Some Conclusions that may be Drawn from the Work Undertaken by the CSDH
(Text by Hernán Sandoval, a Commissioner from Chile Participating in the CSDH Workshop)

The conceptual progress made is as significant as the progress made in the search for mechanisms to put the knowledge available in this field into practice. Achievements to date may be summarized in a few basic documents. The Final Report and Recommendations; the interim statement, accounting for the CDSH’s global vision; the Conceptual Framework for Action, presenting past trajectories and experiences; the reports by the Knowledge Networks and the Civil Society Report. Without prejudice to the valuable information contained therein, the CDSH’s evolution enables us to conclude that:

1. First, there is an implicit starting point representing a particular view of the content and scope of public health actions today. Deep down, this option emerges from the wish to re-found public health as a space for socio-political action rather than as an academic discipline or administrative structure.

2. Second, there is a clear and definitive ethical option that consists in taking social justice to the foreground of health actions, which is expressed in the design of the project as an attempt to improve the population’s health by closing the equity gap, trying to reduce the impact of negative factors, i.e. those contributing to an increased incidence of some diseases among disadvantaged groups vis-à-vis other sectors in society, and by implementing both health and non-health actions. This ethical vision is of the highest relevance, since it shifts the focus of attention and redirects it to where it should always have been, i.e. to the creation of equal opportunities for all members of society through the elimination of social and economic barriers that prevent them from attaining the same health outcomes. The title of the interim statement “Achieving Health Equity: from Root Causes to Fair Outcomes,” reiterates and ratifies the option held from the very beginning: the focus is on ethics together with a social justice imperative. This involves confronting economicist and management-oriented approaches that currently prevail in Public Health. This option also entails bypassing the discussion brought up after the Alma-Ata Declaration, when a reductionist and technocratic approach turned primary health care into a selective process concerned with enhancing efficiency in the application of some techniques of well-known impact, departing from the emphasis placed by Alma-Ata on social development.

3. The third basic aspect is that identifying “social determinants of health” and acting upon them involves adopting a decision as to the way to both study the impact of such social factors and prevent their negative effects. This entails a significant methodological change for two reasons:

Because gaps in health outcomes across social groups —at least measured in terms of life expectancy and disabilities— become more important than average health outcomes at the population level; consequently, new instruments for measuring such differences effectively and relating them with their original causes are required;
Because in the analysis priority is given to how factors interact between one another and with the population dynamics variables, rather than to how much we know about the way in which each factor operates in isolation. Methodologically speaking, rather than dealing with individual, isolated actions, we must tackle the interaction of these factors.

The fourth aspect, representing a deliberate option, refers to the operational dimension, i.e. we may have the ethical vision already described and a new methodological approach, but all this will not be possible in practice unless governments engage in the reorganization of the legal, administrative and financial institutionalization of public health. This is aimed at recovering the ethical vision and original mission of public health: to preserve health and keep the population healthy, in social and environmental contexts that favor well-being and a better quality of life. This contradicts the currently prevailing trend in public health, which focuses in managing  medical care systems to cure diseases, which is an insufficient and particularly inequitable approach to meet the needs of the population in the 21st century, regardless of the development achieved by a society or country, but which keeps a huge business running in the whole world, amounting to USD 8,2 billion, according to the World Health Report by the WHO. This is a clash of interests seeking to keep the status quo.

Promoting a radical change in the conceptualization of public health and especially in its practice creates an active resistance by social groups such as professionals and public health workers, but in particular by financial interests, such as health insurance and big companies of the health sector: private medical care systems, pharmaceutical laboratories, etc. —what Ivan Illich used to call the “industrial-medical complex” almost thirty years ago. Moreover, politicians will react with indifference and incredulity, since they doubt even of the possibility of introducing any change or of the use of change. It is important to clearly state that in order to make the SDH action approach come true, it is necessary to create institutions that adopt this approach and also put it into practice.

This methodological change represents a departure from the sectoral and compartmentalized view of reality and consequently an attempt at overcoming sectoral barriers. This imposes modesty on public health professionals and organic structures and a broad disposition to incorporate other disciplines or viewpoints to their daily tasks. This also implies that governments should be capable of understanding and recognizing that health is not a matter of medical care but is concerned with living conditions and that equity in health results from comprehensive social policies and a better social cohesion. Inclusive societies, welcoming all its members and creating opportunities for them, are more equitable and show better health outcomes. Health is the result of life in society. This is why equity in health is both a goal and a means. It is a goal because it should be understood as social justice, and it is a means because showing equity gaps enables us to clearly locate —in the groups concerned— where there is unfair distribution and thus where the true cause lies. It should be noted how important it is to show health equity gaps across social groups and geographical areas, since this helps identify the factors that produce and maintain them, and design strategies for overcoming them.

The main purpose of the Commission is to foster a change of direction at the regulatory level and to make recommendations so that current knowledge about public health becomes actual international and national policies that may be put into practice for the sake of equity. To this end, the Commission is supported by expert networks in charge of gathering evidence of the main social factors that have a negative impact on health and of policies and actions designed to counteract SDH. The WHO Secretariat, advised by the Commission, will work closely together with a pilot group of countries whose political leaders and health officials, along with their civil societies and stakeholders in general, are strongly willing to implement immediate actions on SDH.

Based on the systematic and expert analysis of SDH information and their impact on the health of the population, the Commission has recommended some priorities to guide public policies, programs and concrete actions aimed at attaining the following.