of the factors that shape the patterns and extent of health inequities in a country, including the nature and type of employment, housing, environmental conditions, income level, security, edu-cation and community resources, lie outside the direct control of health ministries. At the same time, many determinants of health equity and inequity are also priorities in other sectors, includ-ing educational performance, social inclusion, social cohesion, poverty reduction and commu-nity resilience and well-being. These determinants represent a meeting-point for common action among sectors that, if due attention is given to their distribution, will result in benefits for health and health equity.
many countries with long experience in tackling health inequity are moving to an approach based on sharing goals on the determinants of equity with other sectors and stakeholders. In these approaches, health equity is increasingly one of several indicators of progress. Health equity can be considered a guiding value system to promote benefits that accrue to multiple sectors and all of society in terms of social cohesion and quality of life. A key area for action in whole-of-government and whole-of-society approaches to health equity is new or strengthened instruments and mechanisms to promote equity of voice and perspectives in decision-making.
Good governance for health and well-being Governance for health in the 21st century
the rules and standards (the principles) that determine acceptable (that is, ethical) actions in the area of family and community or in terms of governance of society and interactions between communities and societies with different values and principles. values can be global and regional.
The notions of equal rights for all and that people should be treated with respect and dignity are important values that are endorsed virtually universally in principles such as civil and human rights. The epistemology of values such as equity, social justice and human rights is based on moral philosophy. The epistemology of evidence, however, is based on the philosophy of logic and science. According to mcQueen (in press), “These may be seen as very distinct traditions and ones that have often been at odds in European history.” However, in the knowledge society, values and evidence are two sides of the same coin, which influence each other. Whether inten-tionally or not, evidence and values are applied together; the dichotomy between scientific fact and social beliefs is not nearly as substantial as it is commonly held to be, nor are the two easy to separate.
In responding to uncertainty in policy-making, the tendency has been to rely solely on evidence, overlooking the ways in which social values shape evidence. For example, the precautionary prin-ciple represents a value system that overrides evidence (or the lack thereof) as the deciding fac-tor in managing risk. It states that, in the face of uncertainty, an innovation or action should be halted if there is a perceived risk for irreversible damage, whether or not there is scientific evi-dence for such risk. A belief in science is strongly held in European thought. science seeks clear explanations of what works and why. Insofar as medicine is seen as a science and public health as a science-driven field of work, these disciplines are held accountable to the rigour of scientific proof. The rise of accountability, framed in terms such as based medicine and evidence-based policy, runs almost parallel to the rise of such value concerns as equity and social justice in the world of health. mcQueen (in press) further explores the role of values in governance for health.
The precautionary principle was a response to environmental concerns and the convergence of public fear of the perceived risks of developments in the 1990s, such as genetically modified organisms, nuclear energy, ozone depletion and climate change, which collectively led to the concept of a risk society (beck, 1992). This concept catalysed the emergence of governance mechanisms perceived to ensure certainty by preventing or stalling the irreversible environmen-tal changes and social risks associated with emerging technologies. The precautionary principle changes the previously neutral position of science to one of a value system, such that, in the face of scientific uncertainty, “it is more responsible to accept the priority of fear over the predictions of hope in order to prevent potential irreversible damages” (Jonas, 1985; Özdemir & Knoppers, in press; Tallacchini, 2005).
The Institute of medicine (2011) suggests that health in all policies can be “seen as a manifesta-tion of the precaumanifesta-tionary principle: first do no harm to health through policies or laws enacted in other sectors of government”. It cites california’s clean Air Act as embodying this principle.
For example, the precautionary principle implies that the values used to govern should be scrutinized with a rigour equal to that with which evidence is sought and evaluated. Although the strong relation between social determinants and good public health have been known for
Good governance for health and well-being
decades, the report of the WHO commission on social Determinants of Health (2008) brought together this knowledge in a new way, supported by strong evidence. nevertheless, knowledge is not enough for effective action against the value-related causes of poor health. “The science of how effectively to change these causes is highly problematic and, in reality, significant changes in the attributable causes may imply political philosophies that are themselves tied to values that may not be in concert with those of the underlying values that relate to good health.” (mcQueen, in press). for example, behaviour changes are critical in actions to fight risk factors for noncom-municable diseases. Basic values such as freedom of choice are, however, inimical to some ac-tions for addressing determinants of health and influence the type of evidence and arguments that policy-makers of various political orientations are willing to accept.
A new discussion of values in governance for health is therefore essential. Ultimately, the age-old, false separation between science (such as evidence) and society (such as values) must be closed so that these two inseparable strands of knowledge can be interpreted and deliberated jointly. Good governance for health must be based on an expanded understanding of health, in which health is recognized as a core component of human rights, well-being, the global com-mons and social justice. With this understanding of good governance for health and recognition that the whole of government and society should take responsibility for good governance for health, a multistakeholder deliberation should be held to define universal values and guiding prin-ciples for health that transcend the existing ones. sandel (2010) argued that debating differing positions on how equity and justice should be understood and addressed will strengthen societ-ies. His call for politics of moral engagement fits well with the requirement for addressing the complex, diverse factors that shape decisions about the distribution of health and determinants of health.