 How to look for a more comprehensive perspective on SDH
An integrated and strategic framework for SDH actions adopts social position as the key concept whereby health inequity mechanisms are interpreted as the causes of power, wealth and risk distribution, stratifying health outcomes.
From this integrated perspective, the following determinants can be identified:
 Structural determinants defined by social stratification and its sustenance mechanisms.
Intermediary determinants, related to specific social factors and circumstances.
Social stratification engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability, producing differential consequences of ill health for more and less vulnerable groups, including socioeconomic consecuences, as well as differential health outcomes per se.
The degree of social cohesion cuts across and concerns both structural and intermediary factors. The magnitude of the problem affects the socioeconomic and political context, having an impact on mortality and morbidity rates, while affecting economic and social growth.
An integrated and strategic approach to SDH involves considering:
Social stratification as a key factor for the understanding of SDH. This stratification gives rise to inequalities in power, prestige, income and wealth linked to different socioeconomic positions.
That the mechanisms that play a role in stratifying health outcomes operate in the following manner
Social contexts, which assign individual and groups to different social positions, creating and maintaining hierarchies. Such contexts include the labor market, the educational system, political institutions, and social and cultural values.
Differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability according to the population group involved.
Differential consequences of ill health for more and less advantaged groups.
Based on these determinants and structural mechanisms, intermediary determinants develop and operate contributing to the creation of specific situations that shape health outcomes
Material circumstances, such as housing quality, access to food and physical environment.
Psycho-social circumstances, involving social stressors (e.g. strain, violence, coercion), gender and ethnic conflicts and changes in or imitation of behavioral patterns and lifestyles vis-à-vis other groups or cultural contexts.
Biological and behavioral factors, such as nutritional patterns, physical activity, alcohol consumption, and smoking, and genetic factors
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Not to be forgotten, no matter how complex it might be!
In order to build an integrated and strategic approach it is important, first of all, to consider that any serious effort to reduce health inequities will involve changing the distribution of power within society to the benefit of disadvantaged groups, and changes can take place at various levels. Action on the SDH is a political process that engages both the agency of disadvantaged communities and the responsibility of the State, based on collective action. 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.
Implications for policy-making and policy actions:
The analysis of these factors leads us to the need of:
Overcoming depoliticized approaches regarding the role of the State in promoting equity.
Generate intersectoral actions to fight the deepest roots of differential vulnerability and exposure to risks.
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A relevant social determinant of health that cannot be ignored!
Health systems have often not received adequate attention as a SDH.
Much research on health policies has focused its attention on ways to address health problems, mainly on remedial actions and instruments for improving health service efficiency. On the other hand, considerable public health research works mainly draws attention to actions aimed at preventing disease among high-risk groups, prioritizing individual actions concerning lifestyles. Furthermore, within SDH literature, several SDH analytical models have focused on the role played by the organization of health systems in improving health equity. The Final Report of the Health Systems Knowledge Networks* deals specifically with this issue and states that health systems are the result of social and political processes. Consequently, health systems are socially determined and are, in fact, a social determinant of health. The organization and values of any health system may affect people, their exposure and vulnerability. If properly designed, health systems may address the problem of differential exposure and vulnerability among population groups, by improving equity of access, promoting intersectoral actions, encouraging communities to participate in decision-making processes or adopting innovative health-related public policies, among other actions.
Primary health care (PHC) and a focus on the SDH have much in common. Both concepts prioritize the importance of health equity and social justice. PHC is an approach to organizing health systems and broader society with the aim of achieving health equity (as reflected in the “Health for All” target of the Alma-Ata Declaration). SDH provide an analysis of why health inequities exist which encompasses the whole of society. Reducing health inequities provides the most compelling argument for both PHC and for action on SDH. PHC and SDH also share a broad view of health as a human right that traces its roots to the 1948 WHO Constitution. Both concepts place a strong emphasis on health promotion and prevention, and on increasing the ability of people to access the resources required to stay healthy and protect themselves from disease and illness.
PHC and SDH also both focus on the role of communities in ensuring health. PHC emphasizes the importance of health services responding to community need and facilitating community participation -in both service provision and health policy-making. The SDH analysis considers the impact on health of community factors such as social inclusion and exclusion, relative social status and community resiliency and support. Action on the SDH also requires empowerment of marginalized communities and governance structures that genuinely allow a voice for all.
As a result, implementing both PHC and action on SDH requires a strong focus on intersectoral action for health -policies and initiatives beyond the health sector that are required to protect and promote health. Intersectoral action was a key principle of the Alma Ata Declaration, and has been reconfigured more recently as “health in all policies” in the European region. PHC thus recognizes that the health sector is not the only contributor to improving health. The SDH discourse clearly shows how most health inequities are not caused by a lack of access to health services, but by the influence of inequities in other sectors such as housing, occupation, education or income. Action on the SDH thus involves the whole of society, with the health sector being only a single, but important focus, among many other sectors where action is required if health inequities are to be reduced.
In conclusion, PHC needs to be informed by an analysis of SDH and guide action on SDH to achieve its aims of health equity. This requires public policies across all sectors that act on SDH with the specific aim of promoting and protecting health. Furthermore, under a PHC approach, health systems need to be informed and champion action on SDH across the whole of society, while also promoting social participation in policy-making to protect health. |
New Life for Primary Health Care: the Social Determinants of Health | ppt
*Health System Knowledge Network (2007), WHO/CSDH http://www.who.int/social_determinants/en
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