Chapter 3

Chapter 3

Social Determinants of Health: the World Health Organisation's policy agenda

3.1        Over the last several decades, there has been increasing recognition that social determinants of health have an impact on human health, and that they must be addressed if the overarching goals of health equality among all people are to be achieved. At the 1978 International Conference on Primary health Care in Alma Ata, governments from around the globe affirmed a holistic view of health as more than the absence of illness, and that maintaining high standards of health required action in the social and economic spheres, declaring:

The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector.[1]

3.2        Almost a decade later in 1986, the first International Conference on Health Promotion held in Ottawa, Canada, culminated in the 'Ottawa Charter for Health Promotion' (Ottawa Charter). The Ottawa Charter highlighted a number of prerequisites for health including peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity.[2]

3.3        More recently, the 1997 WHO Global Conference on Intersectoral Action for Health, the 2005 Bangkok Health Promotion conference and the 2006 EU's Finnish presidency's theme of Health in All Policies each recognised that political, economic, social, cultural, environmental, behavioural, and biological factors can all favour health or be harmful to it, and the need for all sectors of society to be involved in health policy.[3] These milestones demonstrate an appreciation in the international community that the most effective means of tackling the social determinants of health is through intersectoral action. As most of the determinants of health lie outside of the health sector, the solutions will have to involve areas outside the health sector.

3.4        In 2008 the World Health Organisation's (WHO) Commission on Social Determinants of Health published a report titled 'Closing the gap in a generation: health equity through action on the social determinants of health' (WHO Report).[4] This report refocused attention on the necessity of addressing the social determinants of health. In the words of one of the report's authors, the WHO Report:

...shone a global spotlight on the marked health inequalities that exist between and within countries at the start of the 21st century...the [WHO Report] in 2008 was a call to action to governments and non-governmental agencies around the world to adapt the necessarily general global recommendations into national and local socioeconomic and sociocultural contexts.[5]

3.5        The Australian perspective was actively represented on the Commission with one of the 19 commissioners being Australian. During the preparation of the WHO Report there was also a seminar in Adelaide which considered the social determinants of indigenous health.[6]

3.6        In May 2009, following the publication of the WHO Report, WHO Resolution 62.14 urged member states:

To tackle the health inequities within and across countries through political commitment on the main principles of 'closing the gap in a generation' as a national concern, as is appropriate, and to coordinate and manage intersectoral action for health in order to mainstream health equity in all policies, where appropriate, by using health and health equity impact assessment tools; [and]

...

To take into account health equity in all national policies that address social determinants of health, and to consider developing and strengthening universal comprehensive social protection policies, including health promotion, disease prevention and health care, and promoting availability of and access to goods and services essential to health and well-being.[7]

3.7        In the wake of the report a number of countries around the world and governments in Australia began exploring options to address the social determinants of health within their own populations.  

3.8        The key social determinants of health vary between countries: developed and developing countries necessarily face different challenges and will need to adopt different solutions. In developed countries – such as Australia, a low socioeconomic position means fewer education and employment opportunities, job insecurity, poorer working conditions, a lack of amenities, and unsafe neighbourhoods, with their consequent impact on family life.[8]

Recommendations from the Commission on Social Determinants of Health

3.9        The WHO Report highlighted three broad key areas for action:

3.10      The WHO Report notes that although there are broad principles that can be used to guide action in addressing the social determinants of health, precise policy measures need to be devised by each individual nation depending on their individual circumstances.[10] This chapter highlights the key policy areas nominated by the WHO Report for action. The following chapters will discuss policy options for the Australian context. 

Strengthening public sector leadership

3.11      The Report notes the importance of public sector leadership in effective national and international regulation of products, activities, and conditions that damage health or lead to health inequalities.[11] As the report explains:

Underpinning action on the social determinants of health and health equity is an empowered public sector, based on principles of justice, participation, and intersectoral collaboration. This will require strengthening of the core functions of government and public institutions, nationally and sub-nationally, particularly in relation to policy coherence, participatory governance, planning, regulation development and enforcement, and standard setting.[12]

3.12      A key proposal put forward in the WHO Report to improve the social determinants of health is the inclusion of a health equity impact statement as a component of public policy creation and administration to ensure that all policies are assessed against their potential health impacts.[13] Policy coherence is highlighted as a key area of concern; ensuring that all government policies complement each other in relation to promoting health equity is an important step in addressing the social determinants of health.[14] This extends beyond the traditional domains of health: all policies should be assessed for their health impact.[15] In the words of the WHO: 'The argument for a coherent approach to health equity through action on the social determinants in all socioeconomic and sociocultural contexts is unequivocal.'[16] The WHO Report argues that: 'Health equity impact assessment of policies and programmes must happen as a matter of course – that is, it should be a routine procedure in policy development.'[17]

3.13      One recommendation in the WHO Report is that governments formally commit to improving health equity through action on the social determinants of health as a measure of government performance.[18] One mechanism to achieve this is through reporting mechanisms. This option is discussed in more detail in Chapter 5 of this report.

Ensure universal social protection

3.14      The WHO report argues that universal social protections are important for population health in general, and especially for disadvantaged groups, and recommends that social protection systems are universal in scope and extend across the life course. Universality in this context means that all citizens have access to social protection as a social right. It is argued that:

Universal approaches are important for the dignity and self-respect of those who need social protection the most. And because everybody benefits, rather than just one group that is singled out, universal social protection systems can enhance social cohesion and social inclusion, and can be politically more acceptable. Including the middle classes by means of universal programmes can enhance willingness of large parts of the population to pay the taxes needed to sustain universal and generous policies.[19]  

3.15      The report goes on to note that universal benefits can improve the social status and inclusion of older people who can no longer earn a living in the market, and also decrease gender inequalities as women tend to live longer and earn less than men making contributory pension schemes disadvantageous.[20]

3.16      The WHO Report emphasizes the importance of ensuring universal access to healthcare based on the principle of access rather than ability to pay. Out of pocket expenses are argued to generate 'utilisation inequalities' and potentially exclude vulnerable groups such as the aged and single parents.[21]

3.17      The WHO Report highlights the importance of adequate funding to address the social determinants of health. As the report explains:

Health equity relies on an adequate supply of and access to material resources and services; safe, health-promoting living and working conditions; and learning, working, and recreational opportunities. Supply of and access to these, in turn, requires public investment and adequate levels of public financing, and/or regulation of markets where private provision can be an effective and efficient means of equitable access...Traditionally, governments are expected to play an active role in providing public goods. Left solely to the market, such goods are undersupplied.[22]

Promoting gender equality

3.18      The WHO has pointed out that, globally, women control less capital, receive lower wages, and carry more of the domestic burdens than their male counterparts. This trend is as true in developed as developing countries. In order to address the social determinants of health, there is a need to improve the status and position of women in society; ensuring that they receive the same remuneration as men for the same work, that their domestic contributions are not overlooked, and that they are compensated for reduced earnings caused by familial responsibilities such as child-birth and -rearing.[23] 

3.19      It was suggested that the provision of quality childcare facilities, flexible working hours, and parental leave for men and for women would assist in improving gender equality.[24]

3.20      One of the serious consequences of women receiving lower wages than men and spending more time out of the labour market as a consequence of acting as primary caregivers is that they have lower accumulated retirement incomes. Poverty and low pension benefits are strongly associated with worse health outcomes.[25]

Lesbian, Gay, Bisexual, Transgender and Intersex people

3.21      During the inquiry the committee heard some criticism of the lack of consideration of Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) people in the WHO Report.[26] Although the WHO report discusses the impacts of gender on the health of women and girls, there is no mention of sexuality, nor its impacts on health.

3.22      The committee received evidence from a number of submissions that LGBTI social determinants of health should also be considered in any government response.[27] Evidence provided to the committee highlighted that in Australia sexuality acts a social determinant of health and needs to be recognised as such.[28] Fields such as education and access to healthcare were cited as key areas in which the social determinants of health are acting on LGBTI people.[29]   

Improve understanding of the social determinants of health

3.23      One of the key recommendations of the WHO Report – to improve the measurement and understanding of the social determinants of health – is born out of the acknowledgement that in many areas there is limited data available on the impacts and causes of the social determinants of health. The standard tools found in the researchers toolbox such as controlled trials and benchmarking are difficult (and often unethical) to apply to a community.[30] Establishing chains of cause and effect for social determinants of health is conceptually and empirically difficult as many determinants are distant – spatially and temporally – from the individuals they impact.[31]

3.24      Although the WHO Report recognises the limitations in the available data, especially in relation to the most effective interventions to address the social determinants of health, the available evidence appears to strongly correlate with the theory of social determinants of health as discussed in the previous chapter. Chapter five of this report provides a more fulsome discussion of the importance of research and data to addressing the social determinants of health.

3.25      Successfully tackling the social determinants of health will require evidence-based policies. As the name implies, this will require good data on the extent of the problem, and up-to-date evidence on determinants and on what works to reduce health inequalities. It also requires that policy-makers and other professions understand both the social determinants of health and the evidence available in relation to them.[32]

3.26      In order to successfully research the social determinants of health, adequate research funding needs to be made available. The WHO Report argues that although the largest health improvements come from addressing the social determinants of health, the available research funding remains 'overwhelmingly' biomedically focused.[33]

3.27      In light of the large amount of work that needs to be done to adequately understand the social determinants of health, the WHO Report highlights three key areas of action:

First, research on determinants of health inequalities, rather than determinants of average population health, need further study. Second, more research is needed on what works to reduce health inequalities in what circumstances, and how best to implement interventions such that they contribute to a reduction of these inequalities...The third area for investment is the development of methods for measuring and monitoring health inequities and for evaluating the impact of population-level interventions.[34]

3.28      The WHO Report advocates that governments collect data on the most important social determinants of health ranging from daily living conditions to more structural drivers of health inequality. The system, it is argued, should be designed in such a way that it is possible to follow differences in gender and social-strata outcomes over extended periods of time.[35]

Conclusion

3.29      The theory and evidence for the social determinants of health having a direct impact on the lives of individuals has been well documented by the WHO and researchers from around the world. The WHO Report touches on almost all areas of society and government responsibility. In response to the rising awareness of the expansive nature of the social determinants of health, a number of countries have begun taking a social determinant of health approach to public policy making. There are also several initiatives in Australia which are beginning to address the social determinants of health. The following chapter discusses various social determinants of health and potential means to addressing them in the Australian context.

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