment of previously oppressed groups. “Here the paradigm case is not one of command, but one of enablement in which a disorganized and unfocused group acquires an identity and a resolve to act” 88. However, there can be little doubt that the political expression of vulnerable groups’ “enablement” will generate tensions among those constituencies that perceive their interests as threatened. On the other hand, theories that highlight both the overt and covert forms through which coercive power operates provide a sobering reminder of the obstacles confronting collective action among oppressed groups.

Theorizing the impact of social power on health suggests that the empowerment of vulnerable and disadvantaged social groups will be vital to reducing health inequities. However, the theories reviewed here also encourage us to problematize the concept of “empowerment” itself. They point to the different (in some cases incompatible) meanings this term can carry. What different groups mean by empowerment depends on their underlying views about power. The theories we have discussed acknowledge different forms of power and thus, potentially, different kinds and levels of empowerment. However, these theories urge skepticism towards depoliticized models of empowerment and approaches that claim to empower disadvantaged individuals and groups while leaving the distribution of key social and material goods largely unchanged. Those concerned to reduce health inequities cannot accept a model of empowerment that stresses process and psychological aspects at the expense of political outcomes and downplays verifiable change in disadvantaged groups’ ability to exercise control over processes that affect their well-being. This again raises the issue of state responsibility in creating spaces and conditions under which the empowerment of disadvantaged communities can become a reality. A  model of  community or civil society empowerment appropriate for action on health inequities cannot be separated from the responsibility of the state to guarantee  a comprehensive set of rights and ensure the fair distribution of essential material and social goods among population groups. This theme is explored more fully below.

Key messages of this section:

  • An explicit theorization of power is useful for guiding action to tackle SDH to improve health equity .
  • Classic conceptualizations of power have emphasized two basic aspects: (1) “power to” – the ability to bring about change through willed action; and (2) “power over” – the ability to determine other people’s behavior, associated with domination and coercion.
  • Theories that equate power with domination can be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action. In this perspective, human rights can be understood as embodying a demand on the part of oppressed and marginalized communities for the expression of their collective social power.
  • Any serious effort to reduce health inequities will involve changing the distribution of power within society to the benefit of disadvantaged groups.
  • Changes in power relationships can range from the “micro- level” of individual households or workplaces to the “macro- sphere” of structural relations among social constituencies, mediated through economic, social and political institutions. Micro-level modifications will be insufficient to reduce health inequities unless supported by structural changes but structural changes tha are not cogniscent of incentives at the micro-level will also struggle for impact.
  • This means that action on the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. 

5.3      Relevance of the Diderichsen model for the CSDH framework

The CSDH framework for action draws substantially on the contributions of many previous researchers, most prominently Finn Diderichsen. Diderichsen’s and Hallqvist’s 1998 model of the social production of disease was subsequently adapted by Diderichsen, Evans and Whitehead 92. The concept of social position is  at the center of Diderichsen’s interpretation of “the mechanisms of health inequality” 93. In its initial formulation, the model emphasized the pathway from society through social position and specific exposures to health. The framework was subsequently elaborated to give greater emphasis to “mechanisms that play a role in stratifying health outcomes” 94, including “those central engines of society that generate and distribute power,  wealth and risks” and thereby determine the pattern of social stratification. The model emphasizes how social contexts create social stratification and assign individuals to different social positions. Social stratification in turn engenders differential exposure to health- damaging conditions and differential vulnerability, in terms of health conditions and material resource availability. Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well as differential health outcomes per se).

At the individual level, the figure depicts the pathway from social position, through exposure to specific contributing causal factors, and on to health outcomes. As many different interacting causes in the same pathway might be related to social position, the effect of a single cause might differ across social positions as it interacts with some other cause related to social position 94, 95.

Figure 1. Model of the social production of disease

fig1

Diderichsen’s most recent version of the model provides some additional insights 92, 94. Both differential exposure (Roman numeral I in the diagram above) and differential vulnerability (II) may contribute to the relation between social position and health outcomes, as can be tested empirically. In addition, differential vulnerability is about clustering and interaction between those determinants that mediate the effect of socio-economic health gradient. Ill health has serious social and economic consequences due  to inability to work and the cost of health care. These consequences depend not only on the extent of disability, but also on the individual’s social position (III—differential consequences) and on the society’s environment and social policies. The social and economic consequences of illness may feed back into the etiological pathways and contribute to the further development of disease in the individual (IV). This effect might even, on an aggregate level, feed into the context of society, as well, and influence aggregate social and economic development.

Many of the insights from Diderichsen’s model will be taken up into the CSDH framework that we will now begin to explain, presenting its key components one by one.

Key messages of this section:

  • Social position is at the center of Diderichsen’s model of “the mechanisms of health inequality”.
  • The mechanisms that play a role in stratifying health outcomes operate in the following manner :
    • Social contexts create social stratification and assign individuals to different social positions.
    • Social stratification in turn engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability.
    • Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes per se).

5.4      First element of the CSDH framework: socio-economic and political context 

The social determinants framework developed by the CSDH differs from some others in the importance attributed to the socioeconomic- political context. This is a deliberately broad term that refers to the spectrum of factors in society that cannot be directly measured at the individual level. “Context”, therefore, encompasses a broad set of structural, cultural and functional aspects of a social system whose impact on individuals tends to  elude  quantification but which exert a powerful formative influence on patterns of social stratification and, thus, on people’s health opportunities. In this stated context, one will find those social and political mechanisms that generate, configure and maintain social hierarchies (e.g. the labor market, the educational system and political institutions including the welfare state).

One point noted by some analysts, and which we wish to emphasize, is the relative inattention to issues of political context in a substantial portion of the literature on health determinants. It has become commonplace among population health researchers to acknowledge that the health of individuals and populations is strongly influenced by SDH. It is much less common to aver that the quality of SDH is in turn shaped by the policies that guide how societies (re)distribute material resources among their members 96. In the growing area of SDH research, a subject rarely studied is the impact on social inequalities and health of political movements and parties and the policies they adopt when in government 97.

Meanwhile, Navarro and other researchers have compiled over the years an increasingly solid body of evidence that the quality of many social determinants of health is conditioned by approaches to public policy. To name just one example, the state of Kerala in India has been widely studied, showing the relationship between its impressive reduction of inequalities in the last 40 years and improvements in the health status of its population. With very few exceptions, however, these reductions in social inequalities and improvements in health have rarely been traced to the public policies carried out by the state’s governing communist party, which has governed

in Kerala for the longest period during those 40 years 98. Chung and Muntaner find similarly that few studies have explored the relationship between political variables and population health at the national level, and none has included a comprehensive number of political variables to understand their effect on population health while simultaneously adjusting for economic determinants 99. As an illustration of the powerful impact of political variables on health outcomes, these researchers concluded in a recent study of 18 wealthy countries in Europe, North America and the Asia-Pacific region that 20 % of the differences in infant mortality rate among countries could be explained by the type of welfare state. Similarly, different welfare state models among the countries accounted for about 10 % of differences in the rate of low birth weight babies 99.

Raphael similarly emphasizes how policy decisions impact a broad range of factors that influence the distribution and effects of SDH across population groups. Policy choices are reflected, for example, in: family-friendly labor policies; active employment policies involving training and support; the provision of social safety nets; and the degree to which health and social services and other resources are available to citizens 44, 45. The organization of healthcare is also a direct result of policy decisions made by governments. Public policy decisions made by governments are themselves driven by a variety of political, economic and social forces, constituting a complex space in which the relationship between politics, policy and health works itself out.

It is safe to say that these specifically political aspects of context are important for the social distribution of health and sickness in virtually all settings, and they have been seriously understudied. On the other hand, it is also the case that the most relevant contextual factors (i.e. those that play the greatest role in generating social inequalities) may differ considerably from one country to another 99. For example, in some countries religion will be a decisive factor and less so in others. In general, the construction/mapping of context should include at least six points: (1) governance in the broadest sense and its processes, including definition of needs, patterns of discrimination, civil society participation and accountability/transparence in public administration; (2) macroeconomic policy, including fiscal, monetary, balance of payments and trade policies and underlying labour market structures; (3) social policies affecting factors such as labor, social welfare, land and  housing distribution; (4) public policy in other relevant areas such as education, medical care, water and sanitation; (5) culture and societal values; and (6) epidemiological conditions, particularly in the case of major epidemics such as HIV/AIDS, which exert a powerful influence on social structures and must be factored into global and national policy- setting. In what follows, we highlight some of these contextual elements with particular focus on those with major importance for health equity.

We have adopted the UNDP definition of governance, which is as follows:

“[the] system of values, policies and institutions by which society manages economic, political and social affairs through interactions within and among the state, civil society and private sector. It is the way a society organizes itself to make and implement  decisions”.

It comprises the mechanisms and processes for citizens and groups to articulate their interests, mediate their differences and exercise their legal rights and obligations. These are the rules, institutions and practices that set limits and provide incentives for individuals, organizations and firms. Governance, including its social, political and economic dimensions, operates at every level of human enterprise, be it the household, village, municipality, nation, region or globe” 100,  101. It    is important to acknowledge, meanwhile, that there is no general agreement on the definition of governance, or of good governance. Development agencies, international organizations and academic institutions define governance in different ways, this being generally related to the nature of their interests and mandates.

Regarding labour market policies, we adopt the ideas proposed by the CSDH’s Employment Conditions Knowledge Network 102: “Labour market policies mediate between supply (jobseekers) and demand (jobs offered) in the labour market, and their intervention can take several forms. There are policies that contribute directly to matching workers to jobs and jobs to workers or enhancing workers’ skills and capacities, reducing labour supply, creating jobs or changing the structure of employment in favour of disadvantaged groups (e.g. employment subsidies for target groups). Typical passive programmes are unemployment insurance and assistance and early retirement; typical active measures are labour market training, job creation in form of public and community work programmes, programmes to promote enterprise creation and hiring subsidies. Active policies are usually targeted at specific groups facing particular labour market integration difficulties: younger and older people, women and those particularly hard to place such as the disabled.”

The concept of the “welfare state” is one in which the state plays a key role in the protection and promotion of the economic and social well-being of its citizens. It is based on the principles of equality of opportunity, equitable distribution of wealth and public responsibility for those unable to avail themselves of the minimal provisions for a good life. The general term may cover a variety of forms of economic and social organization. A fundamental feature of the welfare state is social insurance. The welfare state also, usually, includes public provision of basic education, health services and housing (in some cases at low cost or without charge). Anti-poverty programs and the system of personal taxation may also be regarded as aspects of the welfare state. Personal taxation falls into this category insofar as it is used progressively  to achieve greater justice in income distribution (rather than merely to raise revenue), and also insofar as it used to finance social insurance payments and other benefits not completely financed by compulsory contributions. In more socialist countries the welfare state also covers employment and administration of consumer prices 102, 103.

One of the main functions of the welfare state is “income redistribution”; therefore, the welfare state framework has been applied to the fields of social epidemiology and health policy as an amendment to the “relative income hypothesis”. Welfare state variables have been added to measures of income inequality to determine the structural mechanism through which economic inequality affects population health status 104.

Chung and Muntaner provide a classification of welfare state types and explore the health effects of their respective policy approaches. Their study concludes that countries exhibit distinctive levels of population health by welfare regime types, even when adjusted by the level of economic development (GDP per capita) and intra-country correlations. They find, specifically, that Social Democratic countries exhibit significantly better population health status, e.g. lower infant mortality rate and low birth weight rate, compared to other countries 99, 105.

Institutions and processes connected with globalization constitute an important dimension of context as we understand it. “Globalization” is defined by the CSDH Globalization Knowledge Network, following Jenkins, as:

“a process of greater integration within  the  world  economy through movements of goods and services, capital, technology and (to a lesser extent) labour, which lead increasingly to economic decisions being influenced by global conditions”.

– in other words, to the emergence of a global marketplace 106. Non-economic aspects of globalization, including social and cultural aspects, are acknowledged and relevant. However, economic globalization is understood as the force that has driven other aspects of globalization over recent decades. The importance of globalization signifies that contextual analysis on health inequities will often need to examine the strategies pursued by actors such as transnational corporations and supranational political institutions, including the World Bank and International Monetary Fund.

“Context” also includes social and cultural values. The value placed on health and the degree to which health is seen as a collective social concern differs greatly across regional and national contexts. We have argued elsewhere, following Roemer and Kleczkowski, that the social value attributed to health in a country constitutes an important and often neglected aspect of the context in which health policies must be designed and implemented.

In constructing a typology of health systems, Kleczkowski, Roemer and Van der Werff have proposed three domains of analysis to indicate how health is valued in a given society:

  • The extent to which health is a priority in the governmental /societal agenda, as reflected in the level of national resources allocated to health (care), with the need for health care signalling a grave ethical basis for resource redistribution);
  • The extent to which the society assumes collective responsibility for financing and organizing the provision of health services. In maximum collectivism (also referred to as a state-based model), the system is almost entirely concerned with providing collective benefits, leaving little or no choice to the individual. In maximum individualism, ill health and its care are viewed as private concerns; and
  • The extent of societal distributional responsibility. This is a measure  of the degree to which society assumes responsibility for the distribution  of its health resources. Distributional responsibility is at its maximum when the society guarantees equal access to services for all 107, 108.

These criteria are important for health systems policy and evaluating systems performance. They are also relevant to assessing opportunities for action on SDH.

To fully characterize all major components of the socioeconomic and political context is beyond the scope of the present paper. Here, we have considered only a small number of those components likely to have particular importance for health equity in many settings.

5.5      Second element: structural determinants and socioeconomic position

Graham observes that the concept of “social determinants of health” has acquired a dual meaning, referring both to the social factors promoting and undermining the health of individuals and populations and to the social processes underlying the unequal distribution of these factors between groups occupying unequal positions in society. The central concept of “social determinants” thus remains ambiguous, referring simultaneously to the determinants of health and to the determinants of inequalities in health. The author notes that:

“using a single term to refer to both the social factors influencing health and the social processes shaping their social distribution would not be problematic if the main determinants of health—like living standards, environmental influences and health behaviors— were equally distributed between socioeconomic groups” 3.

But the evidence points to marked socioeconomic differences in access to material resources, health- promoting resources, and in exposure to risk factors. Furthermore, policies associated with positive trends in health determinants (e.g. a rise in living standards and a decline in smoking) have also been associated with persistent socioeconomic disparities in the distribution of these determinants (marked socioeconomic differences in living standards and smoking rates) 109, 110. We have attempted to resolve this linguistic ambiguity by introducing additional differentiations within the field of concepts conventionally included under the heading “social determinants”. We adopt the term “structural determinants” to refer specifically to interplay between the socioeconomic-political context, structural mechanisms generating social stratification and the resulting socioeconomic position of individuals. These structural determinants are what we include when referring to the “social determinants of health inequities”. This concept corresponds to Graham’s notion of the “social processes shaping the distribution” of downstream social determinants 3. When referring to the more downstream factors, we will use the term “intermediary determinants of health”. We attach to this term specific nuances that will be spelled out in a later section.

Within each society, material and other resources are unequally distributed. This inequality can be portrayed as a system of social stratification or social hierarchy 111, 112. People attain different positions in the social hierarchy according, mainly, to their social class, occupational status, educational achievement and income level. Their position in the social stratification system can be summarized as their socioeconomic position. (A variety of other terms, such as social class, social stratum and social or socioeconomic status, are often used more or less interchangeably in the literature, despite their different theoretical bases.)

The two major variables used to operationalize socioeconomic position in studies of social inequities in health are social stratification and social class. The term stratification is used in sociology to refer to social hierarchies in which individuals or groups can be arranged along a ranked order of some attribute. Income or years of education provide familiar examples. Measures of social stratification are important predictors of patterns of mortality and morbidity. However, despite their usefulness in predicting health outcomes, these measures do not reveal the social mechanisms that explain how individuals arrive at different levels of economic, political and cultural resources. “Social class”, meanwhile, is defined by relations of ownership or control over productive resources (i.e. physical, financial and organizational) 112. This concept adds significant value, in our view, and for that reason we have chosen to include it as an additional, distinct component in our discussion of socioeconomic position. The particularities of the concept of social class will be described in greater detail when we analyze this concept below.

Two central figures in the study of socioeconomic position were Karl Marx and Max Weber. For Marx, socioeconomic position was entirely determined by ‘‘social class’’, whereby an individual is defined by their relation to the ‘‘means of production’’ (for example, factories and land). Social class, and class relations, is characterized by the inherent conflict between exploited workers and the exploiting capitalists or those who control the means of production. Class, as such, is not an a priori property of individual human beings, but is a social relationship created by societies. One explicit adaptation of Marx’s theory of social class that takes into account contemporary employment and social circumstances is Wright’s social class classification. In this scheme, people are classified according to the interplay of three forms of exploitation: (a) ownership of capital assets, (b) control of organizational assets, and (c) possession of skills or credential assets 113, 114.

Weber developed a different view of social class. According to Weber, differential societal position is based on three dimensions: class, status and party (or power). Class is assumed to have an economic base. It implies ownership and control of resources and is indicated by measures of income. Status is considered to be prestige or honor in the community. Weber considers status to imply “access to life chances” based on social and cultural factors like family background, lifestyle and social networks. Finally, power is related to a political context. In this paper, we use the term “socioeconomic position”, acknowledging the three separate but linked dimensions of social class reflected in the Weberian conceptualization.

Krieger, Williams and  Moss  highlight  that as “socioeconomic position” is an aggregate concept, its use in research needs to be  clarified 115. It includes both resource-based and prestige- based measures, and linked to both childhood and adult social class position. Resource-based measures refer to material and social resources and assets, including income, wealth and educational credentials; terms used to describe inadequate resources include “poverty” and “deprivation”. Prestige-based measures refer to individuals’ rank or status in a social hierarchy, typically evaluated with reference to people’s access to and consumption of goods, services and knowledge, as linked to their occupational prestige, income and educational Given distinctions between the diverse pathways by which resource-based and prestige-based aspects of socioeconomic position affect health across the life cycle, epidemiological studies need to state clearly how measures of socioeconomic position are conceptualized 115. Educational level creates differences between people in terms of access to information and the level of proficiency in benefiting from new knowledge, whereas income creates differences in access to scarce material goods. Occupational status includes both these aspects and adds to them benefits accruing from the exercise of specific jobs, such prestige, privileges, power, and social and technical skills.

Kunst and Mackenbach have argued that there are several indicators for socioeconomic position, and that the most important are occupational status, level of education and income level. Each indicator covers a different aspect of social stratification, and it is, therefore, preferable to use all three instead of only one 111. They add that the measurement of these three indicators is far from straightforward, and due attention should be paid to the application of appropriate classifications, for example, children, women and economically inactive  people,  for  whom  one  or  more of these indicators may not be directly available. Information on education, occupation and income may be unavailable, and it may be necessary to use proxy measures of socioeconomic status like indicators of living standards (for example, car ownership or housing tenure).

Singh-Manoux and colleagues have argued that the social gradient is sensitive to the proximal/ distal nature of the indicator of socioeconomic position employed 116. The idea is that there is valid basis for causal and temporal ordering in the various measures of socioeconomic position. An analysis of the socioeconomic status of individuals at several stages of their lives showed that socioeconomic origins have enduring effects on adult mortality through their effect on later socioeconomic circumstances, such as education, occupation and financial resources. This approach is derived from the life course perspective, where education is seen to structure occupation and income. In this model, education influences health outcomes both directly and indirectly through its effect on occupation and income 116. The disadvantage with education is that it does not capture changes in adult socioeconomic circumstances or accumulated socioeconomic position.

Reporting that educational attainment, occupational category, social class and income are probably the most often used indicators of current socioeconomic status in studies on health inequalities, Lahelman and colleagues find that each indicator is likely to reflect both common impacts of a general hierarchical ranking in society and particular impacts specific to the indicator. (1) Educational attainment is usually acquired by early adulthood. The specific nature of education is knowledge and other non-material resources that are likely to promote healthy lifestyles. Additionally, education provides formal qualifications that contribute to the socioeconomic status of destination through occupation and income. (2) Occupation-based social class relates people to social structure. Occupational social class positions indicate status and power, and they reflect material conditions related to paid work. (3) Individual and household income derive primarily from paid employment. Income provides individuals and families necessary material resources and determines their purchasing power. Thus, income contributes  to  resources needed in maintaining good health. Following these considerations, education is typically acquired first over the life course. Education   contributes to occupational class position and through this  to income. The effect of education on income   is assumed to be mediated mainly through occupation 117.

Socioeconomic position can be measured meaningfully at three complementary levels: individual, household and neighborhood. Each level may independently contribute to distributions of exposure and outcomes. Also, socioeconomic position can be measured at different points of the lifespan (e.g. infancy, childhood, adolescence and adulthood in the current, past 5 years, etc.). Relevant time periods depend on presumed exposures, causal pathways and associated etiologic periods. Today it is also vital to recognize gender, ethnicity and sexuality as social stratifiers linked to systematic forms of discrimination 118.

The CSDH framework posits that structural determinants are those that generate or reinforce social stratification in the society and that define individual socioeconomic position. These mechanisms configure the health opportunities  of social groups based on their placement within hierarchies of power, prestige and access to resources (economic status). We prefer to speak of structural determinants, rather than “distal factors”, in order to capture and underscore the causal hierarchy of social determinants involved in producing health inequities. Structural social stratification mechanisms, joined to and influenced by institutions and processes embedded in the socioeconomic and political context (e.g. redistributive welfare state policies), can together be conceptualized as the social determinants of health inequities.

We now examine briefly each of the major variables used to operationalize socioeconomic position. First we analyse the proxies use to measure social stratification, including income, education and occupation. Income and education can be understood as social outcomes of stratification processes, while occupation serves as a proxy for social stratification. Having reviewed the use of these variables, we then turn to analyse social class, gender and ethnicity that operate as important structural determinants.

5.5.1        Income

Income is the indicator of socioeconomic position that most directly measures the material resources component. As with other indicators, such as education, income has a ‘‘dose-response’’ association with health; it can influence a wide range of material circumstances with direct implications for health 119, 114. Income also has a cumulative effect over the life course, and it is the socioeconomic position indicator that can change most on a short term basis. It is implausible that money in itself directly affects health, thus  it is the conversion of money and assets into health enhancing commodities and  services via expenditure that may be the more relevant concept for interpreting how income affects health. Consumption measures are, however, rarely used in epidemiological studies; and they are, in fact, seriously flawed when used in health equity research, because high medical costs (an element of consumption) may make a household appear non-poor 120.

Income is not a simple variable. Components include wage earning, dividends, interest, child support, alimony, transfer payments and pensions. Kunst and Mackenbach argued that this is a more proximate indicator of access to scarce material resources or of standard of living. It can be expressed most adequately when the income level is measured by: adding all income components (this yield total gross income); subtracting deductions of tax and social contribution (net income); adding the net income of all household members (household income); or adjusting for the size of the household (household equivalent income) 111.

While individual income will capture individual material characteristics, household income may be a useful indicator, since the benefits of many elements of consumption and asset accumulation are shared among household members. This cannot be presumed, especially in  the context  of gender divisions of labour and power within the household, in particular for women, who may not be the main earners in the household. Using household income information to apply to all the people in the household assumes an even distribution of income according to needs within the household, which may or may not be true; however, income is nevertheless the best single indicator of material living standards. Ideally, data are collected on disposable income (what individuals/households can actually spend); but often data are collected instead on gross incomes or incomes that do not take into account in-kind transfers that function as hypothecated income. The meaning of current income for different age groups may vary and be most sensitive during the prime earning years. Income for young and older adults may be a less reliable indicator of their true socioeconomic position, because income typically follows a curvilinear trajectory with age. Thus, measures at one point in time may fail to capture important information about income fluctuations 121, 115. Macinko et al. propose the following summary explanations for the relationship between income inequality and health shown in Table 1 122.

Table 1. Explanations for the relationship between income inequality and health

Explanation

Synopsis of the Argument

Psychosocial (micro): Social status

Income inequality results in “invidious processes of social comparison” that enforce social hierarchies causing chronic stress leading to poorer health outcomes for those at the bottom.

Psychosocial (macro): Social cohesion

Income inequality erodes social bonds that allow people to work together, decreases social resources, and results in less trust and civic participation, greater crime and other unhealthy conditions.

Neo-material (micro): Individual income

Income inequality means fewer economic resources among the poorest, resulting in lessened ability to avoid risks, cure injury or disease, and/or prevent illness.

Neo-material (macro): Social disinvestment

Income inequality results in less investment in social and environmental conditions (safe housing, good schools, etc.) necessary for promoting health among the poorest.

Statistical artifact

The poorest in any society are usually the sickest. A society with high levels of income inequality has high numbers of poor and, consequently, will have more people who are sick.

Health selection

People are not sick because they are poor. Rather, poor health lowers one’s income and limits one’s earning potential.

Galobardes et al. conversely, have argued that income primarily influences health through a direct effect on material resources that are in turn mediated by more proximal factors in the causal chain, such as behaviours 121. The mechanisms through which income could affect health are:

  • Buying access to better quality material resources such as food and shelter;
  • Allowing access to services, which may improve health directly (such as health services, leisure activities) or indirectly (such as education);
  • Fostering self esteem and social standing  by providing the outward material characteristics relevant to participation in society; and
  • Health selection (also referred to as “reverse causality”) may also be considered as income level can be affected by health status.

5.5.2         Education

Education is a frequently used indicator in epidemiology. As formal education is frequently completed in young adulthood and is   strongly

determined by parental characteristics 123, it can be conceptualized within a life course framework as an indicator that in part measures early life socioeconomic position. Education can be measured as a continuous variable (years of completed education) or  as  a categorical variable by assessing educational milestones, such as completion of primary or high school, higher education diplomas, or degrees. Although education is  often used as a generic measure of socioeconomic position, specific interpretations explain its association with health outcomes:

  • Education captures the transition from parents’ (received) socioeconomic position to adulthood (own) socioeconomic position and it is also a strong determinant of future employment and income. It reflects material, intellectual and other resources of the family of origin, it begins at early ages, it is influenced by access to and performance in primary and secondary school, and it reaches final attainment in young adulthood for most people. Therefore, it captures the long-term influences of both early life circumstances on adult health and the influence of adult resources (e.g. through employment status) on health;
  • The knowledge and skills attained through education may affect a person’s cognitive functioning, make them more receptive to health education messages, or better enable them  to  communicate  with  and access appropriate health services; and
  • health in childhood could limit educational attendance and/or attainment and predispose a person to adult disease, generating a health selection influence on health inequalities.

Finally, measuring the number of years of education or levels of attainment may contain no information about the quality of the educational experience, which is likely to be important if conceptualizing the role of education in health outcomes specifically related to knowledge, cognitive skills and analytical abilities; but it may be less important if education is simply used as a broad indicator of socioeconomic position.

5.5.3         Occupation

Occupation-based indicators of socioeconomic position are widely used. Kunst and Mackenbach emphasize that this measure is relevant, because it determines people’s place in the societal hierarchy and not just because it indicates exposure to specific occupational risk, such as toxic compounds 111. Galobardes et al. suggest that occupation can be seen as a proxy for representing Weber’s notion of socioeconomic position, as a reflection of a person’s place in society related to their social standing, income and intellect 121. Occupation can also identify working relations of domination and subordination between employers and employees or, less frequently, characterize people as exploiters or exploited in class relations.

The main issue, then, is how to classify people with a specific job according to their place in the social hierarchy. The most usual approach consists of classifying people based on their position in the labour market into a number of discreet groups or social classes. People can be assigned to social classes by means of a set of detail rules that use information on such items as occupational title, skills required, income pay-off and leadership functions. For example, Wright’s typology distinguishes among four basic class categories: wage laborers, petty bourgeois (self-employed with no more than one employee; small employers with 2-9 employees and capitalist with 10 or more employees). Also, other classifications – called “social class” but more accurately termed “occupational class”- have been used in European public health surveillance and research. Among the best known and longest lived of these occupational class measures is the British Registrar General’s social class schema, developed in 1913. This schema has proven to be powerfully predictive of inequalities in morbidity or mortality, especially among employed men 124, 125. The model has five categories based on a graded hierarchy of occupations ranked according to skill (I Professional, II Intermediate, IIIa Skilled non-manual IIIb Skilled manual, IV Partly skilled, V Unskilled). Importantly, these occupational categories are not necessarily reflective of class relations.

Most studies use the current or longest held occupation of a person to characterize their adult socioeconomic position. However, with increasing interest in the role of socioeconomic position across the life course, some studies include parental occupation as an indicator of childhood socioeconomic position in conjunction with individuals’ occupations at different stages in adult life. Some of the more general mechanisms that may explain the association between occupation and health-related outcomes are as follows:

  • Occupation (parental or own adult) is strongly related to income and, therefore, the association with health may  be  one of a direct relation between material resources—the monetary and other tangible rewards for work that determines material living standards—and health.
  • Occupations reflect social standing and  may be related to health outcomes because of certain privileges—such as easier access to better health care, access to education and more salubrious residential facilities— that are afforded to those of higher standing.
  • Occupation may reflect social networks, work based stress, control and autonomy, and, thereby, affect health outcomes through psychosocial processes.
  • Occupation may also reflect specific toxic environmental or work task exposures, such as physical demands (e.g. transport driver or labourer).

One of the most important limitations of occupational indicators is  that  they  cannot be readily assigned to people who are not currently employed. As a result, if used as the only source of information on socioeconomic position, socioeconomic differentials may be underestimated through the exclusion of retired people, people whose work is inside the home (mainly affecting women), disabled people (including those disabled by work-related illness and injury), the unemployed, students, and people working in unpaid, informal, or illegal jobs  121.

Given the growing prevalence of insecure and precarious employment, knowing a person’s occupation is of limited value without further information about the individual’s employment history and the nature of the current employment relationship. Furthermore, socioeconomic indicators based on occupational classification may not adequately capture disparities in working and living conditions across divisions of race/ ethnicity and gender 115.

5.5.4         Social Class

Social class is defined by relations of ownership or control over productive resources (i.e. physical, financial and organizational). Social class provides an explicit relational mechanism (property, management) that explains how economic inequalities are generated and how they may affect health. Social class has important consequences for the lives of individuals. The extent of an individual’s legal right and power to control productive assets determines an individual’s strategies and practices devoted to acquire income and, as a result, determines the individual’s standard of living. Thus the class position of “business owner” compels its members to hire “workers” and extract labour from them, while the “worker” class position compels its members to find employment and perform labour. Most importantly, class is an inherently relational concept. It is not defined according to an order or hierarchy, but according to relations of power and control. Although there have been few empirical studies of social class and health, the need to study social class has been noted by social epidemiologists 126.

Class, in contrast to stratification, indicates the employment relations and conditions of each occupation. The criteria used to allocate occupations into classes vary somewhat between the two major systems presently in widespread use: the Goldthorpe schema and the Wright schema. According to Wright, power and authority are “organizational assets” that allow some workers to benefit from the abilities and energies of other workers. The hypothetical pathway linking class (as opposed to prestige) to health is that some members of a work organization are expending less energy and effort and getting more (pay, promotions, job security, etc.) in return, while others are getting less for more effort. So the less powerful are at greater risk of running down their stocks of energy and ending up in some kind of physical or psychological “health deficit”.

French industrial sociologists called this “l’usure de travai”—the usury of work. At the most obvious level, the manager sits in an office while the routine workers are exposed to all the dangers of heavy loads, dusts, chemical hazards and the like 127.

The task of class analysis is precisely to understand not only how macro structures (e.g. class relations at the national level) constrain micro processes (e.g. interpersonal behavior), but also how micro processes (e.g. interpersonal behavior) can affect macro structures (e.g. via collective action) 128. Social class is among the strongest known predictors of illness and health and yet   is, paradoxically, a variable about which very little research has been conducted. Muntaner and colleagues have observed that, while there  is substantial scholarship on the psychology of racism and gender, little research has been done on the effects of class ideology (i.e. classism). This asymmetry could reflect that in most wealthy democratic capitalist countries, income inequalities are perceived as legitimate while gender and race inequalities are not 128.

5.5.5         Gender

“Gender” refers to those characteristics of women and men which are socially constructed, whereas “sex” designates those characteristics that are biologically determined 129. Gender involves “culture-bound conventions, roles and behaviors” that shape relations between and among women and men and boys and girls. In many societies, gender constitutes a fundamental basis for discrimination, which can be defined as the process by which members of a socially defined group are treated differently especially unfairly because of their inclusion in that group 41. Socially constructed models of masculinity can have deleterious health consequences for men and boys (e.g. when these models encourage violence or alcohol abuse). However, women and girls bear the major burden of negative health effects from gender-based social hierarchies.

In many societies, girls and women suffer systematic discrimination in access to power, prestige and resources. Health effects of discrimination can be immediate and brutal (e.g. in cases of female infanticide, or when women suffer genital mutilation, rape or gender-based domestic violence). Gender divisions within society also affect health through less visible biosocial processes, whereby girls’ and women’s lower social status and lack of control over resources exposes them to health risks. Disproportionately high levels of HIV infection among young women in some sub-Saharan African countries are fueled by patterns of sexual coercion, forced early marriage and economic dependency among women and girls 130. Widespread patterns of underfeeding girl children, relative to their male siblings, provide another example of how gender-based discrimination undermines health. As Doyal argues, “A large part of the burden of preventable morbidity and mortality experienced by women is related directly or indirectly to the patterning of gender divisions. If this harm is to be avoided, there will need to be significant changes in related aspects of social and economic organization. In particular, strategies will be required to deal with the damage done to women’s health by men, masculinities and male institution” 131.

Gender-based discrimination often includes limitations on girls’ and women’s ability to obtain education and to gain access to respected and well- remunerated forms of employment. These patterns reinforce women’s social disadvantages and, in consequence, their health risks. Gender norms and assumptions define differential employment conditions for women and men and fuel differential exposures and health risks linked to work. Women generally work in different sectors than men and occupy lower professional ranks. “Women are more likely to work in the informal sector, for example in domes¬tic work and street vending” 132. Broadly, gender disadvantage is manifested in women’s often fragmented and economically uncertain work trajectories: domestic responsibilities disrupt career paths, reducing lifetime earning capacity and increasing the risks of poverty in adulthood and old age 133. For these reasons, Doyal argues that “the removal of gender inequalities in access to resources” would be one of the most important policy steps towards gender equity in health. “Since it is now accepted that gender identities are essentially negotiated, policies are needed which will enable people to shape their own identities and actions in healthier ways. These could include a range of educational strategies, as well as … employment policies and changes in the structure of state benefits” 131.

5.5.6         Race/ethnicity

Constructions of racial or ethnic differences are the basis of social divisions and discriminatory practices in many contexts. As Krieger observes, it is important to be clear that “race/ethnicity is a social, not biological, category”. The term refers to social groups, often sharing cultural heritage and ancestry, whose contours are forged by systems in which “one group benefits from dominating other groups, and defines itself and others through this domination and the possession of selective and arbitrary physical characteristics (for example, skin colour)” 42.

In societies marked by racial discrimination and exclusion, people’s belonging to a marginalized racial/ethnic group affects every aspect of their status, opportunities and trajectory throughout the life-course. Health status and outcomes among oppressed racial/ethnic groups are often significantly worse than those registered in more privileged groups or than population averages. Thus, in the United States, life expectancy for African-Americans is significantly lower than for whites, while an African-American woman  is twice as likely as a white woman to give birth to an underweight baby 134, 135. Indigenous groups endure racial discrimination in many countries and often have health indicators inferior to those of non-indigenous populations. In Australia, the average life expectancy of Aboriginal and Torres Strait Islanders lags 20 years behind that of non- Aboriginal Australians. Perhaps as a result of the compounded forms of discrimination  suffered by members of minority and oppressed races/ ethnicities, the “biological expressions of racism” are closely intertwined with the impact of other determinants associated with disadvantaged social positions (low income, poor education, poor housing, etc.).

5.5.7        Links and influence amid sociopolitical context and structural determinants

A close relationship exists between the sociopolitical context and what we term the structural determinants of health inequities. The CSDH framework posits that structural determinants are those that generate or reinforce stratification in the society and that define individual socioeconomic position. In all cases, structural determinants present  themselves in  a specific political and historical context. It is not possible to analyze the impact of structural determinants on health inequities or to assess policy and intervention options, if contextual aspects are not included. As we have noted, key elements of the context include: governance patterns; macroeconomic policies; social policies; and  public policies in  other relevant sectors, among other factors. Contextual aspects, including education, employment and social protection policies, act as modifiers or buffers influencing the effects of socioeconomic position on health outcomes and well-being among social groups. At the same time, the context forms part of the “origin” and sustenance of a given distribution of power, prestige and access to material resources in a society and thus, in the end, of the pattern   of social stratification and social class relations existing in that society. The positive significance of this linkage is that it is possible to address the effects of the structural determinants of health inequities through purposive action on contextual features, particularly the policy dimension.

5.5.8.  Diagram synthesizing the major aspects of the framework shown thus far

In this diagram we have summarized the main elements of the social and political context that model and directly influence the pattern of social stratification and social class existing in   a country. We have included in the diagram, in the far left column, the main contextual aspects that affect inequities in health, e.g. governance, macroeconomic policies, social policies, public policies in other relevant areas, culture and societal values, and epidemiological conditions. The context exerts an influence on health through socioeconomic position.

Moving to the right, in the next column of the diagram, we have situated the main aspects of social hierarchy, which define social structure and social class relationships within the society. These features are given according to the distribution of power, prestige and resources. The principal domain is social class / position within the social structure, which is connected with the economic base and access to resources. This factor is also linked with people’s degree of power, which is in turn is again influenced by the political context (functioning democratic institutions or their absence, corruption, etc.). The other key domain in this area encompasses systems of prestige and discrimination that exist in the society.

Again moving to the right, in the next column, we have described the main aspects of socioeconomic position. Studies and evaluations of equity frequently use income, education and occupation as proxies for these domains (power, prestige and economic status). When we refer to the domains of prestige and discrimination, we find them strongly related to gender, ethnicity and education. Social class also has a close connection to these different domains, as previously indicated. As an inherently relational variable, class is able to provide greater understanding of the mechanisms associated with the social production of health inequities.

Figure 2. Structural determinants: the social determinants of health inequities

fig2

Key messages of this section:

  • The CSDH framework is distinguished from some others by its emphasis on the socioeconomic and political context and the structural determinants of health inequity.
  • “Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market; the educational system political institutions and other cultural and societal values.
  • Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies).
  • In the CSDH framework, the structural mechanisms are those that interplay between context and socio-economic position: generating and reinforcing class divisions that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and policies of the socioeconomic and political context. The most important structural stratifiers and the proxy indicators include:
    • Income
    • Education
    • Occupation
    • Social Class
    • Gender
    • Race/ethnicity.
  • Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” We began this study by asking the question of where health inequities come from. The answer to that question lies here. The structural mechanisms that shape social hierarchies, according to these key stratifiers, are the root cause of inequities in health.

Meanwhile, the patterns according to which people are assigned to socioeconomic positions can turn back to influence the broader context (e.g. by generating momentum for or against particular social welfare policies, or affecting the level of participation in trade unions).

Proceeding again to the next column to the right (blue rectangle), we see that it is socioeconomic position as assigned within the existing social hierarchy that determines differences in exposure and vulnerability to intermediary health-affecting factors, (what we call the ‘social  determinants of health’ in the limited and specific sense), depending on people’s positions in the hierarchy.

Together, context, structural mechanisms and socioeconomic position constitute the social determinants of health inequities, whose effect is to give rise to an inequitable distribution of health, well-being and disease across social groups.

5.6     Third element of the framework: intermediary determinants 

The structural determinants operate through a series of what we will term intermediary social factors or social determinants of health. The social determinants of health inequities are causally antecedent to these intermediary determinants, which are linked, on the other side, to a set of individual-level influences, including health- related behaviors and physiological factors. The intermediary factors flow from the configuration of underlying social stratification and, in turn, determine differences in exposure and vulnerability to health-compromising conditions. At the most proximal point in the models, genetic and biological processes are emphasized, mediating the health effects of social determinants 3. The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant. We once again review these elements in turn.

5.6.1         Material circumstances

This includes determinants linked to the physical environment, such as housing (relating to both the dwelling itself and its location), consumption potential, i.e. the financial means to buy healthy food, warm clothing, etc., and the physical working and neighborhood environments. Depending on their quality, these circumstances both provide resources for health and contain health risks.

Differences in material living standards are probably the most important intermediary factor. The material standards of living are probably directly significant for the health status of marginalized groups; and also for the lower socioeconomic position, especially if we include environmental factors. Housing characteristics measure material aspects of socioeconomic circumstances 109. A number of aspects of housing have direct impact on health: the structure of dwellings; and internal conditions, such as damp, cold and indoor contamination. Indirect housing effects related to housing tenure, including wealth impacts and neighborhood effects, are seen as increasingly important. Housing as a neglected site for public health action include indoor and outdoor housing condition, as well  as, material and social aspects of housing, and local neighborhoods have an impact on health of occupants. Galobardes et al. propose a number of household amenities including access to hot and cold water in the house, having central heating and carpets, sole use of bathrooms and toilets, whether the toilet is inside or outside the home, and having a refrigerator, washing machine, or telephone 121. These household amenities are markers of material circumstances and may also be associated with specific mechanisms of disease. For example, lack of running water and a household toilet may be associated with increased risk of infection 136. In addition to household amenities, household conditions like the presence of damp and condensation, building materials, rooms in the dwelling and overcrowding are housing-related indicators of material resources. These are used in both industrialized and non- industrialized countries 136, 137. Crowding is calculated as the number of persons living in the household per number of rooms  available  in the house. Overcrowding can plausibly affect health outcomes through a number of different mechanisms: overcrowded households are often households with few economic resources and there may also be a direct effect on health through facilitation of the spread of infectious diseases. Galobardes et al. add that recent efforts to better understand the mechanisms underlying socioeconomic inequalities in health have lead  to the development of some innovative area level indicators that use aspects of housing 121. For example, a ‘‘broken windows’’ index measured housing quality, abandoned cars, graffiti, trashand public school deterioration at the census block level in the USA 137.

An explicit definition incorporating the causal relationship between work and health is given by the Spanish National Institute of Work, Health and Safety: “The variables that define the making of any given task, as well as the environment in which it is carried out, determine the health of the workers in a threefold sense: physical, psychological and social” 102. There are clear social differences in physical, mental, chemical and ergonomic strains in the workplace. The accumulation of negative environmental factors throughout working life probably has a significant effect on variations in the general health of the population, especially when people are exposed to such factors over a long period of time. Main types of hazards at the workplace include physical, chemical, ergonomic, biological and psychosocial risk factors. General conditions of work define, in many ways, peoples’ experience of work. Minimum standards for working conditions are defined in each country, but the large majority of workers, including many of those whose conditions are most in need of improvement, are excluded from the scope of existing labour protection measures. In many countries, workers in cottage industries, the urban informal economy, agricultural workers (except for plantations), small shops and local vendors, domestic workers and home workers are outside the scope of protective legislation. Other workers are deprived of effective protection because of weaknesses in labour law enforcement. This is particularly true for workers in small enterprises, which account for over 90 per cent of enterprises in many countries, with a high proportion of women workers.

5.6.2         Social-environmental or psychosocial circumstances

This includes psychosocial stressors (for example, negative life events and job strain), stressful living circumstances (e.g. high debt) and (lack of) social support, coping styles, etc. Different social groups are exposed in different degrees to experiences and life situations that are perceived as threatening, frightening and difficult for coping in the everyday. This partly explains the long-term pattern of social inequalities in health.

Stress may be a causal factor and a trigger that directs many forms of illness; and detrimental, long-term stress may also be part of the causal complex behind many somatic illnesses. A person’s socioeconomic position may itself be a source  of long-term stress, and it will also affect the opportunities to deal with stressful and difficult situations. However, there are also other, more indirect explanations of the pathway from stress to social inequalities in health. Firstly, there is an on-going international debate on what is often called Wilkinson’s “income inequality and social cohesion” model. The model states that, in rich societies, the size of differences in income is more important from a health point of view than the size of the average income. Wilkinson’s hypothesis is  that the greater the income disparities are in a society, the greater becomes the distance between the social strata. Social interaction is thus characterized by less solidarity and community spirit 138. The  people who lose most  are  those at the bottom of the income hierarchy, who are particularly affected by psychosocial stress linked to social exclusion, lack of self-respect and more or less concealed contempt from the people around them. Secondly, there are significant social differences in the prevalence of episodes of stress occurrence of short-term and long-term episodes of mental stress, linked to uncertainty about the financial situation, the labor market and social relations. The same applies to the probability of experiencing violence or threats of violence. Disadvantaged people have experienced far more insecurity, uncertainty and stressful events in their life course, and this affects social inequalities in health. This is illustrated in Table 2 published in the Norwegian Action Plan to Reduce Social Inequalities in Health 2005-06 139.

Some studies refer to the association between socio-economical status and health locus control. This concept refers to the way people perceive the events related to their health — as controllable (internal control) or as controlled by others (external control). People with education below university level more frequently identified an external locus of control. Other important challenges arise from increased incidence and prevalence of precarious and informal employments; consequently, changes in the labor market raise many issues and challenges for health care providers, organizational psychologists, personnel and senior managers, employers and trade union representatives, and workers and their families. Job insecurity and non-employment are also matters of concern to the wider community.

Table 2. Social inequalities affecting disadvantaged people

Social Status:1

Percentages who have experienced in their adult life:

Low:

High:

– serveral episodes of 3+ months of unemployment

11%

1%

– lost their job several times (involuntarily)

7%

2%

– received social security benefits

11%

2%

– had a serious accident

21%

6%

– been unemployed at the age of 55

29%

7%

– been unmarried/had no cohabitant at the age of 55

26%

14%

– had low income at the age of 53

20%

2%

1 Low status = the third with the lowest occupational prestige, high status = the third with the highest occupational prestige. Source: Reproduced with permission from the Norwegian Action Plan to Reduce Social Inequalities in Health 2005-2006

5.6.3        Behavioral and biological factors.

This includes smoking, diet, alcohol consumption and lack of physical exercise, which again can be either health protecting and enhancing (like exercise) or health damaging (cigarette smoking and obesity); in between biological factors we are including genetics factors, as well as from the perspective of social determinants of health, age and sex distribution.

Social inequalities in health have also been associated with social differences in lifestyle or behaviors. Such differences are found in nutrition, physical activity, and tobacco and alcohol consumption. This indicates that differences in lifestyle could partially explain social inequalities in health, but researchers do not agree  on their importance. Some  regard  differences in lifestyle as a sufficient explanation without further elaboration, while others regard them as contributory factors that in turn result from more fundamental causes. For example, Margolis et al. found that the prevalence of both acute and persistent respiratory symptoms in infants showed dose response relationships with SEP. When risk factors such as crowding and exposure to smoking in the household were adjusted for this condition, relative risk associated with SEP was reduced but still remained significant. The data further suggest that risk factors operated differently for different SEP levels; being in day care was associated with somewhat reduced incidence in lower SEP families but with increased incidence among infants from high SEP families 140. Health risk behaviors such as cigarette smoking, physical inactivity, poor diet and substance abuse are closely tied to both SEP and health outcomes. Despite the close ties, the association of SEP and health is reduced, but not eliminated, when these behaviors are statistically controlled 141, 142, 143.

Cigarette smoking is strongly linked to SEP, including education, income and employment status, and it is significantly associated with morbidity and mortality, particularly from cardiovascular disease and cancer 15, 144, 145, 146. A linear gradient between education and smoking prevalence was also shown in a community sample of middle-aged women. Additionally, among current smokers the number of cigarettes smoked was related to SEP. Significant employment grade differences in smoking were found in the Whitehall II study, which examined a new cohort of 10,314 subjects from the British Civil Service beginning in 1985 15, 143. Moving from the lowest to the highest employment grades, the prevalence of current smoking among men was 33.6%, 21.9%, 18.4%, 13.0%, 10.2% and 8.3%, respectively. For women, the comparable figures were 27.5%, 22.7%, 20.3%, 15.2%, 11.6% and 18.3%, respectively. Social class differences in smoking are likely to continue, because rates of smoking initiation are inversely related to SEP and because rates of cessation are positively related to SEP.

Lifestyle factors are relatively accessible for research, so this is one of the causal areas we know a good deal about. Although descriptions of the correlation of lifestyle factors with social status are relatively detailed and well-founded, this should not be taken to indicate that these factors are the most important causes of social inequalities in health. Other, more fundamental, factors may cause variations in both lifestyle and health. Some surveys indicate that differences in lifestyle can only explain a small proportion of social inequalities in health 14, 142. For instance, material factors may act as a source of psychosocial stress and psychosocial stress may influence health-related behaviors. Each of them can influence health through specific biological factors. A diet rich in saturated fat, for example, will lead to atherosclerosis, which will increase the risk of a myocardial infarction. Stress will activate hormonal systems that may increase blood pressure and reduce the immune response. Adoption  of  health-threatening  behaviors  is a response to material deprivation and stress. Environments determine whether individuals take up tobacco, use alcohol, have poor diets and engage in physical activity. Tobacco and excessive alcohol use, and carbohydrate-dense diets, are means of coping with difficult circumstances 100.

5.6.4 The health system as a social determinant of health.

As discussed, various models that have  tried  to explain the functioning and impact of SDH have not made sufficiently explicit the role of the health system as a social determinant. The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability. On the other hand, differences in access to health care certainly do not fully account for the social patterning of health outcomes. Adler et al. for instance, have considered the role of access to care in explaining the SEP-health gradient and concluded that access alone could not explain the gradient 146.

In a comprehensive model, the health system itself should be viewed as an intermediary determinant. This is closely related to models for the organization of personal and non-personal health service delivery. The health system can directly address differences in exposure and vulnerability not only by improving equitable access to care, but also in the promotion of intersectoral action to improve health status. Examples would include food supplementation through the health system and transport policies and intervention for tackling geographic barrier to access health care. A further aspect of great importance is the role the health system plays in mediating the differential consequences of illness in people’s lives. The health system is capable of ensuring that health problems do not lead to a further deterioration of people’s social status and of facilitating sick people’s social reintegration. Examples include programmes for the chronically ill to support their reinsertion in the workforce, as well as appropriate models of health financing that can prevent people from being forced into (deeper) poverty by the costs of medical care. Another important component to analyze relates to the way in which the health system contributes to social participation and the empowerment of the people, if in fact this is defined as one of the main axes for the development of pro-equity health policy. In this context, we can reflect on the hierarchical and authoritarian structure that predominates in the organization of most health systems. Within health systems, people enjoy little participatory space through which to take part in monitoring, evaluation and decision-making about system priorities and the investment of resources.

Diderichsen suggests that services through which the health sector deals with inequalities in health can be of five different types: (1) reducing the inequality level among the poor with respect to the causal factors that mediate the effects of poverty on health in such areas as nutrition, sanitation, housing and working conditions; (2) reinforcing factors that might reduce susceptibility to health effects from inequitable exposures, using various means including vaccination, empowerment and social support; (3) treating and rehabilitating the health problems that constitute the socioeconomic gap of burden of disease (the rehabilitation of disabilities, in particular, is often overlooked as a potential contributor to the reduction of health inequalities); (4) strengthening policies that reproduce contextual factors such as social capital that might modify the health effects of poverty; and (5) protecting against social and economic consequences of ill health though health insurance sickness benefits and labor market policies 92.

Even if there were some dispute as to whether the health system can itself be considered an indirect determinant of health inequities, it is clear that the system influences how people move among the social strata. Benzeval, Judge and Whitehead argue that the health system has three obligations in confronting inequity: (1) to ensure that resources are distributed between areas in proportion to their relative needs; (2) to respond appropriately to the health care needs of different social groups; and (3) to take the lead in encouraging a wider and more strategic approach to developing healthy public policies at both the national and local level, to promote equity in health and social justice 147. On this point the UK Department of Health has argued that the health system should play a more active role in reducing health inequalities, not only by providing equitable access to health care services but also by putting in place public health programmes and by involving other policy bodies to improve the health of disadvantaged communities 147.

5.6.5. Summarizing the section on intermediary determinants

Socioeconomic-political context directly affects intermediary factors, e.g. through kind, magnitude and availability. But for the population, the more important path of influence is through socioeconomic position. Socioeconomic position influences health through more specific, intermediary determinants. Those intermediary factors include: material circumstances, such as neighborhood, working and housing conditions; psychosocial circumstances, and also behavioral and biological factors. The model assumes that members of lower socioeconomic groups live in less favorable material circumstances than higher socioeconomic groups, and that people closer to the bottom of the social scale more frequently engage in health-damaging behaviors and less frequently in heath-promoting  behaviors  than do the more privileged. The unequal distribution of these intermediary factors (associated with differences in exposure and vulnerability to health-compromising  conditions,  as  well  as with differential consequences of ill-health) constitutes the primary mechanism through which socioeconomic position generates health inequities. The model includes the health system as a social determinant of health and illustrates the capacity of the heath sector to influence the process in three ways, by acting upon: differences in exposures, differences in vulnerability and differences in the consequences of illness for people’s health and their social and economic circumstances.

Figure 3. Intermediary determinants of health

fig3

5.6.6 A crosscutting determinant: social cohesion / social capital 149, 150

The concepts of social cohesion and “social capital” occupy an unusual (and contested) place in understandings of SDH. Over the past decade, these concepts have been among the most widely discussed in the social sciences and social epidemiology. Influential researchers have proclaimed social capital a key factor in shaping population health 151, 152, 153, 154. However, controversies surround the definition and importance of social capital.

In the most influential recent discussions, three broad approaches to the characterization and analysis of social capital can be distinguished: communitarian approaches, network approaches and resource distribution approaches. The communitarian approach defines social capital as a psychosocial mechanism, corresponding to a neo-Durkheimian perspective on the relation between individual health and society. This school includes influential authors such as Robert Putnam and Richard Wilkinson. Putnam defines social capital as “features of social organization, such as networks, norms and social trust, that facilitate coordination and cooperation for mutual benefit” 152. Social capital is looked upon as an extension of social relationships and the norms of reciprocity 154, influencing health by way of the social support mechanisms that these relationships provide to those who participate on them. The network approach considers social capital in terms of resources that flow and emerge through social networks. It begins with a systemic relational perspective; in other words, an ecological vision is taken that sees beyond individual resources and additive characteristics. This involves an analysis of the influence of social structure, power hierarchies and access to resources on population health 155. This approach implies that decisions that groups or individuals make, in relation to their lifestyle and behavioral habits, cannot be considered outside the social context where such choices take place. Two of the most outstanding conceptualisations in this regard have been elaborated by James  Coleman and Pierre Bourdieu, whose work has focused primarily on notions of social cohesion. Finally, the resource distribution approach, adopting a materialistic perspective, suggests that there is a danger in promoting social capital as a substitute for structural change when facing health inequity. Some representatives of this group openly criticize psychosocial approaches that have suggested social capital and cohesion as the most important mediators of the association between income and health inequality 156. The resource distribution approach insists that psychosocial aspects affecting population health are a consequence of material life conditions 157, 158.

Recent work by Szreter and Woolcock has enriched the debates around social capital and  its health impacts 155. These authors distinguish between bonding, bridging and linking social capital. Bonding social capital refers to the trust and cooperative relationships between members of a network that are similar in terms of their social identity. Bridging social capital, on the other hand, refers to respectful relationships and mutuality between individuals and groups that are aware that they do not possess the same characteristics in socio-demographic terms. Finally, linking social capital corresponds with the norms of respect and trust relationships between individuals, groups, networks and institutions that interact from different positions along explicit gradients of institutionalised power 153.

Some scholars have critiqued what they see as the faddish, ideologically driven adoption of the term “social capital”. Muntaner, for example, has suggested that the term serves primarily as a “comforting metaphor” for those in public health who wish to maintain that “capitalism … and social cohesion/social integration are compatible”. Beyond such ideological reassurance, Muntaner argues, the vocabulary of social capital provides few if any fresh insights, and may in fact provoke confusion. Those innovations that have been achieved by researchers investigating social capital could just as well “have been carried out under the label of ‘social integration’ or ‘social cohesion’. Indeed, it would be more adequate to use terms such as ‘cohesion’ and ‘integration’ to avoid the confusion and implicit endorsement of [a specific] economic system that the term [social capital] conveys” 159.

We share with Muntaner the concern that the current interest in “social capital” may further encourage depoliticized approaches to population health and SDH. Indeed, it is clear that the concept of social capital has not infrequently been deployed as part of a broader discourse promoting reduced state responsibility for health, linked to an emphasis on individual and community characteristics, values and lifestyles as primary shapers of health outcomes. Logically, if communities can take care of their own health problems by generating “social capital”, then government can be increasingly discharged of responsibility for addressing health and health care issues, much  less  taking steps to tackle underlying social inequities. Navarro suggests that foundational work on social capital, including Putnam’s, “reproduced the classical … dichotomy between civil and political society, in which the growth of one (civil society) requires the contraction of the other (political society— the state)”. From this perspective, the adoption  of social capital as a key for understanding and promoting population health is part of a broader, radically depoliticizing trend 160.

On the other hand, however, it can be argued that the recognition of linking social capital through Szreter’s and Woolcock’s work has contributed to a higher consideration of the dimension of power and of structural aspects in tackling social capital as a social determinant of health. This may help move discussions of social capital resolutely beyond the level of informal relationships and social support. The idea of linking social capital has also been fundamental as a new element when discussing the role that the state occupies or should occupy in the development of strategies that favour equity. Linking social capital offers the opportunity to analyse how relationships that are established with institutions in general, and with the state in particular, affect people’s quality of life. Such discussions highlight the role of political institutions and public policy in shaping opportunities for civic involvement and democratic behaviour 161, 162. The CSDH adopts the position that the state possesses a fundamental role in social protection, ensuring that public services are provided with equity and effectiveness. The welfare state is characterized as systematic defense against social insecurity, this being understood as individuals’, groups’ or communities’ vulnerability to diverse environmental threats 163. In this context, while remaining alert to ways in which notions of ‘social capital’ or community may be deployed to excuse the state from responsibility for the well- being of the population 164, 165, 166, we can also look for aspects of these concepts that shed fresh light on key state functions.

The notion of linking social capital speaks to the idea that one of the central points of health politics should be the configuration of cooperative relationships between citizens and institutions. In this sense, the state should assume the responsibility of developing more flexible systems that facilitate access and develop real participation by citizens. Here, a fundamental aspect is the strengthening of local or regional governments so that they can constitute concrete spaces of participation 162. The development of social capital, understood in these terms, is based on citizen participation. True participation implies a (re)distribution of empowerment, that is to  say, a redistribution of the power that allows the community to possess a high level of influence in decision-making and the development of policies affecting its well-being and quality of life.

The competing definitions and approaches suggest that “social capital” cannot be regarded as a uniform concept. Debate surrounds whether it should be as seen a property of individuals, groups, networks, or communities, and thus where it should be located with respect to other features of the social order. It is unquestionably difficult to situate social capital definitively as either a structural or an intermediary determinant of health, under the categories we have developed here. It may be most appropriate to think of this component as “cross-cutting” the structural and intermediary dimensions, with features that link it to both.

5.7 Impact on equity in health and well-being

This section summarizes some of the outcomes that emerge at the end of the social “production chain” of health inequities depicted in the framework. At this stage (far right side of the framework diagrams), we find the measurable impacts of social factors upon comparative health status and outcomes  among  different  population groups, e.g. health equity. According to the analysis we have developed, the structural factors associated with the key components of socioeconomic position (SEP) are at the root of health inequities measured at the population level. This relationship is confirmed by a substantial body of evidence.

Socioeconomic health differences are captured in general measures of health, like life expectancy, all- cause mortality and self-rated health 100. Differences correlated with people’s socioeconomic  position are found for rates of mortality and morbidity from almost every disease and condition 167. SEP is also linked to prevalence and course of disease and self-rated health. Socioeconomic health inequalities are evident in specific causes of disease, disability and premature death, including lung cancer, coronary heart disease, accidents and suicide. Low birth weight provides an additional important example. This is a sensitive measure of child health and a major risk factor for impaired development through childhood, including intellectual development 168. There are marked differences in national rates of low birth weight, with higher rates in the US and UK and lower rates in Nordic countries like Sweden, Norway and the Netherlands. These rates vary in line with the proportion of the child population living in poverty (in households with incomes below 50% of average income): at their lowest in low-poverty countries like Sweden and Norway, and at their highest in relatively high-poverty countries like the UK and US 169.

5.7.1   Impact along the gradient

There is evidence that the association of SEP and health occurs at every level of the social hierarchy, not simply below the threshold of poverty. Not only do those in poverty have poorer health than those in more favored circumstances, but those at the highest level enjoy better health than do those just below 142. The effects of severe poverty on health may seem obvious through the impact of poor nutrition, crowded and unsanitary living conditions and inadequate medical care. Identifying factors that can account for the link to health all across the SEP hierarchy may shed light on new mechanisms that have heretofore been ignored because of a focus on the more readily apparent correlates of poverty. The most notable of the studies demonstrating the SEP-health gradient is the Whitehall study of mortality (Marmot et al), which covered British civil servants over a period of 10 years. Similar findings emerge from census data in the United Kingdom (Susser, Watson and Hopper) 170, 171. Surprisingly, we know rather little about how SEP operates to influence biological functions that determine health status. Part of  the problem may be the way in which SEP is conceptualized and analyzed. SEP has been almost universally relegated to the status of a control variable and has not been systematically studied as an important etiologic factor in its own right. It is usually treated as a main effect, operating independently of other variables to predict health.

5.7.2   Life course perspective on the impact

Children born into poorer circumstances are at greater risk of the forms of developmental delay associated with intellectual disability, including speech impairments, cognitive difficulties and behavioral problems 172, 173. Some other conditions, like stroke and stomach cancer, appear to depend considerably on childhood circumstances, while for others, including deaths from lung cancer and accidents/violence, adult circumstances play the  more  important  role. In another  group  are  health  outcomes  where it is cumulative exposure that appears to be important. A number of studies  suggest  that this is the case for coronary heart disease and respiratory disease, for example 174.

5.7.3   Selection processes and health-related mobility

As discussed above, people with weaker health resources, allegedly, have a tendency to end up or remain low on the socioeconomic ladder. According to some analysts, the status of research on selection processes and health-related mobility within the socioeconomic structure can be summarized in three points: (1) variations in health in youth have some significance for educational paths and for the kind of job a person has at the beginning of his or her working career; (2) for those who are already established in working life, variations in health have little significance for the overall progress of a person’s career; and (3) people who develop serious health problems in adult life are often excluded from working life, and often long before the ordinary retirement age.

Graham argues that people with intellectual disabilities are more exposed to the social conditions associated with poor health and have poorer health than the wider population 175. She adds that, for example, those with mild disabilities are more likely than non-disabled people to have employment histories punctured by repeated periods of unemployment. Women with mild intellectual disabilities are further disadvantaged by high rates of teenage motherhood 175. In both childhood and adulthood, co-morbidity – the experience of multiple illnesses and functional limitations – disproportionately affects people with intellectual disabilities. For example, in the British 1958 birth cohort study, children with mild mental retardation were at higher risk of sensory impairments and emotional difficulties; they were also more likely to be in contact with psychiatric services. In adulthood, mild mental retardation was associated with limiting long-term illness and disability, and, particularly for women, with depressed mood.

One might assume such effects to be inevitable. But they are in part due to discriminatory practices, in part also to failures to adapt educational institutions and working life to special needs. To the extent that this is the case, social selection is neither necessary, nor inevitable, nor fair. This phenomenon particularly affects persons with disabilities, persons from immigrant backgrounds and, to a certain extent, women 3.

5.7.4   Impact on the socioeconomic and political context

From a population standpoint, we observe that the magnitude of certain diseases can translate into direct effects on features of the socioeconomic and political context, through high prevalence rates and levels of mortality and morbidity. The HIV/AIDS pandemic in sub-Saharan Africa can be seen in this light, with its associated plunge  in life expectancy and stresses on agricultural productivity, economic growth, and sectoral capacities in areas such as health and education. The magnitude of the impact of epidemics and emergencies will depend on the historical, political and social contexts in which they occur, as well as on the demographic composition of the societies affected. These are aspects that must be considered when analyzing welfare state structures, in particular models of health system organization that might respond to such challenges.

5.8 Summary of the mechanisms and pathways represented in the framework

In this section, we summarize key features of the CSDH framework (or model) and begin to sketch some of the considerations for policy-making to which the model gives rise. The next chapter will explore policy implications and entry points in greater depth.

Key messages of this section:

  • The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors.
  • The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant
  • Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment.
  • Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof).
  • Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.
  • The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health. The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people’s lives.
  • The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both.
  • Focus on social capital risks reinforcing depoliticized approaches to public health and SDH; however, certain interpretations, including Szreter’s and Woolcock’s notion of “linking social capital”, have spurred new thinking on the role of the state in promoting equity.
  • A key task for health politics is nurturing cooperative relationships between citizens and institutions. The state should take responsibility for developing flexible systems that facilitate access and participation on the part of the citizens.
  • The social, economic and other consequences of specific forms of illness and injury vary significantly, depending on the social position of the person who falls sick.
  • Illness and injury have an indirect impact in the socioeconomic position of individuals. From the population perspective, the magnitude of certain illnesses can directly impact key contextual factors (e.g. the performance of institutions).
  • Looking at the ultimate impact of social processes on health equity, we find that the structural factors associated with the key components of socioeconomic position (SEP) are at the root of health inequities at the population level. This relationship is confirmed by a substantial body of evidence.
  • Differences correlated with people’s socioeconomic position are found for rates of mortality and morbidity from almost every disease and condition. SEP is also linked to prevalence and course of disease and self-rated health.
  • The magnitude of certain diseases can directly affect features of the socioeconomic and political context, through high prevalence rates and levels of mortality and morbidity. The HIV/AIDS pandemic in sub-Saharan Africa provides one example, with its impact on agriculture, economic growth and sectoral capacities in areas such as health and education.

Figure 4. Summary of the mechanisms and pathways represented in the framework

fig4.png

Figure 4 illustrates the main processes captured in the CSDH framework, as we have explored them, step by step, in the present chapter. The diagram also highlights the reverse or feedback effects through which illness may affect individual social position, and widely prevalent diseases may affect key social, economic and political institutions. Reading the diagram from left to right, we see the social (socioeconomic) and political context, which gives rise to a set of unequal socioeconomic positions or social classes. (Phenomena related to socioeconomic position can also influence aspects of the context, as suggested by the arrows pointing back to the left.) Groups are stratified according to the economic status, power and prestige they enjoy, for which we use income levels, education, occupation status, gender, race/ethnicity and other factors as proxy indicators. This column of the diagram (Social Hierarchy) locates the underlying mechanisms of social stratification and the creation of social inequities.

Moving to the right, we observe how the resultant socioeconomic positions then translate into specific determinants of individual health status reflecting the individual’s social location within the stratified system. The model shows that a person’s socioeconomic position affects his/her  health, but that this effect is not direct. Socioeconomic position influences health through more specific, intermediary determinants.

Based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. Socioeconomic position directly affects the level or frequencies of exposure and the level of vulnerability, in connection with intermediary factors. Also, differences in exposure can generate more or less vulnerability in the population after exposure.

Once again, a distinctive element of this model  is its explicit incorporation of the health system. Socioeconomic inequalities in health can, in fact, be partly explained by the “feedback” effect of health on socioeconomic position, e.g. when someone experiences a drop in income because of a work- induced disability or the medical costs associated with major illness. Persons who are in poor health less frequently move up and more frequently move down the social ladder than healthy persons. This implies that the health system itself can be viewed as a social determinant of health. This is in addition to the health sector’s key role in promoting and coordinating SDH policy, as regards interventions to alter differential exposures and differential vulnerability through action on intermediary factors (material circumstances, psychosocial factors and behavioral/biological factors). It may be noted, in addition, that some specific diseases can impact people’s socioeconomic position, not only by undermining their physical capacities, but also through associated stigma and discrimination (e.g. in the case of HIV/AIDS). Because of their magnitude, certain diseases, such as HIV/AIDS and malaria, can also impact key contextual components directly, e.g. the labour market and governance institutions. The whole set of “feedback” mechanisms just described is brought together under the heading of “differential social, economic and health consequences”. We have included the impact of social position on these mechanisms, indicating that path with an arrow.

We have repeatedly referred to Hilary Graham’s warning about the tendency to conflate the social determinants of health and the social processes that shape these determinants’ unequal distribution, by lumping the two phenomena together under a single label. Maintaining the distinction is more than a matter of precision in language. As Graham argues, blurring these concepts may lead to seriously misguided policy choices. “There are drawbacks to applying health-determinant models to health inequalities.” To do so may “blur the distinction between the social factors that influence health and the social processes that determine their unequal distribution. The blurring of this distinction can feed the policy assumption that health inequalities can be diminished by policies that focus only on the social determinants of health. Trends in older industrial societies over the last 30 years caution against assuming that tackling ‘the layers of influence’ on individual and population health will reduce health inequalities. This period has seen significant improvements in health determinants (e.g. rising living standards and declining smoking rates) and parallel improvements in people’s health (e.g. higher life expectancy). But these improvements have broken neither the link between social disadvantage and premature death nor the wider link between socioeconomic position and health. As this suggests, those social and economic policies that have been associated with positive trends in health-determining social factors have also been associated with persistent inequalities in the distribution of these social influences.” 3, 175

Many existing models of the social determinants of health may need to be modified in order to help the policy community understand the social causes of health inequalities. Because inequalities in determinants are not factored into the models, their central role in driving inequalities in health may not be recognized. They are designed to capture schematically the distinction between health determinants and health inequality determinants, which can be obscured in the translation of research into policy. Evidence points to the importance of representing the concept of social determinants to policymakers in ways that clarify the distinction between the social causes of health and the factors determining their distribution between more and less advantaged groups. Our CSDH framework attempts to fulfill this objective. Indeed, this is one of its most important intended functions.

Graham argues that what is obscured in many previous treatments of these topics:

“is that tackling the determinants of health inequalities is about tackling the unequal distribution of health determinants”175. 

Focusing on the unequal distribution of determinants is important for thinking about policy. This is because policies that have achieved overall improvements in key determinants such as living standards and smoking have not reduced inequalities in these major influences on health. When health equity is the goal, the priority of a determinants-oriented strategy is to reduce inequalities in the major influences on people’s health. Tackling inequalities in  social position is likely to be at the heart of such a strategy. For, according to Graham, social position is the pivotal point in the causal chain linking broad (“wider”) determinants to the risk factors that directly damage people’s health.

Graham emphasizes that policy objectives will be defined quite differently, depending on whether our aim is to address determinants of health or determinants of health inequities:

  • Objectives for health determinants are likely to focus on reducing overall exposure to health-damaging factors along the causal pathway. These objectives are being taken forward by a range of current national and local targets: for example, to raise educational standards and living standards (important constituents of socioeconomic position) and to reduce rates of smoking (a major intermediary risk factor).
  • Objectives for health inequitydeterminants are likely to focus on leveling up the distribution of major health determinants. How these objectives are framed will depend on the health inequities goals that are being pursued. For example, if the goal is to narrow the health gap, the key policies will be those which bring standards of living and diet, housing and local services in the poorest groups closer to those enjoyed by the majority of the population. If the health inequities goal is to reduce the wider socioeconomic gradient in health, then the policy objective will be to lift the level of health determinants across society towards the levels in the highest socioeconomic group.

5.9       Final form of the CSDH conceptual framework 

The diagram below brings together the key elements of the account developed in successive stages throughout this chapter. This image seeks to summarize visually the main lessons of the preceding analysis and to organize in a single comprehensive framework the major categories of determinants and the processes and pathways that generate health inequities.

The framework makes visible the concepts and categories discussed in this paper. It can also serve to situate the specific social determinants on which the Commission has chosen to focus its efforts, and it can provide a basis for understanding how these choices were made (balance of structural and intermediary determinants, etc.).

Figure 5. Final form of the CSDH conceptual framework

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Key messages of this section:

  • This section recapitulates key elements of the CSDH conceptual framework and begins to explore implications for policy.
  • The framework shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions.
  • Illness can “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions.
  • Conflating the social determinants of health and the social processes that shape these determinants’ unequal distribution can seriously mislead policy; over recent decades, social and economic policies that have been associated with positive aggregate trends in health-determining social factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups.
  • Policy objectives will be defined quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities.
  • Thus, Graham argues for the importance of representing the concept of social determinants to policy-makers in ways that clarify the distinction between the social causes of health and the factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework attempts to fulfill this objective.

6  Policies and interventions

In this section, we framework elabora for policy action the issue of conc and their distributi terms of “gaps” or of in health. We then frameworks informe and Diderichsen et a to illustrate the type policy decision-makin number of key direct suggests should guid makers seek to tack SDH action.

6.1 Gaps and gradients

Today, health equity is increasingly embraced as a policy goal by international health agencies and national policy-makers 176. However, political leaders’ commitment to “tackle health inequities” can be interpreted differently to authorize a variety of distinct policy strategies.

Three broad policy approaches to reducing health inequities can be identified: (1) improving the health of low SEP groups through targeted programmes; (2) closing the health gaps between those in the poorest social circumstances and better off groups; and (3) addressing the entire health gradient, that is, the association between socioeconomic position and health across the whole population.

To be successful, all three of these options would require action on SDH. All three constitute potentially effective ways to alleviate the unfair burden of illness borne by the socially disadvantaged. Yet the approaches differ significantly in their underlying values and implications for programming. Each offers specific advantages and raises distinctive problems.

Programmes to improve health among low SEP populations have the advantage of targeting a clearly defined, fairly small segment of the population and of allowing for relative ease in monitoring and assessing results. Targeted programmes to tackle health disadvantage may align well with other targeted interventions in a governmental anti-poverty agenda, for example social welfare programmes focused on particular disadvantaged neighborhoods. On the other hand, such an approach may be politically weakened precisely by the fact that it is not a population- wide strategy but instead benefits sub-groups that make up only a relatively small percentage of the population, thus undermining the politics of solidarity that are important to maintaining support for public provision 177. Furthermore, this approach does not commit itself to bringing levels of health in the poorest groups closer to national averages. Even if a targeted programme is successful in generating absolute health gains among the disadvantaged, stronger progress among better-off groups may mean that health inequalities widen.

An approach targeting health gaps directly confronts the problem of relative outcomes. The UK’s current health inequality targets on infant mortality and life expectancy are examples of such a gaps-focused approach. However, this model, too, brings problems. For one thing, its objectives will be technically more challenging than those associated with strategies conceived only to improve health status among the disadvantaged. “Movement towards the [gap reduction] targets requires both absolute improvements in the levels of health in lower socioeconomic groups and a rate of improvement which outstrips that in higher socioeconomic groups” 175. Meanwhile, gaps- oriented approaches share some of the ambiguities underlying the focus on health disadvantage. Health-gaps models continue to direct efforts to minority groups within the population (they are concerned with the worst-off, measured against the best-off). By adopting this stance, “a health- gaps approach can underestimate the pervasive effect which socioeconomic inequality has on health, not only at the bottom but also across  the socioeconomic hierarchy” 175. By focusing too narrowly on the worst-off, gaps models can obscure what is happening to intermediary groups, including “next to the worst-off ” groups that may also be facing major health difficulties.

Tackling the socioeconomic gradient in health right across the spectrum of social positions constitutes a much more comprehensive model for action on health inequities. With a health- gradient approach, “tackling health inequalities becomes a population-wide goal: like the goal of improving health, it includes everyone”. On the other hand, this model must clearly contend with major technical and political challenges. Health gradients have persisted stubbornly across epidemiological periods and are evident for virtually all major causes of mortality, raising doubts about the feasibility of significantly reducing them even if political leaders have the will to do so. Public policy action to address gradients may prove complex and costly and, in addition, yield satisfactory results only in a long timeframe. Yet it is clear that an equity-based approach to social determinants, carried through consistently, must lead to a gradients focus 175.

Strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. The approaches are complementary and can build on each other. “Remedying health disadvantages is integral to narrowing health gaps, and both objectives form part of a comprehensive strategy to  reduce  health  gradients”.  Thus a sequential pattern emerges, with “each goal add[ing] a further layer to policy impact” 175. Of course the relevance of these approaches and their sequencing will vary with countries’ levels of economic development and other contextual factors. A targeted approach may have little relevance in a country where 80% of the population is living in extreme poverty. Here the CSDH can contribute by linking a deepened reflection on the values underpinning an  SDH  agenda   with country-level contextual analysis and a pragmatic mapping of policy options and sequencing.

6.2      Frameworks for policy analysis and decision-making

Our review of the literature has identified several suggestive analytic frameworks for policy development on SDH. One of the proposals most relevant to current  purposes  was  elaborated in the context of the Dutch national research programme on inequalities in health 177. The programme report highlights phases of analysis for the implementation of interventions and policies on SDH. The first phase involves filling in the social background on health inequalities in the specific country or socioeconomic context. The impact of each social determinant on health varies within a given country according to different socioeconomic contexts. Four intervention areas are identified:

  • The first and the most fundamental option is to reduce inequalities in the distribution of socioeconomic factors or structural determinants, like income and education. An example would be reducing the prevalence of poverty.
  • The second option relates to the specific or intermediary determinants that mediate the effect of socioeconomic position on health, such as smoking or working conditions. Interventions at this level will aim to change the distribution of such specific or intermediary determinants across socioeconomic groups, e.g. by reducing the number of smokers in lower socioeconomic groups, or improving the working conditions of people in lower status jobs.
  • A third option addresses the reverse effect of health status on socioeconomic position. If bad health status leads to a worsening of people’s socioeconomic position, inequalities in health might partly be diminished by preventing ill people from experiencing a fall in  income, such as  a consequence of job loss. An example would be strategies to maintain people with chronic illness within the workforce.
  • The fourth policy option concerns the delivery of curative healthcare. It becomes relevant only after people have fallen ill. One might offer people from lower socioeconomic positions extra healthcare or another type of healthcare, in other to achieve the same effects as among people in higher socioeconomic positions.

This and other policy frameworks should be seen in the light of the preceding discussion  on health disadvantage, gaps and gradients. Following Graham, we argued that improving the health of poor groups and narrowing health gaps are necessary but not sufficient objectives. A commitment to health equity ultimately requires a health-gradients approach. A gradients model locates the cause of health inequalities not only in the disadvantaged circumstances and health- damaging behaviors of the poorest groups, but  in the systematic differences in life chances, living standards and lifestyles associated with people’s unequal positions in the socioeconomic hierarchy 178. While interventions targeted at the most disadvantaged may appeal to policymakers on cost grounds or for other reasons, an unintended effect of targeted interventions may be to legitimize economic disadvantage and make it both more tolerable for individuals and less burdensome for society 178, 179, 180. Health programmes (including SDH programmes) targeted at the poor have a constructive role in responding to acute human suffering. Yet the appeal to such strategies must not obscure the need to address the structured social inequalities that create health inequities in the first place 181.

In another approach, Diderichsen and colleagues propose a typology or mapping of entry points for policy action on SDH that is very closely aligned to theories of causation, as was mapped out for the Commission’s Framework. They identify actions related to: social stratification; differential exposure/differential vulnerability; differential consequences and macro social conditions. The figure elaborated by Diderichsen and colleagues that illustrates these ideas is shown in Figure 6 94.

Figure 6. Typology of Entry Points for Policy Action on SDH

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The following entry points are identified:

  • First, altering social stratification itself, by reducing “inequalities in power, prestige, income and wealth linked to different socioeconomic positions” 93. For example, policies aimed at diminishing gender disparities will influence the position of women relative to men. In this domain, one could envisage an impact assessment of social and economic policies to mitigate their effects on social stratification. While social stratification is often seen as the responsibility  of  other  policy sectors and not central to health policy per se, Diderichsen and colleagues argue that addressing stratification is in fact “the most critical area in terms of diminishing disparities in health”. They propose two general types of policies in this entry point: first the promotion of policies that diminish social inequalities, e.g. labor market, education and family welfare policies; and second a systematic impact assessment of social and economic policies to mitigate their effects on social stratification. In the figure below, this approach is represented by line A.
  • Decreasing the specific exposure to health- damaging factors suffered by people in disadvantaged positions. The authors indicate that most health policies do not differentiate exposure or risk reduction strategies according to social position. Earlier anti-tobacco efforts constitute one illustration. Today there is increasing experience with health policies aiming to combat inequities in health that target the specific exposures of people in disadvantaged positions, including aspects like unhealthy housing, dangerous working conditions and nutritional deficiencies. Children living in extreme poverty (below US$1 per day, according to the World Bank’s contentious and problematic definition) have very different mortality rates in different countries; this shows that the national policy context modifies the effect of poverty (Wagstaff 182). Living in a society with strong safety nets, active employment policies, or strong social cohesion may make day-today life less threatening and relieve some of the social stress involved in having very little money or being unemployed (Whitehead et al. 96, 183). Below, this approach is represented by line B.
  • Lessening the vulnerability of disadvantaged people to the health-damaging conditions they face. An alternative way of thinking about modifying the  effect of exposures is through the concept of differential vulnerability. Intervention in a single exposure may have no effect on the underlying vulnerability of the disadvantaged population. Reduced vulnerability may only be achieved when interacting exposures are  diminished or relative social conditions improve significantly. An example would be the benefits of female education as one of the most effective means of mediating women’s differential vulnerability. This entry point is shown below by line C. This line is bifurcated to emphasize that conditions of differential vulnerability exist previous to specific exposures.
  • Intervening through the health system to reduce the unequal consequences of ill- health and prevent further socioeconomic degradation among disadvantaged people who become ill. Examples would include additional care and support to disadvantaged patients; additional resources for rehabilitation programmes to reduce the effects of illness on people’s earning potential; and equitable health care financing. Policy options should marshal evidence for the range of interventions (both disease-specific and related to the broader social environment) that will reduce the likelihood of unequal consequences of ill health. For instance, additional resources for rehabilitation might be allocated to reduce the social consequences of illness. Equitable health care financing is a critical component at this level. It involves protection from the impoverishment arising from catastrophic illness, as well as an understanding of the implications of various public and private financing mechanisms and  their  use by disadvantaged populations. In poor countries, the impoverishing effects of user fees play an increasing role in the economic consequences of illness. Social consequences of diseases have a much steeper socioeconomic gradient than the incidence and prevalence of the same diseases. The entry point appears below as line D.
  • Policies influencing macro-social conditions (context). Social and economic policies may influence social cohesion, integration and social capital of communities. Channels of influence and intervention can be defined for the development of redistributive policies, strengthening social policies, in particular for the neediest and most vulnerable social groups. This entry point appears in the figure as line E. 

6.3       Key dimensions and directions for policy

On the basis of the model developed in the preceding chapter and the policy analysis frameworks just reviewed, we can identify fundamental  orientations  for  policy  action to reduce health inequities through action on SDH. We do not attempt here to recommend specific policies and interventions, which will be the task of the Commission in its final report; rather,  our aim is to highlight broad policy directions that the CSDH conceptual framework suggests must be considered as decision-makers weigh options and develop more specific strategies. The directions we take up here are the following: (1) the importance of context-specific strategies and tackling structural as well as intermediary determinants; (2) intersectoral action; and (3) social participation and empowerment as crucial components of a successful policy agenda on SDH and health

6.3.1         Context strategies tackling structural and intermediary determinants

A key implication of the CSDH framework, with its emphasis on the impact of socio-political context on health, is that SDH policies must not pin their hopes on a “one-size-fits-all” approach, but should instead be crafted with careful attention to contextual specificities. Since the mechanisms producing social stratification will vary in different settings, certain interventions or policies are likely to be effective for a given socio-political context but not for all. Meanwhile, the timing of interventions with respect to local processes must be considered, as well as partnerships, availability of resources, and how the intervention and/or policy under discussion is conceptualized and understood by participants at national and local levels 184.

In addition to specificities related to sub-national, national and regional factors, context also includes a global component which is of growing importance. The actions of rich and powerful countries, in particular, have effects far outside their borders. Global institutions and processes increasingly influence the socio-political contexts of all countries, in some cases threatening the autonomy of national actors. International trade agreements, the deployment of new communications technologies, the activities of transnational corporations and other phenomena associated with globalization impact health determinants (in)directly through multiple pathways; hence, the importance of the findings and recommendations of the CSDH Knowledge Network on globalization for countries seeking to frame effective SDH policies.

Some of  the major institutions and   processes situated in the socioeconomic and political context (for example, models of governance, labour market structures or the education system) may appear too vast and intractable to be realistic targets for concerted action to bring change. The CSDH may hesitate to recommend ambitious forms of policy action (particularly expanded redistributive policies) that could be considered quixotic. Yet significant aspects of the context in our sense — the established institutional landscape and broad governance philosophies — can be (and historically have been) changed. Such changes have taken place through political action, often spurred by organized social demand. The contextual factors that powerfully shape social stratification and, in turn, the distribution of health opportunities are not (entirely) beyond people’s collective control. This is among the important implications of recent analyses of welfare state policies and health 98, 105. Social policies (covering the areas of “public” and “social” policies from the conceptual framework) matter for health and for the degree of social and health equity that exists in society. Evidence-based action to alter key determinants of health inequities is by no means politically unachievable. Notably, in a 2005 strategy document named The Challenge of the Gradient, the Norwegian Directorate for Health and Social Affairs argues that health inequities will probably be most effectively reduced through “social equalization policies”, though the authors acknowledge the political challenges involved in implementation 139. Indeed, the most significant lesson of the CSDH conceptual framework may be that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants; but they must include policies specifically crafted to tackle the underlying structural determinants of health inequities.

Not all major determinants have been targeted for interventions. In particular, social factors rarely appear to have been the object of interventions aimed at reducing inequity. In contrast, interventions are more frequently aimed at the accessibility of health care and at behavioral risk factors. Regarding the accessibility of health care, a majority of policies are concerned with financing. A notably high proportion of interventions are aimed at those determinants that fall within the domain of regular preventative care, including behavioral factors (individual health promotion and education). Indeed, interventions and policies that address structural determinants of health constitute orphan areas in the determinants field. More work has been done on intermediary determinants (decreasing vulnerability and exposure); but interventions at this level frequently target only one determinant, without relation to other intermediary factors or to the deeper structural factors.

Recent discussions on resource allocation formulas in England have introduced the issue of reducing inequalities in health, not only in access to medical care. Growing political concern about the persistence of social inequalities in health has led the government to add a new resource allocation objective for the NHS: to contribute  to the reduction in avoidable health inequalities 183, 185. The review is not yet finalized, and as an interim solution an index of mortality (years of life lost under age 75) has been proposed. Resource allocation to disease prevention to improve health equity has to be based on an understanding of some of the causal relationships outlined above. Efforts should, therefore, be made to break-up socioeconomic inequality in health into its different causes, so as to allow evaluation of their different roles in mediating the effect of social position and poverty on health.

National policies in Sweden have recently given strong priority to psychosocial working conditions as well as  tobacco smoking and  alcohol abuse as major causes mediating the effect of social position on health. A similar British overview put strong emphasis on living conditions and health behaviors of mothers and children 185, 187. The World Health Report 2002 emphasized the enormous potential impact  of  improvements in nutrition and vaccination programs on the poverty-related burden of disease 187. Common to proposals in both rich and poor countries is the emphasis on strong coordination between social policies and health policies in any effort to mitigate social inequalities in health.


Dahlgren and Whitehead on policy approaches

Dahlgren and Whitehead 188 have produced a list of broad recommendations for policy approaches to reduce underlying social inequities. Their primary focus is on income inequalities, but the principles apply to other structural determinants. Their recommendations for national policy directions include the following:

  • Describe present and future possibilities to reduce social inequalities in income through cash benefits, taxes and subsidized public services. The magnitude of these transfers can be illustrated by an example from the United Kingdom 186:

    “Before redistribution the highest income quintile earn 15 times that of the lowest income quintile. After  distribution of government cash benefits this ratio is reduced to 6 to 1, and after direct and local taxes the ratio falls further to 5 to 1. Finally, after adjustment for indirect taxes and use of certain free government services such as health and education, the highest income quintile enjoys a final income 4 times higher than the lowest income quintile”.

  •  Regulate the invisible hand of the market with a visible hand, promoting equity-oriented and labour-intensive growth strategies. A strong labour movement is important for promoting such policies, and it should be coupled with a broad public debate with strong links to the democratic or political decision-making process. Within this policy framework, the following special efforts should be made:
    • Maintain or strengthen active wage policies, where special efforts are made to secure jobs with adequate pay for those in the weakest position in the labour market. Secure minimum wage levels through agreements or legislation that are adequate and that eliminate the risk of a population of working poor.
    • Introduce or maintain progressive taxation, related both to income and to different tax credits, so that differences in net income are reduced after tax.
    • Intensify efforts to eliminate gender differences in income, by securing equal pay for equal jobs – regardless of sex. Some gender differences in income are also brought about when occupations that are typically male receive greater remuneration than occupations that are seen as female, because women are concentrated in them. These differences also need to be challenged.
    • Increase or maintain public financing of health, education and public transport. The distributional effects of these services are significant – in particular for health services – in universal systems financed according to ability to pay and utilized according to need 188.

6.3.2         Intersectoral action

As the preceding discussion has begun to suggest, a commitment to tackle structural, as well as intermediary, determinants has far-reaching implications for policy. This focus notably requires intersectoral action, because structural determinants of health inequities can only be addressed by policies that reach beyond the health sector. If the aim is attacking the deepest roots of health inequities, an intersectoral approach is indispensable.

Intersectoral action for health has been defined as:

A recognized relationship between part or parts of the health sector and part or parts of another sector, that has been formed to take action on an issue or to achieve health outcomes in a way that is more effective, efficient or sustainable than could be achieved by the health sector working alone 189. 

Since the Alma-Ata era, WHO has recognized a wide range of sectors with the potential to influence the determinants of health and, in some cases, the underlying structures responsible for determinants’ inequitable distribution among social groups. Relevant sectors include agriculture, food and nutrition; education; gender and women’s rights; labour market and employment policy; welfare and social protection; finance, trade and industrial policy; culture and media; environment, water and sanitation; habitat, housing, land use and urbanization 190.

Collaboration with these and other relevant sectors offers distinctive opportunities, while also raising specific challenges. Numerous approaches to planning and implementing intersectoral action exist, and a substantial literature has grown up around the facilitators and inhibitors of such action 191. Challis et 192 divide potential facilitating and obstructing factors into two categories: behavioral and structural. Behavioral elements concern individual attitudes and comportments among those being asked to work collaboratively across sectoral boundaries. Structural influences include political factors (e.g. political backing, political style, values and ideology), policy issues (such as consensus on the nature of problems and their solutions), and specific technical factors related to the policy field(s) in question 192.

Shannon and Schmidt propose a “conceptual framework for emergent governance” 193 that suggests how levels of decision-making from global to local can be brought into flexible but coherent connection (“loose coupling”) by linking intersectoral policy-making and participatory approaches. “Participatory approaches” in this context means “political processes that self-consciously and directly engage the people interested in and affected by [policy] choices”, as well as the officials charged with making and carrying out policy. These authors argue that intersectoral action and participation can work together to enable more collaborative, responsive modes of governance. Specific elements of collaboration in governance include “sharing resources (including staff and budgets), working to craft joint decisions, engaging the opposition in creative solutions to shared problems, and building new relationships as needs and problems arise” 194.

Three frequent approaches to intersectoral action involve policies and interventions defined according to: (1) specific issues; (2) designated target groups within the population; and (3) particular geographical areas (‘area-based strategies’). These approaches can be implemented separately or combined in various forms.

  • Dahlgren and Whitehead 188 have stressed the importance of intersectoral approaches for reducing health inequities and provided illustrative intersectoral strategies focused on the specific issue of improving health equity through education. Policies approaching health from the angle of education can be universal in scope (addressed to the whole population), for example a nationwide Healthy Schools programme or a universal programme to provide greater support in the transition from school to On the other hand, thematically defined intersectoral policies can be linked with social or geographical targeting. Examples would include introducing comprehensive support programmes for children from less privileged families, to promote preschool development 188.
  • Some intersectoral strategies are built around the needs of specific vulnerable groups within the population. This is the case of Chile’s “Puente” programme, for example, which seeks to provide a personalized benefits package to the country’s poorest families to help them assume increased control of their own lives and enjoy measurably improved life quality across 53 indicators of social well-being. The Puente programme, aimed at the “hard core” of Chilean families living in long-term poverty, is constructed to coordinate support services from multiple sectors, including health, education, employment and social welfare, while strengthening families’ social networks and their planning, conflict resolution, relational and life-management skills. A 2005 evaluation of the Puente programme found mixed results after Puente’s first three years of operation, revealing both successful aspects and limitations of the effort to construct a network model of integrated service provision at the local level. Effectiveness of service networking was inconsistent and highly dependent on the quality of local leadership within the municipalities where the programme operates. The evaluation concluded that despite its problems, the Puente model “stands out through its requirement that services connect up in networks to coordinate provision to very poor sectors” 194. Another example of intersectoral action crafted to meet the needs of specific groups is the New Zealand government’s programming for health improvement among the country’s Maori minority 195.
  • A third form of intersectoral policy-making is oriented to designated geographical A widely discussed (and contested) recent example is provided by the United Kingdom’s Health Action Zones (HAZ) 196. Venezuela’s Barrio Adentro (“Inside the Neighborhood”) programme offers a very different model of an area-focused healthcare programme incorporating intersectoral elements. Barrio Adentro forms part of a multi-dimensional national policy effort introduced by the government of President Hugo Chavez to improve health and living conditions for residents of fragile, historically marginalized urban neighborhoods. Barrio Adentro was consciously constructed as an equity- focused response to the neoliberal health care reforms implemented throughout Latin America during the 1980s and 90s, whose result had been to: “redefine health care less as a social right and more as a market commodity”. Muntaner et al. argue that “popular resistance to neoliberalism” helped drive the creation of Barrio Adentro and the array of innovative social welfare measures with which the programme is intertwined. They suggest that Barrio Adentro “not only provides a compelling model of health care reform for other low- to middle-income countries, but also offers policy lessons to wealthy countries” 197.

Of course, the intersectoral nature of SDH challenges adds considerably to their complexity. While WHO and other health authorities have long recognized the importance of intersectoral action for health, effective implementation of intersectoral policies has often proven elusive, and the Commission does not underestimate the challenges involved 190. Stronks and Gunning-Schepers 198 argue that: “Although there is great potential for improving the distribution of health through intersectoral action … there very often will be a conflict of interest with other societal goals. … The major constraint in trying to redress socio-economic health differences results from the fact that interventions on most determinants of health will have to come from [government] departments other than the department of public health. … Whereas the primary goal of health policy is (equality in) health, other policy fields have other primary goals.” (For example, in the area of employment and workforce policies, loosening regulation in the hope of raising the number of new jobs may take precedence over concerns for maintaining a living wage or for workplace safety).…“In intersectoral action, conflicts between the goal of equity in health and goals in other policy fields, especially economic policies, are to be expected”. In light of such concerns, important tasks for the CSDH will be: (1) to identify successful examples of intersectoral action on SDH at the national and sub-national level in jurisdictions with different levels of resources and administrative capacity; (2) to characterize in detail the political and management mechanisms that have enabled effective intersectoral programmes to function sustainably; and (3) to identify key examples of intersectoral action, and needs for future action, in the international frame of reference. These will often require initiatives by several countries acting jointly, within or outside the framework provided by existing multilateral institutions.

6.3.3         Social participation and empowerment

A final crucial direction for policy to promote health equity concerns the participation of civil society and the empowerment of affected communities to become active protagonists in shaping their own health.

Broad social participation in shaping policies to advance health equity is justified on ethical and human rights grounds, but also pragmatically. Human rights norms concern processes as well as outcomes. They stipulate that people have the right to participate actively in shaping the social and health policies that affect their lives. This principle implies a particular effort to include groups and communities  that  have  tended to suffer acute forms of marginalization and disempowerment. Meanwhile, from a strategic point of view, promoting civil society ownership of the SDH agenda is vital to the agenda’s long- term sustainability. The task of implementing the Commission’s recommendations and advancing action for health equity must be taken up by governments. In turn, governments’ commitment in pursuing this work will depend heavily on the degree to which organized demand from civil society holds political leaders accountable. By nurturing civil society participation in action on SDH during its lifetime, the Commission is laying the groundwork for sustained progress  in health equity in the long term. The Cuenca Declaration, adopted at the Second People’s Health Assembly, rightly states that the best hope for equitable health progress comes when empowered communities ally with the  state in action against the economic and political interests currently tending to undermine the public sector 199.

While the primary responsibility for promoting health equity and human rights lies with governments, participation in decision-making processes by civil society groups and movements is “vital in ensuring people’s power and control in policy development” 200. As proposed by the International Association for Public Participation (IAP2), when governments solicit social participation, this term can have a wide range of meanings 201:

  • Informing: To provide people with balanced and objective information to assist them in understanding the problem, alternatives, opportunities and/ or solutions.
  • Consulting: To obtain feedback from affected communities on analysis, alternatives and/or decisions.
  • Involving: To work directly with communities throughout the  process to ensure that public concerns and aspirations are consistently understood and considered.
  • Collaborating: To partner with affected communities in each aspect of the decision, including the development of alternatives and the identification of the preferred solution.
  • Empowering: To ensure that communities have “the last word” – ultimate control over the key decisions that affect their well- being.

Policy-making on social determinants of health equity should work towards the highest form of participation as authentic empowerment of civil society and affected communities.

As noted above, of course, definitions of “empowerment” are diverse and contested. To some, empowerment is a “political concept that involves a collective struggle against oppressive social relations” and the effort to gain power over resources. To others, it “refers to the consciousness of individuals, or the power to express and act on one’s desires” 88. When promoting “empowerment” and “participation” as key aspects of policy strategies to tackle heath inequities, we must be aware of the historical and conceptual ambiguities that surround these terms. The concept of empowerment in particular has generated a voluminous and often polemical recent literature 84, 201. Here, we cannot hope to reflect all the nuances of these debates. However, we can highlight relevant aspects that clarify our interpretation of these concepts and their implications for policy-making.

Historically, key sources of the concept of empowerment include the Popular Education movement and the women’s movement. The Popular Education approach gained prominence in Latin America and  elsewhere in  the 1970s. It is based on the pioneering work of Paulo Freire in the education of oppressed people, and notably on Freire’s model of consciencization (conscientisaçao). In the 1980s, movements inspired by Popular Education played an important role in progressive political struggles and resistance against authoritarian governments in Latin America 202. The actual term “empowerment” first achieved wide usage in the women’s movement, which drew inspiration from Freire’s work. Luttrell and colleagues argue that, in contrast to other progressive intellectual currents dominated by voices from the global north, groundbreaking work on empowerment and gender emerged from the south, for example through the movement of Development Alternatives from  Women  from a New Era (DAWN), which shaped grassroots analysis and strategies for women challenging inequalities 90. Subsequently, notions of collective empowerment became central to the liberation movements of ethnic minorities, including indigenous groups in Latin America and African- Americans in the United States.

During the 1990s, the association between empowerment and progressive politics tended to break down. In the context of neoliberal economic and social policies and the rolling-back of the state, “notions of participation and empowerment, previously reserved to social movements and NGOs, were reformulated and became a central part of the mainstream discourse” 90; a substantially depoliticized model of empowerment emerged. Whereas it was linked to progressive political agendas, empowerment now came increasingly to appear as a substitute for political change. During this same period, the vocabulary of empowerment was being adopted by mainstream international development agencies, including the World Bank. Thus, empowerment came to suffer ambiguities similar to those surrounding social capital 90. Today, critics argue that the embrace of empowerment by leading development actors has not led to any meaningful changes in development practice. Some critiques go further to suggest that the use of the term allows organisations to say they are “tackling injustice without having to back any political or structural change, or the redistribution of resources” (Fiedrich et al., 2003) 90.

In contrast to this depoliticized understanding, we follow recent critics in adopting a political model of the meaning and practice of empowerment. Empowerment, as we understand it, is inseparably linked to marginalized and dominated communities gaining effective control over the political and economic processes that affect their well-being. Like these critics, we value participation but question whether participation alone can  be considered genuinely empowering, without attention to outcomes, namely, the redistribution of resources and power over political processes. We endorse the call to “mov[e] beyond mere participation in decision-making to an  emphasis on control” 90. Indeed, the increased ability of oppressed and marginalized communities to control key processes that affect their lives is the essence of empowerment as we understand it. Their capacity to promote such control should be a significant criterion in evaluating policies on the social determinants of health.

A framework originally developed by Longwe 203 provides a useful way of distinguishing among different levels of empowerment, while also suggesting the step-wise, progressive nature of empowerment processes. The framework describes the following levels:

  • The welfare level: where basic needs are satisfied. This does not necessarily require structural causes to be addressed and tends to assume that those involved are passive recipients.
  • The access level: where equal access to education, land and credit is
  • The conscientisation and awareness-raising level: where structural and institutional discrimination is
  • The participation and mobilisation level: where the equal taking of decisions is enabled.
  • The control level: where individuals can make decisions and are fully recognized and

This framework stresses the importance of gaining of control over decisions and resources that determine the quality of one’s life and suggests that “lower” degrees of empowerment are a pre-requisite for achieving higher ones .

Importantly, the empowerment of disadvantaged communities, as we understand it, is inseparably intertwined with principles of state responsibility. This point has fundamental implications for policy-making on SDH. The empowerment of marginalized communities is not a psychological process unfolding in a private sphere separate from politics. Empowerment happens in ongoing engagement with the political, and the deepening of that engagement is an indicator that empowerment is real. The state bears responsibility for creating spaces and conditions of participation that can enable vulnerable and marginalized communities to achieve increased control over the material, social and political determinants of their own well-being. Addressing this concern defines a crucial direction for policy action on health equity. It also suggests how the policy-making process itself, structured in the right way, might open space for the progressive reinforcement of vulnerable people’s collective capacity to control the factors that shape their opportunities for health.

6.3.4         Diagram summarizing key policy directions and entry points

The diagram below summarizes the main ideas presented in the preceding sections and attempts to clarify their relationships via a visual representation. It recalls that the Commission’s broad aim, politically speaking, is to promote context-specific strategies to address structural, as well as intermediary determinants. Such strategies will necessarily include intersectoral policies, through which structural determinants can be most effectively addressed, and will aim to ensure that policies are crafted so as to engage and ultimately empower civil society and affected communities. These broad directions for policy action can utilize various entry points or levels of engagement, represented in the image by the cross-cutting horizontal bars.

Moving from the lower to the higher bars (from more “downstream” to more structural approaches), these entry points include: seeking to palliate the differential consequences of illness; seeking to reduce differential vulnerabilities and exposures for disadvantaged social groups; and, ultimately, altering the patterns of social stratification. At the same time, policies and interventions can be targeted at the “micro” level of individual interactions; at the “meso” level of community conditions; or at the broadest “macro” level of universal public policies and the global environment.

Figure 7. Framework for tackling SDH inequities

fi67.png

The CSDH and policy partners must also be concerned with an additional set of issues relevant to all these types of policies (summarized in the box at the lower right): monitoring of the effects of policies and interventions on health equity and determinants; assembling and disseminating evidence of effective interventions, including intersectoral strategies; and advocating for the incorporation of health equity as a goal into the formulation and evaluation of health and all social policies (covering the areas labelled “public” and “social” policies identified in the conceptual framework).

As Stewart-Brown 204 points out, to date, public health research has focused more on the impact of social inequalities than on their causes, or a fortiori on realistic political strategies to address underlying causes. Studies of interventions to mitigate the impact of social inequalities have tended to focus on methods of reducing the level of disease at the lower end of the income distribution. The application of public health theory, however, suggests that the causes of social inequalities are likely to lie as much with the attributes of high-income groups as with those of low-income groups 204. This insight sharpens our sense of the political challenges. Solutions such as redistribution of income that may appear simple in the abstract are anything but simple to achieve in reality.

Fundamental to formulating effective policy in this area is the vexed problem of universal vs. targeted approaches. Thandika Mkandawire, while director of the United Nations Research Institute for Social Development, summarized the issue as follows 205:

“For much of its history, social policy has involved choices about whether the core principle behind social provisioning will be ‘universalism’ or selectivity through ‘targeting’. Under ‘universalism’ the entire population is the beneficiary of social benefits as a basic right; while under ‘targeting’, eligibility to social benefits involves some kind of means-testing to determine the “truly deserving”. Policy regimes are hardly ever purely universal or purely based on targeting, however; they tend to lie somewhere between the two extremes on a continuum and are often hybrid, but where they lie on this continuum can be decisive in spelling out individuals’ life chances and in characterizing the social order.” 205

He continues: “Each of the core concerns of social policy—need, deserts and citizenship—are social constructs that derive full meaning from the cultural and ideological definition of ‘deserving poor’, ‘entitlement’ and ‘citizens’ rights’. Although in current parlance, the choice between targeting and universalism is couched in the language of efficient allocation of resources subject to budget constraints and the exigencies of globalization, what is actually at stake is the fundamental question about a polity’s values and its responsibilities to all its members. The technical nature of the argument cannot conceal the fact that, ultimately, value judgments matter not only with respect to determining the needy and how they are perceived, but also in attaching weights to the types of costs and benefits of approaches chosen. Such a weighting is often reflective of one’s ideological predisposition. In addition, societies chose either targeting or universalism in conjunction with other policies that are ideologically compatible with the choice, and that are deemed constitutive of the desired social and economic policy regime” 205.

Mkandawire highlights the contradictions of dominant approaches: “One remarkable feature of the debate on universalism and targeting is the disjuncture between an unrelenting argumentation for targeting, and a stubborn slew of empirical evidence suggesting that targeting is not effective in addressing issues of poverty (as broadly understood). Many studies clearly show that identifying the poor with the precision suggested in the theoretical models involves extremely high administrative costs and an administrative sophistication and capacity that may simply not exist in developing countries. An interesting phenomenon is that while the international goals are stated in international conferences, in universalistic terms (such as ‘education for all’ and ‘primary health care for all’), the means for reaching them are highly selective and targeted. The need to create institutions appropriate for targeting has, in many cases, undermined the capacity to provide universal services. Social policies not only define the boundaries of social communities and the position of individuals in the social order of things, but also affect people’s access to material well- being and social status. This follows from the very process of setting eligibility criteria for benefits and rights. The choice between universalism and targeting is therefore not merely a technical one dictated by the need for optimal allocation of limited resources. Furthermore, it is necessary to consider the kind of political coalitions that would be expected to make such policies politically sustainable. Consequently, there is a lot of reinvention of the wheel, and wasteful and socially costly experimentation with ideas that have been clearly demonstrated to be the wrong ones for the countries in which they are being imposed. There is ample evidence of poor countries that have significantly reduced poverty through universalistic approaches to social provision, and from whose experiences much can be learnt (Ghai 1999; Mehrotra and Jolly 1997a, 1997b). Although we have posed the issue in what Atkinson calls ‘gladiator terms’, in reality most governments tend to have a mixture of both universal and targeted social policies. However, in the more successful countries, overall social policy itself has been universalistic, and targeting has been used as simply one instrument for making universalism effective; this is what Theda Skocpol has referred as ‘targeting within universalism’, in which extra benefits are directed to low-income groups within the context of a universal policy design (Skocpol 1990) and involves the fine-tuning of what are fundamentally universalist policies” 205.

We now present a summary of examples of SDH interventions, organized according to the framework for action developed in this paper. This summary draws, among other sources, on the policy measures discussed in the Norwegian Health Directorate’s 2005 publication named The Challenge of the Gradient 139.

Table 3. Examples of SDH interventions

Entry Point Strategies
Universal Selective
Social Stratification: Policies to reduce inequalities and mitigate effects of stratification.
  • Active policies to reduce income inequality through taxes and subsidized public  services.
  • Free and universal services such as health, education, and public  transport.
  • Active labour market policies to secure jobs with adequate payment. Labour intensive growth strategies.
  • Social redistribution policies and improved mechanisms for resource allocation in health care and other social sectors.
  • Promote equal opportunities for women and gender equity.
  • Promote the development and strengthening of autonomous social movements.
  • Social security schemes for specific population groups in disadvantaged positions.
  • Child welfare measures: Implement Early Child Development programmes including the provision of nutritional supplements, regular monitoring of child development by health staff. Promotion of cognitive development of children at pre- schooling age. Promote pre-school development.
Exposure: Policies to reduce exposure of disadvantaged people to health damaging factors.
  • Healthy and safe physical neighbourhood environments. Guaranteed access to basic neighbourhood services.
  • Healthy and safe physical and social living environments. Access to water and sanitation.
  • Healthy and safe working environments.
  • Policies for health promotion and healthy lifestyle (e.g. smoking cessation, alcohol consumption, healthy eating and others).
  • Policies and programs to address exposures for specific disadvantaged groups at risk (cooking fuels, heating, etc).
  • Policies on subsidized housing for disadvantaged people.
Vulnerability: Policies to reduce vulnerability of specific groups.
  • Employment insurance and social protection policies for the unemployed.
  • Social protection policies for single mothers and programs for access to work and education opportunities.
  • Policies and support for the creation and development of social networks in order to increase community empowerment.
  • Extra support for students from less privileged families facilitating their transition from school to work.
  • Free healthy school lunches.
  • Additional access and support for health promotion activities.
  • Income generation, employment generation activities through cash benefits or cash transfers.
Unequal Consequences: Policies to reduce the unequal consequences of social, economic, and ill-health for disadvantaged people.
  • Equitable health care financing and protection from impoverishment for people affected by catastrophic illness.
  • Support workforce reintegration of people affected by catastrophic or chronic illness.
  • Active labour policies for incapacitated people.
  • Social and income protection for people affected with chronic illness and injuries.
  • Additional care and support for disadvantaged patients affected by chronic, catastrophic illness and injuries.
  • Additional resources for rehabilitation programs for disadvantaged people.

Key messages of this section:

  • Three broad approaches to reducing health inequities can be identified, based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population.
  • A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other.
  • Policy development frameworks, including those from Stronks et al. and Diderichsen, can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups.
  • The CSDH framework suggests a number of broad directions for policy action. We highlight three:
    • Context-specific strategies to tackle both structural and intermediary determinants
    • Intersectoral action
    • Social participation and
  • SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science.
  • Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle underlying structural determinants through addressing structural mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. These mechanisms are rooted in the key institutions and policies of the socioeconomic and political context.
  • To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches. A key task for the CSDH will be: (1) to identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and (2) to characterize in detail the political and management mechanisms that have enabled effective intersectoral policy-making and programmes to function sustainably.
  • Participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward after the Commission has completed its work.

7  Conclusion

This paper has sought to clarify shared understandings around a series of foundational questions. The architects of the CSDH gave it the mission of helping to reduce health inequities, understood as avoidable or remediable health differences among population groups defined socially, economically, demographically or geographically. Getting to grips with this mission requires finding answers to three basic problems:

  1. If we trace health differences among social groups back to their deepest roots, where do they originate?
  2. What pathways lead from root causes to the stark differences in health status observed at the population level?
  3. In light of the answers to the first two questions, where and how should we intervene to reduce health inequities?

The framework presented in these pages has been developed to provide responses to these questions and to buttress those responses with solid evidence, canvassing a range of views among theorists, researchers and practitioners in the field of SDH and other relevant disciplines. To the first question, on the origins of health inequities, we have answered as follows. The root causes of health inequities are to be found in the social, economic and political mechanisms that give rise to a set of hierarchically ordered socioeconomic positions within society, whereby groups are stratified according to income, education, occupation, gender, race/ethnicity and other factors. The fundamental mechanisms that produce and maintain (but that can also reduce or mitigate effect) this stratification include: governance; the education system; labour market structures; and redistributive welfare state policies (or their absence). We have referred to the component factors of socioeconomic position as structural determinants. Structural determinants, include the features of the socioeconomic and political context that mediate their impact, and constitute the social determinants of health inequities. The structural mechanisms that shape social hierarchies, according to key stratifiers, are the root cause of health inequities.

Our answer to the second question, about pathways from root causes to observed inequities in health, was elaborated by tracing how the underlying social determinants of health inequities operate through a set of what we call intermediary determinants of health to shape health outcomes. The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant. We argued that the important complex of phenomena toward which the unsatisfactory term “social capital” directs our attention cannot be classified definitively under the headings of either structural or intermediary determinants of health. “Social capital” cuts across the structural and intermediary dimensions, with features that link it to both. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors.

This paper provides only a partial answer to the third and most important question: what we should do to reduce health inequities. The Commission’s final report will bring a robust set of responses to this problem. However, we believe the principles sketched here to be of importance in suggesting directions for action to improve health equity. We derive three key policy orientations from the CSDH framework:

  1. Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies crafted to tackle structural determinants. In conventional usage, the term “social determinants of health” has often encompassed only intermediary determinants. However, interventions addressing intermediary determinants can improve average health indicators while leaving health inequities unchanged. For this reason, policy action on structural determinants is necessary. To achieve solid results, SDH policies must be designed with attention to contextual specificities; this should be rigorously characterized using methodologies developed by social and political science.
  2. Intersectoral policy-making and implementation are crucial for progress on SDH. This is because structural determinants can only be tackled through strategies that reach beyond the health sector. Key tasks for the CSDH will be to: (1) identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and (2) characterize in detail the political and management mechanisms that have enabled effective intersectoral policy- making and programmes to function sustainably.
  3. Participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Social participation is an ethical obligation for the CSDH and its partner governments. Moreover, the empowerment of civil society and communities and their  ownership of the SDH agenda is the best way to build a sustained global movement for health equity that will continue after the Commission completes its work.

The broad policy directions mapped by this framework are empty unless translated into concrete action. To be effective, however, action in the complex field of health inequities must be guided by careful theoretical analysis grounded in explicit value commitments. The framework offered here proposes basic conceptual foundations for the Commission’s work in, we hope, a clear form, so that they can be subjected to examination and reasoned debate.


List of abbreviations

CSDH               Commission on Social Determinants of Health

SDH                  Social determinants of health

UNDP               United Nations Development Programme

SEP                    Socioeconomic position


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