Social Determinants of Health

Clara Ejembi

MPH Lecture 1
 Objectives

1. Discuss the role of population-level determinants on the

health status and health care of individuals and populations
2. Identify underlying causes of health disparities
3. Describe the social determinants of health
4. Describe strategies to address the social determinants of
health
5. Discuss health in all policies and how to operationalize it

MPH Lecture 2
What determines how healthy we are?

MEDICAL
CARE
Medical
Genetics
5-15%ENET care 10%

INDIVIDUAL
BEHAVIORS
Behaviour
/Lifestyle 30%
2012 NMAHC/M. McMurray-Avila
What really are the determinants of health?
Social, Economic & Environmental Determinants of
Health Built Environment
Civic Engagement
Culture
Early Childhood Experiences
Education
Employment/Income
Environment - Air, Water, Toxins
Food Security/Nutrition
Health Care - Physical/Mental
Housing
Land Use Policy
Social Support
Transportation
Working Conditions

2012 NMAHC/M. McMurray-Avila

What are the social determinants of health?
Social determinants of health

Social determinants of Health are the environmental conditions

in which people are born, grow, live, learn, work, play, worship,
and age that influence many health functions and quality of
health outcomes.

MPH Lecture 6
Dramatic inequities dominate global health
today
Global Programme on Evidence for Health Policy, 2000 data
Probability of dying between the ages of 15 and 60 years

Country Probability of death/1000

Sweden 4
UK 6
USA 14
South Africa 67
Ghana 117
Senegal 127
Nigeria 197
Niger 259

Source World Health Report 2006

MPH Lecture 9
Inequalities also exist within countries

MPH Lecture 10
Economic gradient along continuum
of care - Nigeria
 The poor health of the poor, the social gradient in health
between and within countries and the marked inequities
between countries are caused by:

Structural determinants
the unequal distribution in power, money, goods and services,
globally, nationally and locally

Conditions of daily life

The consequent unfairness in the immediate circumstances
in people’s lives - access to schools, education, health care,
conditions of work and leisure, their homes, communities,
towns or cities
Commission on Social Determinants of Health, 2008
Why focus on social determinants of health

 Has direct impact on health

 Social determinants of health structure other causes of ill
health
 Environment
 Behaviour
 Services
 Is the ‘cause of causes’

MPH Lecture 13
Conceptual framework for Social Determinants of
Health

MPH Lecture 14
Examples of SDH on some diseases

MPH Lecture 15
Addressing the social determinants
of health

 Involves the medical care and public health

systems, but clearly extends beyond these

 Requires collaboration with multiple sectors

outside of health, including education, housing,
labor, justice, transportation, agriculture, and
environment
Addressing the social determinants
of equity

 Involves monitoring for inequities in exposures

and opportunities, as well as for disparities in
outcomes

 Involves examination of structures, policies,

practices, norms, and values to answer, “How are
these inequities being maintained?”

 Requires intervention on societal structures and

attention to systems of power
We need to do both

 Address the social determinants of health,

including poverty, in order to achieve large and
sustained improvements in health outcomes

 Address the social determinants of equity,

including poverty and gender, in order to achieve
social justice and eliminate health disparities
CSDH three overarching recommendations:

1. Improve daily living conditions

2. Tackle the unequal distribution of power, money

and resources

3. Measure and understand the problem and assess

the impact of action
Framework for addressing Social Determinants of Health

Source: WHO

MPH Lecture 20
Early Life

Over 200 million children under 5 are not

reaching their developmental potential
Grantham-McGregor et al. Lancet 2007
Effects of nutritional supplementation and psychosocial stimulation
on stunted children in a 2 year study, Jamaica

Granthan-McGregor et al 1991
Urban health challenges

 Communicable and non-communicable diseases

 HIV/AIDS
 Road traffic injuries
 Urban violence and crime
 Substance abuse and illicit drug use
 Underweight and overweight

KNUS report 2007

Employment and Working Conditions
 Regional variation in the percentage of people in
work living on US$2/day or less

ILO, 2008
 Cost of a Standard Healthy Living Basket as a percentage
of Weekly Household Income, 2005

Friel et al, 2005. Standard of healthy living on the Island of Ireland. FSPB
 Precarious employment and mental health
35

30

25 Permanent

Fixed term
Percent

20
temporary
Non-fixed term
15 temporary
No contract
10

0
Men Women

Artazcoz et al, 2005

Economic and social policies matter for
health and health equity
Health Care

Every year, 100 million people are forced into

poverty by health care costs (ILO 2005).
Policy Challenge

Reorientation of health care

– Primary health care
– Disease prevention
– Health promotion

Progressive building of universal health care

services organised around PHC
2. Tackle the unequal distribution of power,
money and resources

“in a world that is so divided by inequalities in

wealth and opportunity, it is easy to forget that
we are part of one humanity”
Desmond Tutu in HDR, 2007.
Policy Challenges

Good Global
Governance
Political Health Equity in all
empowerment Policies,
– inclusion and voice Systems and Programmes

Gender Equity Fair Financing

Market
Responsibility
Overseas development assistance from donor countries
relative to per capita wealth, 1961-2002

EMERGING KEY ISSUES

Health Care
 Family policy generosity and child poverty

Lundberg et al, 2007

Power and Governance

Participatory
Processes

Health equity
HEiPSP at
the table
3:Measure, evaluate, expand the knowledge
base, improve skills and raise awareness

No data, no problem, no action

Claire
Delperdange
 KNOWLEDGE NETWORK THEMES
Diseases
of Public
Health Early Child
Measurement Impute Development

Health Women +
systems Building Gender
Health & Equity
Health
Equity

Globalization Urban Settings

Employment Social
Conditions Exclusion
 Monitoring and Evaluation

Life expectancy at birth (men)

The power of Glasgow (deprived) 54
data India 61
Korea 65
• Stratified data Poland 71
• Measures of health inequity Mexico 72
• Cuba 75
Surveillance system
• US 75
Different types of data /
UK 76
knowledge
Glasgow (affluent) 82
Monitoring and Evaluation

Knowing the impact on

health equity

• Tools to assess the impact of policy and

programmes
Improved human capacity

• Training needs
• medical, other health and non-health curricula
• workforce competencies

• Funding for evidence generation

• Push-pull factors: underlying determinants

• Public awareness and concern

Health in All Policies/Intersectoral Collaboration

42
Health in ALL POLICIES

 “Health in All Policies” (HiAP) is a way to operationalize the

understanding that our health is affected by multiple sectors of our
society and those sectors all have a role to play in helping us get
and stay healthy.

 HiAP is a collaborative approach to improving the health of all

people by incorporating health considerations into decision-making
across sectors and policy areas.

 HiAP, at its core, is an approach to addressing the social

determinants of health that are the key drivers of health outcomes
and health inequities.

HiAP is an approach, a process and a philosophy.

Context…

The public health challenges of

the 21st century are extremely
complex, and solutions will
require actions that go beyond
the purview of public health,
bringing together partners
across policy areas and sectors.

Messy, wicked problems

More Context…

Health in All Policies has gained significant traction in the

last few years, but its origins go back over 35 years to the
World Health Organization Declaration of Alma-Ata in 1978.

While public health has a long history of intersectoral

collaboration, Health in All Policies is an emerging approach
that aims to formalize the consideration of health in
decision-making at all levels of government in order to
promote healthy community environments and prevent
adverse health impacts in the future.
HiAP – 5 Key Elements

1. Promote health, equity and sustainability

2. Support intersectoral collaboration
3. Benefit multiple partners
4. Engage stakeholders
5. Create structural or procedural change
1. Promote health, equity and
sustainability

HiAP promotes health, equity and sustainability

through two avenues:
1) Incorporating health, equity and sustainability into
specific policies, programs, and processes, and
2) Embedding health, equity and sustainability
considerations into government decision-making
processes so that healthy public policy becomes
the normal way of doing business. Promoting
equity is an essential part of HiAP given the strong
ties between inequity and poor health outcomes.
2. Support intersectoral collaboration

HiAP brings together partners from

many sectors to:
recognize the links between health
and other issue and policy areas,
break down silos,
build new partnerships to promote
health and equity, and
increase government efficiency.
Breaking down silos…

LAND USE
PLANNING
ECONOMIC
EDUCATION
DEVELOPMENT

TRANSPORTATION

Agencies that are not typically considered as health

agencies play a major role in shaping the economic,
physical, social, and service environments in which people
live, and therefore have an important role to play in
promoting health and equity.
3. Benefit multiple partners

HiAP is built upon the idea of “co-benefits”

and “win-wins.” HiAP work should benefit
multiple partners, simultaneously addressing
the goals of public health agencies, other
government agencies and community
stakeholders to benefit more than one end
(achieve co-benefits) and create efficiencies
across sectors (find win-wins).
Co-benefits

Public health practitioners have a unique role to play in improving

the quality of life in our nation, but genuine efforts to improve
health must be made in partnership with other sectors.

The concept of co-benefits is essential for:

 securing support from partners
 reducing redundancies, and
 ensuring more effective use of scarce government resources.

Finding a balance between multiple goals will sometimes be

difficult, and requires negotiation, patience, and learning about and
valuing others’ priorities.
4. Engage stakeholders

HiAP engages a variety of stakeholders, beyond government

partners, such as community members, policy experts,
advocates, the private sector, and funders. Robust stakeholder
engagement is essential for ensuring that work is responsive to
community needs and for garnering valuable information
necessary to create meaningful and impactful change.
5. Create structural or procedural change

Over time, HiAP creates permanent changes in how

agencies relate to each other and how government
decisions are made. This requires maintenance of:
structures which can sustain intersectoral collaboration
mechanisms which can ensure a health and equity lens
in decision-making processes across the whole of
government.

This can be thought of as “embedding” or

“institutionalizing” HiAP within existing or new structures
and processes of government.
Strategies for implementation

HiAP actions and groups can take many forms. It can be

implemented through:
 creation of a new structure or group
 be applied to existing processes such as strategic
planning and grant-making
 or both
Many options exist for how to consider health in decision-
making, from using formal health impact assessment tools
to an informal application of a health lens. Partners,
leaders, and focus areas will vary, depending upon
political support, community needs, and resources.
Where do we start?
Look for “Windows of Opportunity”

1. Opportunistic approach – Identify existing issues, policies or

relationships that can provide early success for all partners
2. Issue approach – Identify policies that have major impact on
specific public health priorities (e.g., violence prevention,
hunger alleviation, or reduction of poverty)
3. Sector approach – Focus on one specific policy area with a
large health impact
(e.g., transportation or agriculture)
 Opportunistic Approach:
Food for Thought…

 Are there any existing or newly forming interagency initiatives

that have potential health implications?
 What single-agency initiatives would benefit from partnership
with additional agencies?
 Is your agency, or is another agency, going through a strategic
planning process?
 Is there a new or ongoing process where health metrics or
data could be added?
 What partners have you worked with successfully in the past?
Issue Approach: Root Cause Map

Lack of
physical
activity

Lack of
healthy
food
Sector Approach: Transportation
Characteristics of successful collaboration

 Identify a champion on the ground, such as a local

coalition that might have an interest in the issue.
 Build on past successes and define small wins that
can be accomplished early, are politically and
practically feasible, and have implications for health.
 Use active listening.
 Use a definition of health that addresses root causes.
 Highlight what partners have to gain from
participation and what you have to offer partners.
 Create a shared understanding of a mutual goal that
cannot be achieved alone.
Characteristics of successful collaboration

 Become familiar with the other sector’s policy making

processes, regulations, and any constraints that may impact
the ability to act on health recommendations.
 Identify shared goals and activities in statewide action plans.
 Build trust through transparency, frequent meetings, and
responsiveness to questions, concerns and limitations raised
by non-health partners.
 Social justice is a matter of life and death.
It affects the way people live, their
consequent chance of illness, and their
risk of premature death…

www.who.int/social_determinants
Interventions aimed at reducing
disease and saving lives succeed only
when they take the social
determinants of health adequately into
account (…)

That knowledge needs to be more fully

developed and widely shared so that it
can be used.

WHO Director-General Dr J.W. Lee

The Lancet, vol.365, 19 March 2005
Why treat population
... and later put them in the same life conditions ?