Learnings from the Special Initiative for Action on the Social Determinants of Health are important for strengthening health equity strategies

Rising inequalities and health equity

Social inequalities continue to grow within countries, while public goods for health are being transferred into private corporate hands, with fewer resources for health owned by the public than in the past fifty years (Chancel et al., 2021). These inequalities (for example, measured by income inequalities), are symptomatic of and contribute to social divisions at the root of growing health inequities (unfair and avoidable, or remedial, differences in health outcomes between social groups). Health coverage progress has slowed since 2015 with increasing inequalities; households spending more than 10% of household budgets on health care, continues to rise, pushing people into poverty (WHO, World Bank, 2023).

This picture calls for strengthening strategies to address health equity. Structural determinants, characterised by policies, institutions, culture and values generating social inequalities, continue to impact exposures to health risks, unhealthy behaviours and to shape health service access and disease consequences. The COVID-19 pandemic exemplified how the status quo as regards social protection sick leave policies fuelled higher infection rates (WHO, 2021). Social inequalities also lie at the root of or mediate many other social problems like climate change (Green and Healy, 2022).

Social inequalities continue to grow within countries, while public goods for health are being transferred into private corporate hands, with fewer resources for health owned by the public than in the past fifty years.

Health equity strategies

Health equity strategies typically aim to reduce social inequalities and their impact on health outcomes through three applying a social determinants lens to: public health functions, healthcare access and support for community and social development. The 1970s primary health care (PHC) health for all strategies advocated for specific elements of social and public policy interventions. Interventions on food security, housing, water and sanitation and the education and empowerment of women and girls promoted the development of underserved, often rural, communities (Irwin and Scali, 2010). PHC highlighted the importance of intersectoral action and social participation, with specific proof of concept illustrated in successes in Costa Rica, Cubaand Sri Lanka.

Fast forward 40 years, in 2011 national governments called for action in the Rio Political Declaration on the Social Determinants of Health (WHO, 2011), following the landmark WHO Commission on Social Determinants of Health report (CSDH, 2008). For national governments, the scope of social interventions includes inter-/multi-sectoral action for governance for health and development (Health in All Policies processes); community and social participation (including social movements); reforming health financing incentives, programmes and services; and improving situation assessment of and monitoring of social determinants of health and health inequalities. In the past decade since Rio, governments have advanced Health in All Policies approaches, among others, to address health equity (Lilly et al., 2023; Donkin et al. 2017), but progress has been variable and equity strategies are in need of strengthening. A new global initiative to champion health equity, reaching its third out of eight years, has several important lessons to share.

The Special Initiative for Action on the Social Determinants of Health for Advancing Health Equity (the Initiative)

With intersectorality and social participation at is core, in 2020 the Special Initiative for Action on the Social Determinants of Health for Advancing Health Equity, was launched by WHO (headquarters with three regions – Pan American Health Organization (PAHO), the Western Pacific Regional Office, the Eastern Mediterranean Regional Office). The Initiative is propelled by an innovative partnership with the Swiss Agency for Development and Cooperation (innovator in international development policy), University College London, Institute of Health Equity (UCL/IHE) (academic think-tank and leading global equity champion), and the University of Lausanne (UNISANTE (UNIL/UNISANTE) (clinical group working to integrate health equity into clinical teaching and health services practice) (for more information, see: Solar, Valentine et al., 2023).

Building on the landmark report of the WHO Commission on the Social Determinants of Health in 2008 (CSDH 2008), and experiences of country action from Alma Ata to Health (or health and well-being/health equity) in All Policies strategies (Lilly et al. 2023), the Special Initiative advocates for health actors to take a key role in improving health equity. The Initiative is creating a space for an action-learning laboratory for actors spearheading health equity strategies. Spanning three WHO regions, the action-learning laboratory is propelled by country Pathfinders from Chile, Colombia, Costa Rica, Peru, Morocco, occupied Palestinian territory (prior to the war), Lao PDR, and the Philippines. The Initiative provides seed funding to governments and technical support and creates forums for narrative and evidence development, capacity building and learning.

The Initiative is propelled by an innovative partnership with the Swiss Agency for Development and Cooperation (innovator in international development policy), University College London, Institute of Health Equity (UCL/IHE) (academic think-tank and leading global equity champion), and the University of Lausanne (UNISANTE (UNIL/UNISANTE).

(...) The Special Initiative advocates for health actors to take a key role in improving health equity.

Learnings from the Initiative to further health equity strategies

(i) Multi-level narratives for engagement and assessment of needs

Policy-makers need evidence-based narratives to engage in broader social inequality debates. Pathways described typically are: decreased social cohesion resulting in political polarisation/social fractures and lack of trust in government; reduced trust in government leading to lower fiscal space and lower investments in public health and prevention; poorer living conditions resulting in increased opportunities for higher transmissions of infectious diseases; and diminished state capacity resulting in de-regulation of living and working environments translating to higher risks for noncommunicable disease (pollution, obesogenic commercial practices, higher psychosocial stress from precarious employment). Often this narrative translates into alignment and health security agendas providing relatively unchallenging for the status quo (while derivatives of these address more the status quo as exemplified by the “well-being economy” (Williams et al., 2023)).

A secondary level of narrative building, is a focus on social groups most impacted. This is where the Initiative country Pathfinders started their work, emerging from the health security environment during 2021 where the COVID-19 pandemic highlighted the importance of social policies for all.Hardest hit social groups were “essential workers”, that included categories of precarious and informal workers, and ethnic minorities many of whom as migrants and refugees had reduced legal access services and experienced discrimination (and within both of these women and girls).

Policy-makers need evidence-based narratives to engage in broader social inequality debates.

But recognizing overarching narratives and knowledge are insufficient to start the transformational change needed for social interventions, the Initiative country Pathfinders began work on building narratives with local implementation teams. In PAHO, the use of Theory of Change workshops helped Initiative country Pathfinders in the Americas to jointly plan work and to develop their monitoring and evaluation frameworks. Evaluation workshops were another process used to elaborate narratives that feed sustainability.

In Lao PDR evaluation workshops during 2023 examined results of the CONNECT work over 2020-2022 illustrated tangible impacts of a governance intervention on COVID-19 vaccination rates. CONNECT is a governance intervention that reorientates local government, regional governance and village health centres working with communities, largely in rural areas, towards identifying and addressing all the determinants of health. The intervention is governed by a Memorandum of Understanding between the Ministry of Health and the Ministry of Interior/Local Government. A series of Health in All Policies training workshops held by the Ministry of Health in Morocco in 2023 was used to sensitise partners from within and beyond the health sector and is another way to develop a shared narrative.

But recognizing overarching narratives and knowledge are insufficient to start the transformational change needed for social interventions, the Initiative country Pathfinders began work on building narratives with local implementation teams.

(ii) Integration involving the healthcare services at local levels and the PHC approach

As the greatest asset for the health sector is in its workforce, and social interventions require adaptive responses, the express involvement of health services (not only public health functions) from the local level is critical. An overarching entry point is thus the redesign of the Primary Health Care approach (WHO, 2019), given the many synergies between PHC and health equity goals. Also of relevance are: specific health programme responses for noncommunicable diseases; health security and climate resilience concerns and local government decentralisation and community development reforms based on human rights.

Through PHC and other local services, Initiative country Pathfinders are broadening how local healthcare, public health and intersectoral management deal with equity, intersectoral action and participatory public health. For example, in Chile, the health policy reform focus on Primary Health Care has designated local teams in eight municipalities to work on management and service models to alignment social programmes and health services and involve communities. Related programmes to reenforce infrastructure resilience for earthquakes and climate emergencies also have an equity lens. In the case of Costa Rica, with social development mechanisms proposed by a ‘non-health’ ministry (ministry of social development) in the beginning and local government in this momentum have facilized the engagement with communities and other sectors to link health and social services and strength the relations. In Lao, the extensive health centre network with primary health care staff in rural areas serves as an asset to local government partners. In the occupied Palestinian territories, before the war, there was extensive planning to undertake local health equity assessments as part of local government prioritisation. The use of noncommunicable disease multisectoral and multistakeholder mechanisms in the Philippines engages actors defending patients with chronic health conditions.

An overarching entry point is thus the redesign of the Primary Health Care approach (WHO, 2019), given the many synergies between PHC and health equity goals.

(iii) Knowledge and practice sharing networks

Building systems from the ground up requires networks of people whose shared experiences and narratives transform the institutions and policies within which they work. Network-building is thus critical from community, services, policy and academic sectors. To support regional networking with affected communities, PAHO put in place a formal collaboration with the regional association of domestic workers. This collaboration has raised the visibility of health for workers in the informal economy. In 2023 PAHO launched networks to exchange experiences and learning on intersectoral action and social participation, to strengthen capacities and competencies at the local level. (paho.org/sites/default/files/declaracion_intersectorialidad_la_habana_0.pdf).

At the global level, capacity building networks are being furthered through publications and summer schools on health equity, as spearheaded by the UNIL/UNISANTE. Looking ahead, the WHO will hold the first global Initiative country Pathfinder meeting to share experiences on health equity strategies. To amplify experiences globally, a global platform will launched through UCL/IHE based on success of the Health Equity Network (healthequitynetwork.co.uk/).

Health strategies require securing a role for health actors as active contributors and change agents for social problems and champions of health equity.

Conclusions

Health strategies require securing a role for health actors as active contributors and change agents for social problems and champions of health equity. Strategies need to address the transformation of institutions and vision, leadership and planning of the health sector. People in health in governance, management and services are critical as they allocate resources to build assets and services that impact health, are most aware of health impacts and need to be exemplar advocates. Narratives, robust health sector involvement and networks create enabling conditions for starting and sustaining health equity strategies.

References

• Chancel, L., Piketty, T., Saez, E., Zucman, G. et al. (2022). World Inequality Report 2022, World Inequality Lab (wir2022.wid.world). https://wir2022.wid.world/www-site/uploads/2021/12...
• CSDH (2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. World Health Organization, Geneva. (who.int/publications/i/item/WHO-IER-CSDH-08.1)
• Donkin, A., Goldblatt, P., Allen, J., Nathanson, V., Marmot, M. (2017). “Global action on the social determinants of health”. BMJ Glob Health; 1;3(Suppl 1):e000603. https://gh.bmj.com/content/bmjgh/3/Suppl_1/e000603...
• Green, L., Ashton, K., Bellis, M.A., Clemens, T., Douglas, M. (2021). “’Health in All Policies’-A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World”. Int J Environ Res Public Health;18(18):9468. (ncbi.nlm.nih.gov/pmc/articles/PMC8468680/)
• Green, F. Healy, N. (2022). “How inequality fuels climate change: The climate case for a Green New Deal”, One Earth; 5(6): 635-649. (sciencedirect.com/science/article/pii/S2590332222002202) https://www.sciencedirect.com/science/article/pii/...
• Irwin A., Scali E.(2010). “Action on the Social Determinants of Health: learning from previous experiences”. Social Determinants of Health Discussion Paper 1 (Debates). Geneva: World Health Organization.
• Lilly, K., Kean, B., Hallett, J., Robinson, S., Selvey, L.A. (2023). “Factors of the policy process influencing Health in All Policies in local government: A scoping review”. Front Public Health [Internet]. 2023 Feb 9;11:1010335. (ncbi.nlm.nih.gov/pmc/articles/PMC9949293/) https://www.frontiersin.org/articles/10.3389/fpubh...
• Solar, O., Valentine, N., Castedo, A. et al. (2022). Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative. Int J Equity Health 21 (Suppl 3), 193. (doi.org/10.1186/s12939-022-01798-y)
• Virchow, R. (1848a). “Die Medicin ist eine sociale Wissenschaft, und die Politik ist weiter nichts, als Medicin im Grossen.” In: 'Der Armenarzt' (Poor Doctor), Die Medizinische Reform (3 Nov 1848), 3(18):125. As translated in Henry Ernest Sigerist, Medicine and Human Welfare, (1941) 93.
• Virchow, R. (1848b). “Die Ärzte sind die natürlichen Anwälte der Armen und die sociale Frage fallt zu einem erheblichen Theil in ihre Jurisdiction.” In: Introductory article. DieMedizinische Reform (10 Jul 1848). As translated in Rudolf Virchow and L.J. Rather (ed.), Collected Essays on Public Health and Epidemiology (1985), Vol. 1(4)Elsewhere seen translated as “Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them,” or “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”
• Williams, C., Smith, J.A., Valentine, N., Baum, F., Friel, S., Williams, J., Schmitt, D. (2023). “The well-being economy and health in all policies: Fostering action for change”. Health Promot J Austr;34(3):623-625.
• World Health Organization (2011). Rio Political Declaration on Social Determinants of Health Rio de Janeiro, Brazil, 21 October 2011. Geneva: World Health Organization. (who.int/publications/m/item/rio-political-declaration-on-social-determinants-of-health)
• World Health Organization (2019). Review of 40 years of primary health care implementation at country level. Geneva: World Health Organization. (who.int/docs/default-source/documents/about-us/evaluation/phc-final-report.pdf)
• World Health Organization (2021). COVID-19 and the social determinants of health and health equity: evidence brief. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789240038...
• World Health Organization, International Bank for Reconstruction and Development / The World Bank (2023). Tracking universal health coverage: 2023 global monitoring report. Geneva: WHO and International Bank for Reconstruction and Development / The World Bank. https://www.who.int/publications/i/item/9789240080...