The Commission on Social Determinants of Health (27) set out three main principles for action.
• Improve the conditions of daily life – the circumstances in which people are born, grow, live, work and age.
• Tackle the inequitable distribution of power, money and resources – the structural drivers of the conditions of daily life – globally, nationally and locally.
• measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health and raise public awareness about the social determinants of health.
Addressing political, social, economic and institutional environments is vital for advancing the health of the population. Intersectoral policies are both necessary and indispensable. Whole-of-government responsibility for health requires that the entire government at all levels of responsibility fundamentally considers effects on health in developing all regulatory and social and economic policies (41).
Health and well-being can be significantly improved when countries, regions and cities set common objectives and carry out joint investment by health and other sectors. Priority areas include educational performance, employment and working conditions, social protection and reducing poverty. Approaches include addressing community resilience, social inclusion and cohesion and promoting assets for well-being, that is, the individual and community strengths that protect and promote health, such as individual skills and a sense of belonging. Setting year-on-year targets or reducing health inequalities can help drive action, as one of the main ways of assessing health development at all levels. Action must be both systematic and sustained.
Addressing social inequalities contributes substantially to health and well-being. Reducing health gradients requires a comprehensive policy goal of equalizing health chances across socioeconomic groups, including remedying importance of adopting strategic approaches that assess challenges from a whole-system perspective.
It does this by recognizing that the various determinants of health are interrelated, with a mix of biophysical, psychological, social and environment factors all being important. This reinforces the importance of developing multifaceted strategies that avoid a one-off or isolated campaigns approach and instead seek to mobilize action across a range of areas to achieve a combined synergistic effect on the challenges being addressed.
The classic and well-known model shown below (Fig. 1) helps to illustrate the interrelationships between the different determinants of health, recognizing that it is important to consider both the factors that directly influence individual and community behaviour and the important wider social determinants. The social determinants are especially important to address because not only can they directly influence health (such as the effects of poor housing or sanitation) but, importantly, they also influence the genuine options and choices people have, their life chances and circumstances, which in turn affect their personal decisions and choices and lifestyles.
Adapted from Dahlgren & Whitehead (40).
Fig. 1. The interacting determinants of health
health disadvantage and narrowing health gaps. Action to reduce these inequities will touch all those affected if it is applied universally across society.
universal social protection will reduce poverty and have greater effects on people in need than narrowly targeted programmes. nevertheless, inequity will only be reduced cost-effectively if the intensity of the action taken is proportionate to the needs of each individual or group in society. In this context, needs means the health and social problems that are amenable to action by reasonable means that are known to be effective. With this approach, action is greatest in addressing the needs of the most deprived and vulnerable people but is not delivered exclusively to them.
Taking action on the social and environmental determinants of health can effectively address many types of inequalities in health. Inequities in health cannot be reduced without addressing inequities in the causes of ill health – the conditions of daily life and the distribution of power, money and resources.
These are reflected, for example, in gender and other social inequities, unequal exposure to harm and differential levels of resilience and unfairness in the immediate, visible circumstances of people’s lives – their access to health care, schools and education, their conditions of work and leisure, their homes, communities, towns and cities – and their chances of leading a flourishing, healthy life (8,27,42,43). Addressing these inequities means that everyone should have a minimum standard of healthy living, based on the material conditions that ensure a decent life and a good start in life (universal access to high-quality early-years development, education and employment); and empowerment – that is control over one’s life, a political voice and the ability
to participate in decision-making processes. Fully realizing these human rights is critical for improving health and reducing inequity, and member States have an obligation to respect, protect and fulfil them (27,44,45).
Action should be taken on a universal basis but, given the social gradient in health, delivered with an intensity that relates to social and health needs – proportionate universalism (46). Reducing the socioeconomic gradient and the overall health gap within a given population requires that health improve at a faster rate in the lowest socioeconomic groups than in the highest ones.
Accordingly, addressing the social gradient requires efforts not only targeting the most vulnerable people. The gradient approach implies a combination of broad universal measures with strategies targeted at high-risk groups. An approach targeting only disadvantaged groups would not alter the distribution of the determinants of health across the whole socioeconomic spectrum.
A statement of the action that is needed globally was summarized in the World Health Assembly’s 2009 resolution WHA62.14 on reducing health inequities through action on the social determinants of health (47). The recent World Conference on Social Determinants of Health held in Rio de Janeiro, Brazil also adopted a statement of the action needed globally (8), yet real change will require more than declarations alone, even when they are backed by powerful evidence and good will. As follow-up to the World Health Assembly resolution and the Conference, a WHO strategy and global plan of action on the social determinants of health (2012–2017) is now being elaborated.
Addressing socially determined inequities in health requires strong political commitment, integrated action, a strong systems approach, effective and high-performing systems and policy coherence across a range of government policies, particularly, but not exclusively, health (48,49).
Taking an approach based on the social determinants of health is often contrasted with one based on opportunities, free will and personal responsibility for health, for example for health-determining behaviour. In practice, however, since analysis of high mortality rates (outcomes) shows that these result from the conditions in which people are born, grow, live, work and age, it is plainly difficult for individuals to take personal responsibility for their health without social action to create the conditions in which people can have control over their lives. In practice, the debate is not about whether reducing inequity in health outcomes is desirable but about what is avoidable by reasonable means (50). To be effective, the measures adopted need to command public and political support.
It is recommended that all 53 countries in the European Region establish clear strategies to redress the current patterns and magnitude of health inequities by taking strong action on the social determinants of health (Box 6), as part of a whole-system strategic approach, that balances measures focusing on individual and community behavioural factors. It is recognized that countries are at very different starting points in terms of health, health equity, and social and economic development. While this may limit what is feasible in the short term and the timescale for addressing specific issues, it should not affect the long-term aspirations of the strategy.
Box 6. Areas to be covered by strategies for reducing health inequities The areas covered by the strategies should include the following.
Life-course stage
Ensure adequate social and health protection for women, mothers-to-be and young families.
Provide universal high-quality and affordable early-years education and care system.
Eradicate exposure to unhealthy, unsafe work and strengthen measures to secure healthy workplaces and access to employment and high-quality work.
Take coherent effective intersectoral action to tackle inequalities at older ages, both to prevent and manage the development of chronic morbidity and to improve survival across the social gradient.
Wider society
Improve the level and distribution of social protection, according to need, in order to improve health and address health inequalities.
mobilize and ensure concerted efforts to reduce inequalities in the local determinants of health, through both co-creation and partnership with those affected, civil society and a range of civic partners.
Take action on socially excluded groups, building on and extending systems already in place for the wider society, with the aim of creating systems that are more sustainable, cohesive and inclusive.
Adopt a gender equity approach in order to understand and tackle socioeconomic and health inequities between men and women.
Broader context
use the system of taxes and transfers to promote equity. The proportion of the budget spent on health and social protection programmes should be increased for countries below the current Eu average.
Plan for the long term and safeguard the interests of future generations by identifying links between environmental, social and economic factors and all policies and practices.
Systems
governance for the social determinants of health and health equity requires greater coherence of action across all sectors (policies, investment and services) and stakeholders (public, private and voluntary) at all levels of government (transnational, national, regional and local).
The long-term nature of equitably preventing and treating ill health requires a comprehensive response, in order to achieve sustained and equitable change in preventing and treating ill health.
There should be regular reporting and public scrutiny of inequalities in health and their social determinants at all levels of governance, including at transnational, national, regional and local levels.