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WORLD HEALTH ORGANIZATION

AVENUE APPIA

1211 GENEVA 27

SWITZERLAND

WWW.WHO.INT/SOCIAL_DETERMINANTS

Social Determinants of Hea

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SOCIAL DETERMINANTS OF HEALTH

ACCESS TO POWER, MONEY AND RESOURCES AND THE CONDITIONS OF DAILY LIFE —THE CIRCUMSTANCES IN WHICH PEOPLE ARE BORN, GROW, LIVE, WORK, AND AGE

A CONCEPTUAL FACTION ON THE SOF HEALTH

DEBATES, POLICY & PRAC

ISBN 978 92 4 150085 2

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World Health OrganizationGeneva

2010

A CONCEPTUAL

FRAMEWORK FORACTION ON THE SOCIALDETERMINANTS OFHEALTH

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Te Series:Te Discussion Paper Series on Social Determinants o Health provides a orum or sharing knowledge on how to tackle the socialdeterminants o health to improve health equity. Papers explore themes related to questions o strategy, governance, tools, andcapacity building. Tey aim to review country experiences with an eye to understanding practice, innovations, and encouragingrank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed.

Background:A first draf o this paper was prepared or the May 2005 meeting o the Commission on Social Determinants o Health held inCairo. In the course o discussions the members and the Chair o the CSDH contributed substantive insights and recommendedthe preparation o a revised draf, which was completed and submitted to the CSDH in 2007. Te authors o this paper are OrielleSolar and Alec Irwin.

Acknowledgments:Valuable input to the first draf o this document was provided by members o the CSDH Secretariat based at the ormer Departmento Equity, Poverty and Social Determinants o Health at WHO Headquarters in Geneva, in particular Jeanette Vega. In additionto the Chair and Commissioners o the CSDH, many colleagues offered valuable comments and suggestions in the course o therevision process. Tanks are due in particular to Joan Benach, Sharon Friel, anja Houweling, Ron Labonte, Carles Muntaner,ed Schrecker, and Sarah Simpson. Any errors are responsibility o the principal writers. Nicole Valentine edited the paper and

coordinated production.

Suggested Citation:Solar O, Irwin A. A conceptual ramework or action on the social determinants o health. Social Determinants o Health DiscussionPaper 2 (Policy and Practice). Geneva, World Health Organization, 2010.

WHO Library Cataloguing-in- Publication DataA conceptual ramework or action on the social determinants o health.

(Discussion Paper Series on Social Determinants o Health, 2)

1.Socioeconomic actors. 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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Printed by the WHO Document Production Services, Geneva, Switzerland.

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A conceptual framework for action on the social determinants of health

FOREWORD 3

EXECUTIVE SUMMARY 4

1. INTRODUCTION 9

2. HISTORICAL TRAJECTORY 10

3. DEFINING CORE VALUES: HEALTH EQUITY, HUMAN RIGHTS,

AND DISTRIBUTION OF POWER 12

4. PREVIOUS THEORIES AND MODELS 15

4.1 Current directions in SDH theory 15

4.2 Pathways and mechanisms through which SDH influence health 16

4.2.1 Social selection perspective 16

4.2.2 Social causation perspective 17

4.2.3 Lie course perspective 18

5. CSDH CONCEPTUAL FRAMEWORK 20

5.1 Purpose o constructing a ramework or the CSDH 20

5.2 Teories o power to guide action on social determinants 20

5.3 Relevance o the Diderichsen model or the CSDH ramework 23

5.4 First element o the CSDH ramework: socio-economic and political context 255.5 Second element: structural determinants and socioeconomic position 27

5.5.1 Income 30

5.5.2 Education 31

5.5.3 Occupation 32

5.5.4 Social Class 33

5.5.5 Gender 33

5.5.6 Race/ethnicity 34

5.5.7 Links and influence amid socio-political context and structural determinants 34

5.5.8 Diagram synthesizing the major aspects o the ramework shown thus ar 35

5.6 Tird element o the ramework: intermediary determinants 36 5.6.1 Material circumstances 37

Contents

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5.6.2 Social-environmental or psychosocial circumstances 38

5.6.3 Behavioral and biological actors. 39

5.6.4 Te health system as a social determinant o health. 39

5.6.5 Summarizing the section on intermediary determinants 40 5.6.6 A crosscutting determinant: social cohesion / social capital 41

5.7 Impact on equity in health and well-being 43

5.7.1 Impact along the gradient 43

5.7.2 Lie course perspective on the impact 44

5.7.3 Selection processes and health-related mobility 44

5.7.4 Impact on the socioeconomic and political context 44

5.8 Summary o the mechanisms and pathways represented in the ramework 44

5.9 Final orm o the CSDH conceptual ramework 48

6. POLICIES AND INTERVENTIONS 50

6.1 Gaps and gradients 50

6.2 Frameworks or policy analysis and decision-making 51

6.3 Key dimensions and directions or policy 53

6.3.1 Context strategies tackling structural and intermediary determinants 54

6.3.2 Intersectoral action 56

6.3.3 Social participation and empowerment 58

6.3.4 Diagram summarizing key policy directions and entry points 60

7. CONCLUSION 64

LIST OF ABBREVIATIONS 66

REFERENCES 67

LIST OF FIGURES

Figure A: Final orm o the CSDH conceptual ramework 6

Figure B: Framework or tackling SDH inequities 8

Figure 1: Model o the social production o disease 24Figure 2. Structural determinants: the social determinants o health inequities 35

Figure 3: Intermediary determinants o health 41

Figure 4: Summary o the mechanisms and pathways represented in the ramework 46

Figure 5: Final orm o the CSDH conceptual ramework 48

Figure 6: ypology o entry points or policy action on SDH 53

Figure 7: Framework or tackling SDH inequities 60

LIST OF TABLES

able 1: Explanations or the relationship between income inequality and health 31

able 2: Social inequalities affecting disadvantaged people 38

able 3: Examples o SDH interventions 62

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Foreword

C

onceptual rameworks in a public health context shall in the best o worlds serve two equallyimportant purposes: guide empirical work to enhance our understanding o determinants and

mechanisms and guide policy-making to illuminate entry points or interventions and policies.Effects o social determinants on population health and on health inequalities are characterized

by working through long causal chains o mediating actors. Many o these actors tend to clusteramong individuals living in underprivileged conditions and to interact with each other. Epidemiologyand biostatistics are thereore acing several new challenges o how to estimate these mechanisms. TeCommission on Social Determinants o Health made it perectly clear that policies or health equityinvolve very different sectors with very different core tasks and very different scientific traditions. Policiesor education, labour market, traffic and agriculture are not primarily put in place or health purposes.Conceptual rameworks shall not only make it clear which types o actions are needed to enhance their“side effects” on health, but also do it in such a way that these sectors with different scientific traditionsfind it relevant and useul.

Tis paper pursues an excellent and comprehensive discussion o conceptual rameworks or scienceand policy or health equity, and in so doing, takes the issue a long way urther.

Finn Diderichsen MD, PhDProessor, University o CopenhagenOctober, 2010

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C

omplexity defines health. Now, more than ever, in the age o globalization, is this so. TeCommission on Social Determinants o Health (CSDH) was set up by the World Health

Organization (WHO) to get to the heart o this complexity. Tey were tasked with summarizingthe evidence on how the structure o societies, through myriad social interactions, norms and

institutions, are affecting population health, and what governments and public health can do aboutit. o guide the Commission in its mammoth task, the WHO Secretariat conducted a review andsummary o different rameworks or understanding the social determinants o health. Tis review wassummarized and synthesized into a single conceptual ramework or action on the social determinantso health which was proposed to and, largely, accepted by, the CSDH or orienting their work. A keyaim o the ramework is to highlight the difference between levels o causation, distinguishing betweenthe mechanisms by which social hierarchies are created, and the conditions o daily lie which thenresult. Tis paper describes the review, how the proposed conceptual ramework was developed, andidentifies elements o policy directions or action implied by the proposed conceptual ramework andanalysis o policy approaches.

A key lesson rom history (including results rom the previous “historical” paper - see DiscussionPaper 1 in this Series), is that international health agendas have tended to oscillate between: a ocuson technology-based medical care and public health interventions, and an understanding o health asa social phenomenon, requiring more complex orms o intersectoral policy action. In this context,the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutionalcommitments to health equity and social justice.

Having health ramed as a social phenomenon emphasizes health as a topic o social justice more broadly.Consequently, health equity (described by the absence o unair and avoidable or remediable differencesin health among social groups) becomes a guiding criterion or principle. Moreover, the raming o social justice and health equity, points towards the adoption o related human rights rameworks as vehiclesor enabling the realization o health equity, wherein the state is the primary responsible duty bearer.

In spite o human rights having been interpreted in individualistic terms in some intellectual and legaltraditions, notably the Anglo-Saxon, the rameworks and instruments associated with human rightsguarantees are also able to orm the basis or ensuring the collective well-being o social groups. Havingbeen associated with historical struggles or solidarity and the empowerment o the deprived they orma powerul operational ramework or articulating the principle o health equity.

Theories on the social production of health and disease

With this general raming in mind, developing a conceptual ramework on social determinants o health(SDH) or the CSDH needs to take note o the specific theories o the social production o health. Treemain theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2)

social production o disease/political economy o health; and (3) eco-social rameworks.

Executive summary

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

A very persuasive account o how differences in social position account or health inequities is oundin the Diderichsen’s model o “the mechanisms o health inequality”. Didierichsen’s work identifies howthe ollowing mechanisms stratiy health outcomes:

∏ Social contexts, which includes the structure o society or the social relations in society, createsocial stratification and assign individuals to different social positions.

∏ Social stratification in turn engenders differential exposure to health-damaging conditionsand differential vulnerability , in terms o health conditions and material resource availability.

∏ Social stratification likewise determines differential consequences o ill health or more andless advantaged groups (including economic and social consequences, as well differential healthoutcomes per se).

Te role o social position in generating health inequities necessitates a central role or a urther twoconceptual clarifications. First, the central role o power. While classical conceptualizations o powerequate power with domination, these can also be complemented by alternative readings that emphasizemore positive, creative aspects o power, based on collective action as embodied in legal system class suits.In this context, human rights embody a demand on the part o oppressed and marginalized communitiesor the expression o their collective social power. Te central role o power in the understanding osocial pathways and mechanisms means that tackling the social determinants o health inequities is apolitical process that engages both the agency o disadvantaged communities and the responsibility othe state. Second, it is important to clariy the conceptual and practical distinction between the socialcauses o health and the social actors determining the distribution o these causes between more and lessadvantaged groups. Te CSDH ramework makes a point o making clear this distinction.

On this second point o clarification, conflating the social determinants o health and the social processesthat 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 actors (e.g. income and educational attainment) have also been associated withpersistent inequalities in the distribution o these actors across population groups. Furthermore, policyobjectives are defined quite differently, depending on whether the aim is to address determinants ohealth or determinants o health inequities.

The CSDH Conceptual Framework

Bringing these various elements together, the CSDH ramework, summarized in Figure A, shows howsocial, economic and political mechanisms give rise to a set o socioeconomic positions, whereby

populations are stratified according to income, education, occupation, gender, race/ethnicity and otheractors; these socioeconomic positions in turn shape specific determinants o health status (intermediarydeterminants) reflective o 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 “eed back” on a given individual’s social position, e.g. by compromising employmentopportunities and reducing income; certain epidemic diseases can similarly “eed back” to affect theunctioning o social, economic and political institutions.

“Context” is broadly defined to include all social and political mechanisms that generate, configure andmaintain social hierarchies, including: the labour market; the educational system, political institutionsand other cultural and societal values. Among the contextual actors that most powerully affect healthare the welare state and its redistributive policies (or the absence o such policies). In the CSDH

ramework, structural mechanisms are those that generate stratification and social class divisions inthe society and that define individual socioeconomic position within hierarchies o power, prestigeand access to resources. Structural mechanisms are rooted in the key institutions and processes o thesocioeconomic and political context.

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

ogether, context, structural mechanisms and the resultant socioeconomic position o individuals are“structural determinants” and in effect it is these determinants we reer to as the “social determinantso health inequities.” Te underlying social determinants o health inequities operate through a seto intermediary determinants o health to shape health outcomes. Te vocabulary o “structuraldeterminants” and “intermediary determinants” underscores the causal priority o the structural actors.Te main categories o intermediary determinants o health are: material circumstances; psychosocialcircumstances; behavioral and/or biological actors; and the health system itsel as a social determinant.

∏ Material circumstances include actors such as housing and neighborhood quality, consumptionpotential (e.g. the financial means to buy healthy ood, warm clothing, etc.), and the physicalwork environment.

∏ Psychosocial circumstances include psychosocial stressors, stressul living circumstances andrelationships, and social support and coping styles (or the lack thereo).

∏ Behavioral and biological actors include nutrition, physical activity, tobacco consumption and

alcohol consumption, which are distributed differently among different social groups. Biologicalactors also include genetic actors.

Te CSDH ramework departs rom many previous models by conceptualizing the health system itselas a social determinant o health (SDH). Te role o the health system becomes particularly relevantthrough the issue o access, which incorporates differences in exposure and vulnerability, and throughintersectoral action led rom within the health sector. Te health system plays an important role inmediating the differential consequences o illness in people’s lives.

Figure A. Final form of the CSDH conceptual framework

Governance

IMPACT ON

EQUITY IN

HEALTH

AND

WELL-BEING

Material Circumstances

(Living and Working,

Conditions, Food

Availability, etc. )

Behaviors and

Biological Factors

Psychosocial Factors

SOCIOECONOMIC

AND POLITICAL

CONTEXT

Culture and

Societal Values

Public Policies

Education, Health,Social Protection

Social PoliciesLabour Market,Housing, Land

MacroeconomicPolicies

STUCTURAL DETERMINANTS

SOCIAL DETERMINANTS OF

HEALTH INEQUITIES

Socioeconomic

Position

Social Class

Gender

Ethnicity (racism)

Education

Occupation

Income

Social Cohesion &Social Capital

INTERMEDIARY DETERMINANTS

SOCIAL DETERMINANTS

OF HEALTH

Health System

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Te concepts o social cohesion and social capital occupy a conspicuous (and contested) place indiscussions o SDH. Social capital cuts across the structural and intermediary dimensions, with eaturesthat link it to both. Yet ocus on social capital, depending on interpretation, risks reinorcing depoliticizedapproaches to public health and the SDH, when the political nature o the endeavour needs to be anexplicit part o any strategy to tackle the SDH. Certain interpretations have not depoliticized socialcapital, notably the notion o “linking social capital”, which have spurred new thinking on the role o thestate in promoting equity, wherein a key task or health politics is nurturing cooperative relationshipsbetween citizens and institutions. According to this literature, the state should take responsibility ordeveloping flexible systems that acilitate access and participation on the part o the citizens.

Policy action

Finally, in turning to policy action on SDH inequities, three broad approaches to reducing healthinequities can be identified. Tese may be based on: (1) targeted programmes or disadvantaged

populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing thesocial health gradient across the whole population. A consistent equity-based approach to SDH mustultimately lead to a gradients ocus. However, strategies based on tackling health disadvantage, healthgaps and gradients are not mutually exclusive. Tey can complement and build on each other.

Policy development rameworks can help analysts and policymakers to identiy levels o intervention andentry points or action on SDH, ranging rom policies tackling underlying structural determinants toapproaches ocused on the health system and reducing inequities in the consequences o ill health sufferedby different social groups. Te review showed the ramework that Diderichsen and colleagues proposed- atypology or mapping o entry points or policy action on SDH inequities - to be very useul in the wayit is very closely aligned to theories o causation. Tey identiy actions related to: social stratification;differential exposure/ differential vulnerability; differential consequences and macro social conditions.

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

Policy action challenges for the CSDH

Arguably the single most significant lesson o the CSDH conceptual ramework is that interventionsand policies to reduce health inequities must not limit themselves to intermediary determinants, butmust include policies specifically crafed to tackle the social mechanisms that systematically producean inequitable distribution o the determinants o health among population groups (see Figure B). otackle structural, as well as intermediary, determinants requires intersectoral policy approaches.

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Figure B. Framework for tackling SDH inequities

Key dimensions and directions for policy Context-specific

strategies tacklingboth structural and

intermediary

determinantsIntersectoral

Action

Social Participation

and Empowerment

Policies on stratification to reduce inequalities,

mitigate effects of stratification

Policies to reduce exposures of disadvantaged

people to health-damaging factors

Policies to reduce vulnerabilities of

disadvantaged people

Policies to reduce unequal consequences of

illness in social, economic and health terms

Monitoring and follow-up of health equity and SDH

Evidence on interventions to tackle social

determinants of health across government

Include health equity as a goal in health

policy and other social policies

Globalization

Environment

Macro Level:

Public Policies

Mesa Level:

Community

Micro Level:

Individual

interaction

A key task or the CSDH will be:1 to identiy successul examples o intersectoral action on SDH in jurisdictions with different

levels o resources and administrative capacity; and to characterize in detail the political andmanagement mechanisms that have enabled effective intersectoral programmes to unctionsustainably.

2 to demonstrate how participation o civil society and affected communities in the designand implementation o policies to address SDH is essential to success. Empowering socialparticipation provides both ethical legitimacy and a sustainable base to take the SDH agendaorward afer the Commission has completed its work.

3 Finally, SDH policies must be crafed with careul attention to contextual specificities, whichshould be rigorously characterized using methodologies developed by social and political science.

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O

n announcing his intention to create theCommission on Social Determinants

o Health (CSDH), World HealthOrganization (WHO) Director-General

Lee Jong-wook identiied the Commission aspart o a comprehensive effort to promote greaterequity in global health in a spirit o social justice 1.Te Commission’s goal, then, is to advance healthequity, driving action to reduce health differencesamong social groups, within and betweencountries. Getting to grips with this missionrequires finding answers to three undamentalproblems:1 Where do health differences among social

groups originate, i we trace them back totheir deepest roots?2 What pathways lead rom root causes

to the stark differences in health statusobserved at the population level?

3 In light o the answers to the first twoquestions, where and how should weintervene to reduce health inequities?

his paper seeks to make explicit a sharedunderstanding o these issues to orient the worko the CSDH. We recall the historical trajectory owhich the CSDH orms a part; and then we make

explicit the Commission’s undamental values,in particular the concept o health equity andthe commitment to human rights. We describethe broad outlines o current major theories onthe social determinants o health, and we reviewperspectives on the causal pathways that lead romsocial conditions to differential health outcomes.Aterwards a new ramework or analysis andaction on social determinants is presented as apotential contribution o the CSDH to publichealth - the “CSDH ramework”.

he CSDH conceptual ramework synthesizesmany elements rom previous models, yet we

believe it represents a meaningul advance. Weground the ramework in a theorization o socialpower and make clear our debt to the work oDiderichsen and colleagues. We present thecore components o the ramework, including:(1) socioeconomic and political context; (2)structural determinants o health inequities; and(3) intermediary determinants o health. Ouranswers to the first two questions above will bearticulated by way o these concepts. In the lastsection o the paper, we deduce key directions orpro-equity policy action based on the ramework,

providing broad elements o a response to thethird question.

An important definitional issue must be clarifiedin advance. Te CSDH has purposely adopted abroad initial definition o the social determinantso health (SDH). Te concept encompasses theull set o social conditions in which people liveand work, summarized in arlov’s phrase as“the social characteristics within which livingtakes place” 2. A broad initial definition o SDHis important in order not to oreclose ruitulavenues o investigation; however, within the

field encompassed by this concept, not all actorshave equal importance. Causal hierarchies will beascertained, leading to crucial distinctions 3. Mucho this paper will be concerned with clariyingthese distinctions and making explicit therelationships between underlying determinantso health inequities and the more immediatedeterminants o individual health.

1 Introduction

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H

ealth is a complex phenomenon, and itcan be approached rom many angles.

Over recent decades, internationalhealth agendas have tended to oscillate

between: (1) approaches relying on narrowlydefined, technology-based medical and publichealth interventions; and (2) an understanding ohealth as a social phenomenon, requiring morecomplex orms o intersectoral policy action,and sometimes linked to a broader social justiceagenda.

WHO’s 1948 Constitution clearly acknowledgesthe impact o social and political conditions

on health, and the need or collaboration withsectors such as agriculture, education, housingand social welare to achieve health gains. Duringthe 1950s and 1960s, however, WHO and otherglobal health actors emphasized technology-driven, ‘vertical’ campaigns targeting speciicdiseases, with little regard or social contexts 4.A social model o health was revived by the 1978Alma-Ata Declaration on Primary Health Careand the ensuing Health or All movement, whichreasserted the need to strengthen health equity byaddressing social conditions through intersectoralprogrammes 5.

Many governments embraced the principle ointersectoral action on SDH, under the banner oHealth or All; however, the neoliberal economicmodels that gained global ascendancy during the1980s created obstacles to policy action. In thehealth sector, neoliberal approaches mandatedmarket-oriented reorms that emphasizedeiciency over equity as a system goal andoten reduced disadvantaged social groups’access to health care services 6. On the level omacroeconomic policy, the structural adjustment

programmes (SAPs) imposed on many developingcountries by the international financial institutionsmandated sharp reductions in governments’ social

sector spending, constraining policy-makers’capacity to address SDH 7.

Even as these market-oriented reorms werebeing applied in both developing and developedcountries, new and more systematic analyses othe powerul impact o social conditions on healthbegan to emerge. A series o prominent studies,including those o McKeown and Illich, challengedthe dominant biomedical paradigm and debunkedthe idea that better medical care alone can generatemajor gains in population health 8,9,10,11,12. heUK’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 reducinghealth gaps between privileged and disadvantagedsocial groups in Britain would require ambitiousinterventions in sectors such as education, housingand social welare, in addition to improved clinicalcare 13.

Troughout the 1980s and early 1990s, the BlackReport sparked debates and inspired a serieso national inquiries into health inequities inother countries, e.g. the Netherlands, Spain andSweden. Te pervasive effects o social gradients

on health were progressively clarified, in particularby the Whitehall Studies o Comparative HealthOutcomes among British civil servants 14, 15.Important work at WHO’s European Office in theearly 1990s laid conceptual oundations or a newhealth equity agenda, and the vocabulary o SDHbegan to achieve wider dissemination 16, 17.

By the late 1990s and early 2000s, in responseto mounting documentation o the scope oinequities, and evidence that existing health andsocial policies had ailed to reduce equity gaps 3,16, 18, 19

, health equity and the social determinantso health had been embraced as explicit policyconcerns by a growing number o countries,

2 Historical trajectory

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particularly but not exclusively in Europe. In theUK, the arrival in 1997 o a Labour governmentexplicitly committed to reducing health inequalitiesocused resh attention on SDH. Australia andNew Zealand explored options or addressinghealth determinants, with New Zealand’s 2000health strategy reflecting a strong SDH ocus 20.In 2002, Sweden approved a new, determinants-oriented national public health strategy, arguablythe most comprehensive model o national policyaction on SDH. New policies ocused on tacklinghealth inequities were passed in England, Ireland,Italy, the Netherlands, Northern Ireland, Scotlandand Wales during this period 3. Meanwhile, indeveloping regions, including sub-SaharanArica, Asia, the Eastern Mediterranean and

Latin America, resurgent critical traditions allyinghealth and social justice agendas, such as the LatinAmerican social medicine movement, reinedtheir critiques o market-based, technology-drivenneoliberal health care models and called or actionto tackle the social roots o ill-health 21, 22, 23.

In 2003, Lee Jong-wook took office as Director-General o WHO, on a platorm marked by

commitments to health equity, social justice anda reinvigoration o the values o Health For All.Lee’s first announcement o his intention to createa Commission on Social Determinants o Health,at the 2004 World Health Assembly, positionedthe CSDH as a key component o his equityagenda. Lee welcomed rising global investmentsin health, but affirmed that “interventions aimedat reducing disease and saving lives succeed onlywhen they take the social determinants o healthadequately into account” 24. Lee charged theCommission to mobilize emerging knowledgeon social determinants in a orm that could beturned swifly into policy action in the low- andmiddle-income countries where needs are greatest.In his speech at the launch o the CSDH in Chile

in March 2005, Lee noted that the Commissionwould deliver its report in 2008 or the thirtiethanniversary o the Alma-Ata conerence and sixtyyears afer the ormal entry into orce o the WHOConstitution. He urged the Commission to carryorward the values that had inormed global publichealth in its most visionary moments, translatingthem into practical action or a new era.

Key messages from this section:

p Over recent decades, international health agendas have tended to oscillatebetween: (1) a focus on technology-based medical care and public healthinterventions; and (2) an understanding of health as a social phenomenon,requiring more complex forms of intersectoral policy action.

p The 1978 Declaration of Alma-Ata and the subsequent Health for All movementgave 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.

p The late 1990s and early 2000s witnessed mounting evidence on the failure ofexisting 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 andpractical approaches into effective policy action.

p 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 thirtiethanniversary of the Alma-Ata conference and sixty years after the WHOConstitution. He instructed the Commission to carry forward the values that haveinformed global public health in its most visionary moments, translating theminto practical action.

p The CSDH revives WHO constitutional commitments to health equity and socialjustice and reinvigorates the values of Health for All.

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Policy choices are guided by values, which maybe implicit or explicit. Te concept o healthequity is the explicit ethical oundation othe Commission’s work, while human rights

provide the ramework or social mobilization andpolitical leverage to advance the equity agenda.Realizing health equity requires empoweringpeople, particularly socially disadvantaged groups,to exercise increased collective control over theactors that shape their health.

WHO’s Secretariat (the (then) Department o Equity,

Poverty and Social Determinants o Health) definedhealth equity (also reerred to as socioeconomichealth equity) as “the absence o unair andavoidable or remediable differences in health amongpopulation groups defined socially, economically,demographically or geographically” 25. In essence,health inequities are health dierences that aresocially produced, systematic in their distributionacross the population, and unair 26. Identiying ahealth difference as inequitable is not an objectivedescription, but necessarily implies an appeal toethical norms 27.

Primary responsibility or protecting and enhancinghealth equity rests in the first instance with nationalgovernments. An important strand o contemporarymoral and political philosophy was built on thework o Amartya Sen to link the concepts ohealth equity and agency and to make explicit theimplications or just governance 28. Joining Sen,Anand stresses that health is a “special good” whoseequitable distribution merits the particular concerno political authorities. here are two principalreasons or regarding health as a special good: (1)health is directly constitutive o a person’s well-being;

and (2) health enables a person to unction as anagent 29. Inequalities in health are thus recognizedas “inequalities in people’s capability to unction”

which prooundly compromise reedom. When suchinequalities arise systematically as a consequence oan individual’s social position, governance has ailedin one o its prime responsibilities, i.e. ensuringair access to basic goods and opportunities thatcondition people’s reedom to choose among lie-plans they have reason to value 30. Ruger arguessimilarly or the importance o health equity as agoal o public policy, based on “the importanceo health or individual agency” 31. Nonetheless,the causal linkages between health and agency arenot uni-directional. Health is a prerequisite or ull

individual agency and reedom; yet at the same time,social conditions that provide people with greateragency and control over their work and lives areassociated with better health outcomes 32. One cansay that health enables agency, but greater agencyand reedom also yield better health. Te mutuallyreinorcing nature o this relationship has importantconsequences or policy-making.

Te international human rights ramework is theappropriate conceptual structure within which toadvance towards health equity through action onSDH. Te ramework is based on the 1948 Universal

Declaration o Human Rights (UDHR). Te UDHRholds that ‘Everyone has the right to a standard oliving adequate or the health and well-being ohimsel and his amily, including ood, clothing,housing and medical care and necessary socialservices’ (Art. 25) 33, and additionally that ‘Everyoneis entitled to a social and international order in whichthe rights and reedoms set orth in this Declarationcan be ully realized’ (Art. 28). Te human rightsaspects o health, and in particular connectionsbetween the right to health and social and economicconditions, were clarified in the 1966 International

Covenant on Economic, Social and Cultural Rights(ICESCR). In ICESCR Article 12, States signatoriesacknowledge “the right o everyone to the enjoyment

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

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KEY MESSAGES OF THIS SECTION:

p The guiding ethical principle for the CSDH is health equity, defined as theabsence of unfair and avoidable or remediable differences in health amongsocial groups.

p Primary responsibility for protecting health equity rests with governments.

p The international human rights framework is the appropriate conceptual andlegal structure within which to advance towards health equity through action onSDH.

p The realization of the human right to health implies the empowerment ofdeprived communities to exercise the greatest possible control over the factors

that determine their health.

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T

he CSDH does not begin in its conceptualwork in a vacuum. Te concepts presented

here build on the contributions o manyprior and contemporary analysts. In this

section, we first cite three important directionsemerging recently in social epidemiology theory.hen we review a number o perspectives onthe pathways through which social conditionsinluence health outcomes. hese discussionsuncover important elements to be included ina ramework or action or the CSDH. Finallywe highlight areas that previous theories havelef insufficiently clarified, and upon which, theproposed CSDH ramework can shed new light.

4.1 Current directions in SDHtheory

he three main theoretical directions invokedby current social epidemiologists, which are notmutually exclusive, can be designated as ollows:(1) psychosocial approaches; (2) social productiono disease/political economy o health; and (3)ecosocial theory and related multi-level rameworks.All three approaches seek to elucidate principlescapable o explaining social inequalities in health,

and all represent what Krieger has called theorieso disease distribution that cannot be reduced tomechanism–oriented theories o disease causation.Where they differ is in their respective emphasis ondifferent aspects o social and biological conditionsin shaping population health, how they integratesocial and biological explanations, and thus theirrecommendations or action 41, 42, 43.

∏ Te first school places primary emphasison psychosocial factors, and is associatedwith the view that people’s “perception andexperience o personal status in unequal

societies lead to stress and poor health”44,

45. Tis school traces its origins to a classicstudy by Cassel 46, in which he argued that

stress rom the ‘social environment’ altershost susceptibility, affecting neuroendocrine

unction in ways that increase the organism’s vulnerabi lity to disease. More rec entresearchers, most prominently RichardWilkinson, have sought to link alteredneuroendocrine patterns and compromisedhealth capability to people’s perception andexperience o their place in social hierarchies.According to these theorists, the experienceo living in social settings o inequality orcespeople constantly to compare their status,possessions and lie circumstances with thoseo others, engendering eelings o shame

and worthlessness in the disadvantaged,along with chronic stress that undermineshealth. At the level o society as a whole,meanwhile, steep hierarchies in incomeand social status weaken social cohesion,with this disintegration o social bonds alsoseen as negative or health. Tis researchhas generated a substantial literature on therelationship between (perceptions o) socialinequality, psychobiological mechanisms,and health status 47, 48, 49, 50, 51, 52.

∏ A social production of disease/politicaleconomy of health ramework explicitly

addresses economic and politicaldeterminants o health and disease.Researchers adopting this theoreticalapproach also sometimes described as amaterialist or neo-materialist position, donot deny negative psychosocial consequenceso income inequality. However, they arguethat interpretation o links between incomeinequality and health must begin with thestructural causes o inequalities, and not

just ocus on perceptions o that inequality.Under this interpretation, the eect o

income inequality on health reflects bothlack o resources held by individuals andsystematic under-investments across a wide

4 Previous theories andmodels

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owing to varying eligibility or and coverage bysocial insurance or similar mechanisms (exampleo “indirect selection”). Blane and Manor argue thatthe effect o the “direct selection” mechanism on thesocial gradient is small, and, thereore, direct socialmobility cannot be regarded as a main explanationor inequalities in health. More commonly socialmobility is considered selective on determinantso health (hence “indirect selection”), not onhealth itsel 58. It is also important to take intoaccount that the health determinants on whichindirect selection takes place could themselvesarise rom living circumstances o earlier stageso lie. Indirect selection would then be part o amechanism o accumulation o disadvantage overthe lie course. Te process o health selection may,

thereore, contribute to the cumulative effects osocial disadvantage across the lie span, but, todate, the inclusion o health selection into studieso lie course relationships is scarce.

4.2.2 Social causation perspective

From this perspective, social position determineshealth through intermediary actors. Longitudinalstudies in which socioeconomic status has beenmeasured beore health problems are present,and in which the incidence o health problems

has been measured during ollow-up, showhigher risk o developing health problem inthe lower socioeconomic groups, and suggest“social causation” as the main explanation orsocioeconomic inequalities in health 15. hiscausal effect o socioeconomic status on healthis likely to be mainly indirect, through a numbero more speciic health determinants that aredierently distributed across socioeconomicgroups. Socioeconomic health differences occurwhen the quality o these intermediary actorsare unevenly distributed between the differentsocioeconomic classes: socioeconomic status

determines a person’s behavior, lie conditions,etc., and these determinants induce higher orlower prevalence o health problems. Te maingroups o actors that have been identiied asplaying an important part in the explanation ohealth inequalities are material, psychosocial, andbehavioral and/or biological actors.

Material factors are linked to conditionso 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 rom the dierentialaccumulation o exposures and experiences

that have their sources in the material world.Meanwhile, material actors and social (dis)advantages predictably intertwine, such that“people who have more resources in terms oknowledge, money, power, prestige, and socialconnections are better able to avoid risk … and toadopt the protective strategies that are available ata given time and a given place” 76.

Psychosocial factors are highlightedby the psychosocial theory described above.Relevant actors include stressors (e.g. negativelie events), stressul living circumstances, lacko social support, etc. Researchers emphasizingthis approach argue that socioeconomicinequalities in morbidity and mortality cannot

be entirely explained by well-known behavioralor material risk actors o disease. For example,in cardiovascular disease outcomes, risk actorssuch as smoking, high serum cholesterol andblood pressure can explain less than hal o thesocioeconomic gradient in mortality. Marmot,Shipley and Rose 142 have argued that the similarityo the risk gradient or a range o diseases couldindicate the operation o actors affecting generalsusceptibility. Meanwhile, the inverse relationbetween height and mortality suggests that actorsoperating rom early lie may influence adult death

rates

77

.

Behavioral factors, such as smoking, diet,alcohol consumption and physical exercise,are certainly important determinants ohealth. Moreover, since they can be unevenlydistributed between dierent socioeconomicpositions, they may appear to have importantweight as determinants o health inequalities.Yet this hypothesis is controversial in light o theavailable evidence. Patterns differ significantlyrom one country to another. For example,smoking is generally more prevalent among lower

socioeconomic groups; however, in SouthernEurope, smoking rates are higher among higherincome groups, and in particular among women.Te contribution o diet, alcohol consumption andphysical activities to inequalities in health is lessclear and not always consistent. However, there ishigher prevalence o obesity and excessive alcoholconsumption in lower socioeconomic groups,particularly in richer countries 19, 78, 79.

The health system itself constitutes anadditional relevant intermediary actor, though

one which has oten not received adequateattention in the literature. We will discuss thistopic in detail in subsequent sections o the paper.

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4.2.3 Life course perspective

A lie course perspective explicitly recognizes theimportance o time and timing in understandingcausal links between exposures and outcomeswithin an individual lie course, across generations,and in population-level diseases trends. Adoptinga lie course perspective directs attention to howsocial determinants o health operate at every levelo development—early childhood, childhood,adolescence and adulthood—both to immediatelyinfluence health and to provide the basis or healthor illness later in lie. Te lie course perspectiveattempts to understand how such temporalprocesses across the lie course o one cohort arerelated to previous and subsequent cohorts and are

maniested in disease trends observed over time atthe population level. ime lags between exposure,disease initiation and clinical recognition (latencyperiod) suggest that exposures early in lie areinvolved in initiating disease processes prior toclinical maniestations; however, the recognitiono early-lie influences on chronic diseases does notimply deterministic processes that negate the utilityo later-lie intervention.

In a table produced by Ben-Shlomo and Kuh 80 the authors propose a simply classiication o

potential lie course models o health. wo mainmechanisms are identified.

The “critical periods” model is when anexposure acting during a specific period has lastingor lielong eects on the structure or unctiono organs, tissues and body systems that are notmodified in any dramatic way by later experiences.Tis is also known as “biological programming”,and it is sometimes reerred to as a “latency”model. Tis conception is the basis o hypotheseson the etal origins o adult diseases. Tis approachdoes recognize the importance o later lie effect

modifiers (e.g. in the linkage o coronary heartdisease, high blood pressure and insulin resistancewith low birth weight) 81.

The “accumulation of risk” model suggeststhat actors that raise disease risk or promotegood health may accumulate gradually over thelie course, although there may be developmentalperiods when their effects have greater impact onlater health than actors operating at other times.Tis idea is complementary to the notion that asthe intensity, number and/or duration o exposures

increase, there is increasing cumulative damageto biological systems. Understanding the health

eects o childhood social class by identiyingspecific aspects o the early physical or psychosocialenvironment (such as exposure to air pollution oramily conflict) or possible mechanisms (such asnutrition, inection or stress) that are associatedwith adult disease will provide urther etiologicalinsights. Circumstances in early lie are seen as theinitial stage in the pathway to adult health but withan indirect effect, influencing adult health throughsocial trajectories, such as restricting educationalopportunities, thus inluencing socioeconomiccircumstances and health in later lie. Risk actorstend to cluster in socially patterned ways, orexample, those living in adverse childhood socialcircumstances are more likely to be o low birthweight, and be exposed to poor diet, childhood

inections and passive smoking. Tese exposuresmay raise the risk o adult respiratory disease,perhaps through chains o risk or pathways overtime where one adverse (or protective) experiencewill tend to lead to another adverse (protective)experience in a cumulative way.

Ben-Shlomo and Kuh 80 argue that the lie courseapproach is not limited to individuals within asingle generation but should intertwine biologicaland social transmission o risk across generations.It must contextualize any exposure both within

a hierarchical structure as well as in relation togeographical and secular differences, which maybe unique to that cohort o individuals. Recentlythe potential or a lie course approach to aidunderstanding o variations in the health anddisease o populations over time, across countriesand between social groups has been given moreattention. Davey Smith 70 and his colleagues suggestthat explanations or social inequalities in cause-specific adult mortality lie in socially-patternedexposures at different stages o the lie course.

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p In contemporary social epidemiology, three main theoretical explanations ofdisease distribution are: (1) psychosocial approaches; (2) social productionof disease/political economy of health; and (3) eco-social and other emergingmulti-level frameworks. All represent theories which presume but cannot bereduced to mechanism–oriented theories of disease causation.

p The main social pathways and mechanisms through which social determinantsaffect people’s health can usefully be seen through three perspectives: (1)“social selection”, or social mobility; (2) “social causation”; and (3) life courseperspectives.

p These frameworks/directions and perspectives are not mutually exclusive. On the contrary, they are complementary.

p Certain of these frameworks have paid insufficient attention to politicalvariables. The CSDH framework will systematically incorporate these factors.

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5.1 Purpose of constructing aframework for the CSDH

We now proceed to present in detail the specificconceptual ramework developed or the CSDH.his is an action-oriented ramework, whoseprimary purpose is to support the CSDH inidentiying where CSDH recommendations willseek to promote change in tackling SDH throughpolicies. A comprehensive SDH ramework shouldachieve the ollowing:

∏ Identiy the social determinants o healthand the social determinants o inequitiesin health;

∏

Show how major determinants relate toeach other;∏ Clariy the mechanisms by which social

determinants generate health inequities;∏ Provide a ramework or evaluating which

SDH are the most important to address;and

∏ Map speciic levels o intervention andpolicy entry points or action on SDH.

o include all these aspects in one ramework isdifficult and may complicate understanding. In anearlier version o the CSDH conceptual ramework,

drafed in 2005, we attempted to include all othese elements in a single synthetic diagram;however, this approach was not necessarily themost helpul. In the current elaboration o theramework, we separate out the various majorcomponents.

We begin by sketching additional importantbackground elements not covered in the previoustheoretical rameworks and perspectives asollows:1 insights rom the theorization o social

power, which can help to clariy thedynamics o social stratification; and

2 an existing model o the social productiono disease developed by Diderichsen

and colleagues, rom which the CSDHramework draws significantly.

With these background elements in place, weproceed to examine the key components o theCSDH ramework in turn, including:1 the socio-political context;2 structural determinants and socioeconomic

position; and

3 intermediary determinants.

We conclude the presentation with a synthetic

review o the ramework as a whole. Te issueo entry points or policy action will be taken upexplicitly in the next chapter.

5.2 Theories of power to guideaction on social determinants

Health inequities low rom patterns o socialstratiication—that is, rom the systematicallyunequal distribution o power, prestige andresources among groups in society. As a criticalactor shaping social hierarchies and thus

conditioning health differences among groups,“power” demands careul analysis rom researchersconcerned with health equity and SDH.Understanding the causal processes that underliehealth inequities, and assessing realistically whatmay be done to alter them, requires understandinghow power operates in multiple dimensions oeconomic, social and political relationships.

he theory o power is an active domain oinquiry in philosophy and the social sciences.While developing a ull-ledged theory o

power lies beyond the mandate o the CSDH,the Commission can draw on philosophical and

5 CSDH conceptualframework

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political analyses o power to guide its raming othe relationships among health determinants andits recommendations or interventions .

Power is “arguably the single most importantorganizing concept in social and political theory” 82,yet this central concept remains contested andsubject to diverse and oten contradictoryinterpretations. We review several approaches toconceptualizing power.

First, classic treatments o the concept o powerhave emphasized two undamental (and largelynegative) aspects: (1) “power to”, i.e. what Giddenshas termed “the transormative capacity o humanagency”, in the broadest sense “the capability o

the actor to intervene in a series o events so asto alter their course”; and (2) “power over”, whichcharacterizes a relationship in which an actor orgroup achieves its strategic ends by determiningthe behavior o another actor or group. Power inthis second, more limited but politically crucialsense may be understood as the capability to secureoutcomes where the realization o these outcomesdepends upon the agency o others. “Power over” isclosely linked to notions o coercion, dominationand oppression; it is this aspect o power whichhas been at the heart o most influential modern

theories o power

83

.

It is important to observe, meanwhile, that“domination” and “oppression” in the relevantsenses need not involve the exercise o brutephysical violence nor even its overt threat. In aclassic study, Steven Lukes showed that coercivepower can take covert orms. For example,power expresses itsel in the ability o advantagedgroups to shape the agenda o public debate anddecision-making in such a way that disadvantagedconstituencies are denied a voice. At a stilldeeper level, dominant groups can mold people’s

perceptions and preerences, or example throughcontrol o the mass media, in such a way that theoppressed are convinced they do not have anyserious grievances. “Te power to shape people’sthoughts and desires is the most effective kind opower, since it pre-empts conflict and even pre-empts an awareness o possible conflicts” 84. IrisMarion Young develops related insights on thepresence o coercive power even where overt orceis absent. She notes that “oppression” can designate,not only “brutal tyranny over a whole people by aew rulers”, but also “the disadvantage and injustice

some people suffer … because o the everydaypractices o a well-intentioned liberal society”.

Young terms this “structural oppression”, whoseorms are “systematically reproduced in majoreconomic, political and cultural institutions” 85.For all their explanatory value, power theorieswhich tend to equate power with domination leavekey dimensions o power insufficiently clarified.As Angus Stewart argues, such theories mustbe complemented by alternative readings thatemphasize more positive, creative aspects o power.

A crucial source or such alternative more positivemodels is the work o philosopher HannahArendt. Arendt challenged undamental aspectso conventional western political theory bystressing the inter-subjective character o powerin collective action. In Arendt’s philosophy,

“power is conceptually and above all politicallydistinguished, not by its implication in agency,but above all by its character as collective action83.“Power corresponds to the human ability not justto act, but to act in concert. Power is never theproperty o an individual; it belongs to a groupand remains in existence only so long as the groupkeeps together” 86. From this vantage point, powercan be understood as:

“a relation in which people are not

dominated but empowered through

critical reflection leading to shared

action” 87 .

Recent eminist theory has urther enriched theseperspectives. Luttrell and colleagues 88 ollowRowlands 89 in distinguishing our undamentaltypes o power:

∏ Power over (ability to influence or coerce)∏ Power to (organize and change existing

hierarchies)∏ Power with (power rom collective action)∏ Power within (power rom individual

consciousness).

Tey note that these different interpretations opower have important operational consequencesor development actors’ efforts to acilitate theempowerment o women and other traditionallydominated groups. An approach based on“power over” emphasizes greater participation

o previously excluded groups within existingeconomic and political structures. In contrast,

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models based on “power to” and “power with”,emphasizing new orms o collective action, pushtowards a transormation o existing structuresand the creation o alternative modes o power-sharing: “not a bigger piece o the cake, but adifferent cake” 90.

his emphasis on power as collective actionconnects suggestively with a model o socialethics based on human rights. As one analysthas argued: “Troughout its history, the struggleor human rights has a constant: in very differentorms and with very dierent contents, thisstruggle has consisted o one basic reality: ademand by oppressed and marginalized socialgroups and classes or the exercise o their social

power ” 91. Understood in this way, a human rightsagenda means supporting the collective action ohistorically dominated communities to analyze,resist and overcome oppression, asserting theirshared power and altering social hierarchies in thedirection o greater equity.

he theories o power we have reviewed arerelevant to analysis and action on the socialdeterminants o health in a number o ways. First,and most undamentally, they remind us thatany serious effort to reduce health inequities will

involve changing the distribution o power withinsociety to the benefit o disadvantaged groups.Changes in power relationships can take place at various levels, rom the “micro-level” o individualhouseholds or workplaces to the “macro-sphere”o structural relations among social constituencies,mediated through economic, social and politicalinstitutions. Power analysis makes clear, however,that micro-level modifications will be insufficientto reduce health inequities unless micro-levelaction is supported and reinorced throughstructural changes.

By deinition, then, action on the socialdeterminants o health inequities is a politicalprocess that engages both the agency odisadvantaged communities and the responsibilityo the state. Tis political process is likely to becontentious in most contexts, since it will be seenas pitting the interests o social groups againsteach other in a struggle or power and control oresources. Teories o power rooted in collectiveaction, such as Arendt’s, open the perspective o aless antagonistic model o equity-ocused politics,emphasizing the creative sel-empowerment o

previously oppressed groups. “Here the paradigmcase is not one o command, but one o enablementin which a disorganized and unocused groupacquires an identity and a resolve to act” 88.However, there can be little doubt that the politicalexpression o vulnerable groups’ “enablement”will generate tensions among those constituenciesthat perceive their interests as threatened. Onthe other hand, theories that highlight both theovert and covert orms through which coercivepower operates provide a sobering reminder othe obstacles conronting collective action amongoppressed groups.

Teorizing the impact o social power on healthsuggests that the empowerment o vulnerable

and disadvantaged social groups will be vital toreducing health inequities. However, the theoriesreviewed here also encourage us to problematizethe concept o “empowerment” itsel. Tey pointto the dierent (in some cases incompatible)meanings this term can carry. What dierentgroups mean by empowerment depends on theirunderlying views about power. Te theories wehave discussed acknowledge different orms opower and thus, potentially, different kinds andlevels o empowerment. However, these theoriesurge skepticism towards depoliticized models

o empowerment and approaches that claim toempower disadvantaged individuals and groupswhile leaving the distribution o key socialand material goods largely unchanged. hoseconcerned to reduce health inequities cannotaccept a model o empowerment that stressesprocess and psychological aspects at the expenseo political outcomes and downplays verifiablechange in disadvantaged groups’ ability to exercisecontrol over processes that affect their well-being.Tis again raises the issue o state responsibilityin creating spaces and conditions under whichthe empowerment o disadvantaged communities

can become a reality. A model o communityor civil society empowerment appropriate oraction on health inequities cannot be separatedrom the responsibility o the state to guaranteea comprehensive set o rights and ensure the airdistribution o essential material and social goodsamong population groups. Tis theme is exploredmore ully below.

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p An explicit theorization of power is useful for guiding action to tackle SDH toimprove health equity .

p 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 withdomination and coercion.

p Theories that equate power with domination can be complemented byalternative readings that emphasize more positive, creative aspects of power,based on collective action. In this perspective, human rights can be understoodas embodying a demand on the part of oppressed and marginalized communitiesfor the expression of their collective social power.

p Any serious effort to reduce health inequities will involve changing thedistribution of power within society to the benefit of disadvantaged groups.

p Changes in power relationships can range from the “micro- level” of individualhouseholds or workplaces to the “macro- sphere” of structural relationsamong social constituencies, mediated through economic, social and politicalinstitutions. Micro-level modifications will be insufficient to reduce healthinequities unless supported by structural changes but structural changes thatare not cogniscent of incentives at the micro-level will also struggle for impact.

p

This means that action on the social determinants of health inequities is apolitical process that engages both the agency of disadvantaged communitiesand the responsibility of the state.

5.3 Relevance of theDiderichsen model for theCSDH framework

he CSDH ramework or action drawssubstantially on the contributions o many

previous researchers, most prominently FinnDiderichsen. Diderichsen’s and Hallqvist’s 1998model o the social production o disease wassubsequently adapted by Diderichsen, Evans andWhitehead 92. Te concept o social position isat the center o Diderichsen’s interpretation o“the mechanisms o health inequality” 93. In itsinitial ormulation, the model emphasized thepathway rom society through social positionand specific exposures to health. Te rameworkwas subsequently elaborated to give greateremphasis to “mechanisms that play a role in

stratiying health outcomes”94

, including “thosecentral engines o society that generate anddistribute power, wealth and risks” and thereby

determine the pattern o social stratification. Temodel emphasizes how social contexts createsocial stratiication and assign individuals todifferent social positions. Social stratification inturn engenders differential exposure to health-damaging conditions and differential vulnerability,

in terms o health conditions and materialresource availability. Social stratification likewisedetermines differential consequences o ill healthor more and less advantaged groups (includingeconomic and social consequences, as well asdifferential health outcomes per se).

At the individual level, the igure depicts thepathway rom social position, through exposureto specific contributing causal actors, and on tohealth outcomes. As many different interactingcauses in the same pathway might be related to

social position, the effect o a single cause mightdiffer across social positions as it interacts withsome other cause related to social position 94, 95.

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Diderichsen’s most recent version o the modelprovides some additional insights 92, 94. Bothdierential exposure (Roman numeral I in thediagram above) and differential vulnerability (II)may contribute to the relation between socialposition and health outcomes, as can be testedempirically. In addition, differential vulnerabilityis about clustering and interaction betweenthose determinants that mediate the eect osocio-economic health gradient. Ill health has

serious social and economic consequences dueto inability to work and the cost o health care.Tese consequences depend not only on the extento disability, but also on the individual’s socialposition (III—differential consequences) and onthe society’s environment and social policies.Te social and economic consequences o illnessmay eed back into the etiological pathways andcontribute to the urther development o disease inthe individual (IV). Tis effect might even, on anaggregate level, eed into the context o society, aswell, and influence aggregate social and economic

development.

Many o the insights rom Diderichsen’s modelwill be taken up into the CSDH ramework that

Figure 1. Model of the social production of disease


p Social position is at the center of Diderichsen’s model of“the mechanisms of health inequality”.

p The mechanisms that play a role in stratifying healthoutcomes operate in the following manner :

• Social contexts create social stratification andassign individuals to different social positions.

• Social stratification in turn engenders differentialexposure to health-damaging conditions anddifferential vulnerability, in terms of healthconditions and material resource availability.

• Social stratication likewise determinesdifferential consequences of ill health for more andless advantaged groups (including economic andsocial consequences, as well differential healthoutcomes per se).

Source: Reproduced with permission rom Diderichsen et al. (2001)

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we will now begin to explain, presenting its keycomponents one by one.

5.4 First element of the CSDHframework: socio-economicand political context

Te social determinants ramework developedby the CSDH diers rom some others in theimportance attributed to the socioeconomic- political context . Tis is a deliberately broad termthat reers to the spectrum o actors in societythat cannot be directly measured at the individuallevel. “Context”, thereore, encompasses a broadset o structural, cultural and unctional aspects

o a social system whose impact on individualstends to elude quantiication but which exerta powerul ormative inluence on patterns osocial stratification and, thus, on people’s healthopportunities. In this stated context, one willfind those social and political mechanisms thatgenerate, configure and maintain social hierarchies(e.g. the labor market, the educational system andpolitical institutions including the welare state).

One point noted by some analysts, and which wewish to emphasize, is the relative inattention to

issues o political context in a substantial portiono the literature on health determinants. It hasbecome commonplace among population healthresearchers to acknowledge that the health oindividuals and populations is strongly influencedby SDH. It is much less common to aver that thequality o SDH is in turn shaped by the policiesthat guide how societies (re)distribute materialresources among their members 96. In the growingarea o SDH research, a subject rarely studied is theimpact on social inequalities and health o politicalmovements and parties and the policies they adoptwhen in government 97.

Meanwhile, Navarro and other researchershave compiled over the years an increasinglysolid body o evidence that the quality o manysocial determinants o health is conditioned byapproaches to public policy. o name just oneexample, the state o Kerala in India has beenwidely studied, showing the relationship betweenits impressive reduction o inequalities in thelast 40 years and improvements in the healthstatus o its population. With very ew exceptions,however, these reductions in social inequalities and

improvements in health have rarely been tracedto the public policies carried out by the state’sgoverning communist party, which has governed

in Kerala or the longest period during those40 years 98. Chung and Muntaner find similarlythat ew studies have explored the relationshipbetween political variables and population healthat the national level, and none has included acomprehensive number o political variables tounderstand their eect on population healthwhile simultaneously adjusting or economicdeterminants 99. As an illustration o the powerulimpact o political variables on health outcomes,these researchers concluded in a recent study o 18wealthy countries in Europe, North America andthe Asia-Pacific region that 20 % o the differencesin inant mortality rate among countries could beexplained by the type o welare state. Similarly,different welare state models among the countries

accounted or about 10 % o differences in the rateo low birth weight babies 99.

Raphael similarly emphasizes how policy decisionsimpact a broad range o actors that influencethe distribution and eects o SDH acrosspopulation groups. Policy choices are reflected,or example, in: amily-riendly labor policies;active employment policies involving trainingand support; the provision o social saety nets;and the degree to which health and social servicesand other resources are available to citizens 44, 45.

Te organization o healthcare is also a directresult o policy decisions made by governments.Public policy decisions made by governmentsare themselves driven by a variety o political,economic and social orces, constituting a complexspace in which the relationship between politics,policy and health works itsel out.

It is sae to say that these specifically political aspectso context are important or the social distributiono health and sickness in virtually all settings,and they have been seriously understudied. Onthe other hand, it is also the case that the most

relevant contextual actors (i.e. those that play thegreatest role in generating social inequalities) maydiffer considerably rom one country to another 99.For example, in some countries religion will be adecisive actor and less so in others. In general, theconstruction/mapping o context should includeat least six points: (1) governance in the broadestsense and its processes, including definition oneeds, patterns o discrimination, civil societyparticipation and accountability/transparence inpublic administration; (2) macroeconomic policy, including fiscal, monetary, balance o payments

and trade policies and underlying labour marketstructures; (3) social policies aecting actorssuch as labor, social welare, land and housing

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distribution; (4) public policy in other relevantareas such as education, medical care, water andsanitation; (5) culture and societal values; and (6)epidemiological conditions, particularly in thecase o major epidemics such as HIV/AIDS, whichexert a powerul influence on social structures andmust be actored into global and national policy-setting. In what ollows, we highlight some o thesecontextual elements with particular ocus on thosewith major importance or health equity.We have adopted the UNDP deinition ogovernance, which is as ollows:

“[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 orcitizens and groups to articulate their interests,mediate their dierences and exercise theirlegal rights and obligations. Tese are the rules,institutions and practices that set limits and provideincentives or individuals, organizations and firms.Governance, including its social, political andeconomic dimensions, operates at every level ohuman enterprise, be it the household, village,municipality, nation, region or globe” 100, 101. Itis important to acknowledge, meanwhile, thatthere is no general agreement on the definition ogovernance, or o good governance. Development

agencies, international organizations and academicinstitutions define governance in different ways,this being generally related to the nature o theirinterests and mandates.

Regarding labour market policies, we adopt theideas proposed by the CSDH’s EmploymentConditions Knowledge Network 102: “Labourmarket policies mediate between supply(jobseekers) and demand (jobs offered) in thelabour market, and their intervention can takeseveral orms. Tere are policies that contribute

directly to matching workers to jobs and jobs

to workers or enhancing workers’ skills andcapacities, reducing labour supply, creating jobs orchanging the structure o employment in avour odisadvantaged groups (e.g. employment subsidiesor target groups). ypical passive programmesare unemployment insurance and assistance andearly retirement; typical active measures are labourmarket training, job creation in orm o public andcommunity work programmes, programmes topromote enterprise creation and hiring subsidies.Active policies are usually targeted at speciicgroups acing particular labour market integrationdifficulties: younger and older people, womenand those particularly hard to place such as thedisabled.”

Te concept o the “welare state” is one in whichthe state plays a key role in the protection andpromotion o the economic and social well-beingo its citizens. It is based on the principles oequality o opportunity, equitable distribution owealth and public responsibility or those unableto avail themselves o the minimal provisions ora good lie. Te general term may cover a varietyo orms o economic and social organization. Aundamental eature o the welare state is socialinsurance. Te welare state also, usually, includespublic provision o basic education, health services

and housing (in some cases at low cost or withoutcharge). Anti-poverty programs and the system opersonal taxation may also be regarded as aspectso the welare state. Personal taxation alls intothis category insoar as it is used progressivelyto achieve greater justice in income distribution(rather than merely to raise revenue), and alsoinsoar as it used to inance social insurancepayments and other beneits not completelyfinanced by compulsory contributions. In moresocialist countries the welare state also coversemployment and administration o consumerprices 102, 103.

One o the main unctions o the welare state is“income redistribution”; thereore, the welarestate ramework has been applied to the fieldso social epidemiology and health policy as anamendment to the “relative income hypothesis”.Welare state variables have been added tomeasures o income inequality to determine thestructural mechanism through which economicinequality affects population health status 104.

Chung and Muntaner provide a classification o

welare state types and explore the health effects

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o their respective policy approaches. Teir studyconcludes that countries exhibit distinctive levelso population health by welare regime types,even when adjusted by the level o economicdevelopment (GDP per capita) and intra-countrycorrelations. Tey find, specifically, that SocialDemocratic countries exhibit significantly betterpopulation health status, e.g. lower inant mortalityrate and low birth weight rate, compared to othercountries 99, 105.

Institutions and processes connected withglobalization constitute an important dimensiono context as we understand it. “Globalization” isdefined by the CSDH Globalization KnowledgeNetwork, ollowing 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 o a globalmarketplace 106 . Non-economic aspects oglobalization, including social and cultural aspects,are acknowledged and relevant. However, economicglobalization is understood as the orce that hasdriven other aspects o globalization over recentdecades. Te importance o globalization signifiesthat contextual analysis on health inequities willofen need to examine the strategies pursued by

actors such as transnational corporations andsupranational political institutions, including theWorld Bank and International Monetary Fund.

“Context” also includes social and cultural values.Te value placed on health and the degree to whichhealth is seen as a collective social concern differsgreatly across regional and national contexts. Wehave argued elsewhere, ollowing Roemer andKleczkowski, that the social value attributed tohealth in a country constitutes an important andofen neglected aspect o the context in which

health policies must be designed and implemented.

In constructing a typology o health systems,Kleczkowski, Roemer and Van der Werff haveproposed three domains o analysis to indicatehow health is valued in a given society:

∏ Te extent to which health is a priorityin the governmental /societal agenda, asreflected in the level o national resourcesallocated to health (care), with the need orhealth care signalling a grave ethical basisor resource redistribution);

∏ Te extent to which the society assumescollective responsibility or financing andorganizing the provision o health services.In maximum collectivism (also reerredto as a state-based model), the system isalmost entirely concerned with providing

collective beneits, leaving little or nochoice to the individual. In maximumindividualism, ill health and its care are viewed as private concerns; and

∏ he extent o societal distributionalresponsibility. his is a measure othe degree to which society assumesresponsibility or the distribution oits health resources. Distributionalresponsibility is at its maximum when thesociety guarantees equal access to servicesor all 107, 108.

Tese criteria are important or health systemspolicy and evaluating systems perormance. Teyare also relevant to assessing opportunities oraction on SDH.

o ully characterize all major components othe socioeconomic and political context isbeyond the scope o the present paper. Here, wehave considered only a small number o thosecomponents likely to have particular importanceor health equity in many settings.

5.5 Second element:structural determinants andsocioeconomic position

Graham observes that the concept o “socialdeterminants o health” has acquired a dualmeaning, reerring both to the social actorspromoting and undermining the health oindividuals and populations and to the socialprocesses underlying the unequal distribution othese actors between groups occupying unequal

positions in society. Te central concept o “social

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determinants” thus remains ambiguous, reerringsimultaneously to the determinants o health andto the determinants o inequalities in health. Teauthor 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 socioeconomicdifferences in access to material resources, health-promoting resources, and in exposure to riskactors. Furthermore, policies associated withpositive trends in health determinants (e.g. a risein living standards and a decline in smoking) havealso been associated with persistent socioeconomicdisparities in the distribution o these determinants

(marked socioeconomic dierences in livingstandards and smoking rates) 109, 110 .We haveattempted to resolve this linguistic ambiguity byintroducing additional differentiations within thefield o concepts conventionally included under theheading “social determinants”. We adopt the term“structural determinants” to reer specifically tointerplay between the socioeconomic-politicalcontext, structural mechanisms generating socialstratiication and the resulting socioeconomicposition o individuals. hese structuraldeterminants are what we include when reerringto the “soc

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