ConceptualframeworkforactiononSDH eng

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1 Social Determinant H t Heal of S of conditions and resources — and money , power to access the life daily the age and , work , live , grow , born are people which in circumstances [energy] [justice] [investment] [water] [community/gov.] [food] [accessible & safe] [supply & safety] [providers of services, education, etc.] or A Con C e P tu A l Fr A mework F A C tion on t H e So C i A l Determin A nt S H F He A l t o Social Determinants of Health Discussion Paper 2 ISBN 978 92 4 150085 2 H World Healt or G a NIZ at I o N ve a a N ue a pp I ev N 1211 Ge a 27 P , CASE STUDIES DEBATES, e oli CY & P r AC ti C d WI Z erla N t S IN a N t IN WWW . o. WH t/ S S I al_determ oc

2 A COnCeptu Al FrAmeWOrk FOr ACtiOn On tHe SOCiAl DeterminAntS OF HeAltH World Health Organization Geneva 2010

3 The Series: The Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the social determinants of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, and capacity building. They aim to review country experiences with an eye to understanding practice, innovations, and encouraging frank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed. Background: A first draft of this paper was prepared for the May 2005 meeting of the Commission on Social Determinants of Health held in Cairo. In the course of discussions the members and the Chair of the CSDH contributed substantive insights and recommended the preparation of a revised draft, which was completed and submitted to the CSDH in 2007. The authors of this paper are Orielle Solar and Alec Irwin. Acknowledgments: Valuable input to the first draft of this document was provided by members of the CSDH Secretariat based at the former Department of Equity, Poverty and Social Determinants of Health at WHO Headquarters in Geneva, in particular Jeanette Vega. In addition to the Chair and Commissioners of the CSDH, many colleagues offered valuable comments and suggestions in the course of the revision process. Thanks are due in particular to Joan Benach, Sharon Friel, Tanja Houweling, Ron Labonte, Carles Muntaner, Ted Schrecker, and Sarah Simpson. Any errors are responsibility of the principal writers. Suggested Citation: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). WHO Library Cataloguing-in- Publication Data A conceptual framework for action on the social determinants of health. (Discussion Paper Series on Social Determinants of Health, 2) 1.Socioeconomic factors. 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) © World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by the WHO Document Production Services, Geneva, Switzerland.

4 A conceptual framework for action on the social determinants of health Contents 3 foreword executive Summary 4 1. introduction 9 2. HiS torical trajectory 10 3. defining core valueS: HealtH equity, Human rigHt S, tribution of power 12 and diS 4. previouS tHeorieS and modelS 15 Current directions in SDH theory 4.1 15 4.2 16 Pathways and mechanisms through which SDH influence health 4.2.1 Social selection perspective 16 4.2.2 Social causation perspective 17 4.2.3 Life course perspective 18 5. cSdH conceptual framework 20 5.1 Purpose of constructing a framework for the CSDH 20 5.2 Theories of power to guide action on social determinants 20 5.3 Relevance of the Diderichsen model for the CSDH framework 23 First element of the CSDH framework: socio-economic and political context 5.4 25 5.5 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 33 5.5.5 Gender 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 of the framework shown thus far 35 5.6 Third element of the framework: intermediary determinants 36 5.6.1 Material circumstances 37 1

5 5.6.2 Social-environmental or psychosocial circumstances 38 39 5.6.3 Behavioral and biological factors. 5.6.4 The health system as a social determinant of health. 39 5.6.5 Summarizing the section on intermediary determinants 40 41 5.6.6 A crosscutting determinant: social cohesion / social capital 43 Impact on equity in health and well-being 5.7 5.7.1 Impact along the gradient 43 5.7.2 Life 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 44 5.8 Summary of the mechanisms and pathways represented in the framework 5.9 48 Final form of the CSDH conceptual framework 6. policieS and interventionS 50 Gaps and gradients 50 6.1 Frameworks for policy analysis and decision-making 51 6.2 6.3 Key dimensions and directions for 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 t of abbreviationS liS 66 referenceS 67 liS t of figureS Figure A: Final form of the CSDH conceptual framework 6 Figure B: Framework for tackling SDH inequities 8 Figure 1: Model of the social production of disease 24 Figure 2. Structural determinants: the social determinants of health inequities 35 Figure 3: Intermediary determinants of health 41 Figure 4: Summary of the mechanisms and pathways represented in the framework 46 Figure 5: Final form of the CSDH conceptual framework 48 Figure 6: Typology of entry points for policy action on SDH 53 Figure 7: Framework for tackling SDH inequities 60 liS t of tableS Table 1: Explanations for the relationship between income inequality and health 31 Table 2: Social inequalities affecting disadvantaged people 38 62 Table 3: Examples of SDH interventions 2

6 A conceptual framework for action on the social determinants of health Foreword onceptual frameworks in a public health context shall in the best of worlds serve two equally important purposes: guide empirical work to enhance our understanding of determinants and mechanisms and guide policy-making to illuminate entry points for interventions and policies. C Effects of social determinants on population health and on health inequalities are characterized by working through long causal chains of mediating factors. Many of these factors tend to cluster among individuals living in underprivileged conditions and to interact with each other. Epidemiology and biostatistics are therefore facing several new challenges of how to estimate these mechanisms. The Commission on Social Determinants of Health made it perfectly clear that policies for health equity involve very different sectors with very different core tasks and very different scientific traditions. Policies for education, labour market, traffic and agriculture are not primarily put in place for health purposes. Conceptual frameworks shall not only make it clear which types of actions are needed to enhance their “side effects” on health, but also do it in such a way that these sectors with different scientific traditions find it relevant and useful. This paper pursues an excellent and comprehensive discussion of conceptual frameworks for science and policy for health equity, and in so doing, takes the issue a long way further. Finn Diderichsen MD, PhD Professor, University of Copenhagen October, 2010 3

7 executive summary omplexity defines health. Now, more than ever, in the age of globalization, is this so. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization (WHO) to get to the heart of this complexity. They were tasked with summarizing the evidence on how the structure of societies, through myriad social interactions, norms and C institutions, are affecting population health, and what governments and public health can do about it. To guide the Commission in its mammoth task, the WHO Secretariat conducted a review and summary of different frameworks for understanding the social determinants of health. This review was summarized and synthesized into a single conceptual framework for action on the social determinants of health which was proposed to and, largely, accepted by, the CSDH for orienting their work. A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result. This paper describes the review, how the proposed conceptual framework was developed, and identifies elements of policy directions for action implied by the proposed conceptual framework and analysis of policy approaches. A key lesson from history (including results from the previous “historical” paper - see Discussion Paper 1 in this Series), is that international health agendas have tended to oscillate between: a focus on technology-based medical care and public health interventions, and an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action. In this context, the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutional commitments to health equity and social justice. Having health framed as a social phenomenon emphasizes health as a topic of social justice more broadly. Consequently, health equity (described by the absence of unfair and avoidable or remediable differences in health among social groups) becomes a guiding criterion or principle. Moreover, the framing of social justice and health equity, points towards the adoption of related human rights frameworks as vehicles for enabling the realization of health equity, wherein the state is the primary responsible duty bearer. In spite of human rights having been interpreted in individualistic terms in some intellectual and legal traditions, notably the Anglo-Saxon, the frameworks and instruments associated with human rights guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having been associated with historical struggles for solidarity and the empowerment of the deprived they form a powerful operational framework for articulating the principle of health equity. Theories on the social production of health and disease With this general framing in mind, developing a conceptual framework on social determinants of health (SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three main theoretical non-mutually exclusive explanations were reviewed: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social frameworks. 4

8 A conceptual framework for action on the social determinants of health All three of these theoretical traditions, use the following main pathways and mechanisms to explain causation: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives. Each of these theories and associated pathways and mechanisms strongly emphasize the concept of “social position”, which is found to play a central role in the social determinants of health inequities. A very persuasive account of how differences in social position account for health inequities is found in the Diderichsen’s model of “the mechanisms of health inequality”. Didierichsen’s work identifies how the following mechanisms stratify health outcomes: ∏ Social contexts, which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions. ∏ Social stratification in turn engenders differential exposure to health-damaging conditions and , in terms of health conditions and material resource availability. differential vulnerability ∏ Social stratification likewise determines of ill health for more and differential consequences less advantaged groups (including economic and social consequences, as well differential health outcomes per se). The role of social position in generating necessitates a central role for a further two health inequities conceptual clarifications. First, the central role of power. While classical conceptualizations of power equate power with domination, these can also be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action as embodied in legal system class suits. In this context, human rights embody a demand on the part of oppressed and marginalized communities for the expression of their collective social power. The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of social the state. Second, it is important to clarify the conceptual and practical distinction between the causes of health and the social factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework makes a point of making clear this distinction. On this second point of clarification, conflating the social determinants of health and the social processes that 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 factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups. Furthermore, policy objectives are defined quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities. The CSDH Conceptual Framework Bringing these various elements together, the CSDH framework, summarized in Figure A, shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of 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 “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions. “Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market; the educational system, political institutions and other cultural and societal values. Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies). In the CSDH framework, structural mechanisms are those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and processes of the 5 socioeconomic and political context.

9 The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity. Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors. The main categories of are: material circumstances; psychosocial intermediary determinants of health circumstances; behavioral and/or biological factors; and the health system itself as a social determinant. ∏ Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment. ∏ Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof ). ∏ Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors. The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people’s lives. Figure A. Final form of the CSDH conceptual framework SOCIOECONOMIC AND POLITICAL CONTEXT Governance Socioeconomic Material Circumstances Macroeconomic Position (Living and Working, Policies IMPACT ON Conditions, Food EQUITY IN Availability, etc. ) Social Policies Social Class HEALTH Labour Market, Gender Behaviors and AND Housing, Land Ethnicity (racism) Biological Factors WELL-BEING Psychosocial Factors Public Policies Education Education, Health, Social Protection Social Cohesion & Social Capital Occupation Culture and Income Societal Values Health System STUCTURAL DETERMINANTS INTERMEDIARY DETERMINANTS SOCIAL DETERMINANTS OF SOCIAL DETERMINANTS HEALTH INEQUITIES OF HEALTH 6

10 A conceptual framework for action on the social determinants of health The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both. Yet focus on social capital, depending on interpretation, risks reinforcing depoliticized approaches to public health and the SDH, when the political nature of the endeavour needs to be an explicit part of any strategy to tackle the SDH. Certain interpretations have not depoliticized social capital, notably the notion of “linking social capital”, which have spurred new thinking on the role of the state in promoting equity, wherein a key task for health politics is nurturing cooperative relationships between citizens and institutions. According to this literature, the state should take responsibility for developing flexible systems that facilitate access and participation on the part of the citizens. Policy action Finally, in turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified. These may be based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population. A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other. Policy development frameworks can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. The review showed the framework that Diderichsen and colleagues proposed- a typology or mapping of entry points for policy action on SDH inequities - to be very useful in the way it is very closely aligned to theories of causation. They identify actions related to: social stratification; differential exposure/ differential vulnerability; differential consequences and macro social conditions. Considerations of these policy action frameworks lead to discussion of three key strategic directions for policy work to tackle the SDH, with a particular emphasis on tackling health inequities: (1) the need for strategies to address context; (2) intersectoral action; and (3) social participation and empowerment. Policy action challenges for the CSDH Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups (see Figure B). To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches. 7

11 Figure B. Framework for tackling SDH inequities Context-specific Key dimensions and directions for policy strategies tackling both structural and intermediary Social Participation Intersectoral determinants and Empowerment Action Globalization Environment Policies on to reduce inequalities, stratification mitigate effects of stratification Macro Level: of disadvantaged exposures Policies to reduce Public Policies people to health-damaging factors Mesa Level: Policies to reduce vulnerabilities of disadvantaged people Community of unequal consequences Policies to reduce illness in social, economic and health terms Micro Level: Individual interaction 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 A key task for the CSDH will be: 1 to identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and to characterize in detail the political and management mechanisms that have enabled effective intersectoral programmes to function sustainably. 2 to demonstrate how participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward after the Commission has completed its work. 3 Finally, SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science. 8

12 A conceptual framework for action on the social determinants of health A conceptual framework for action on the social determinants of health A conceptual framework for action on the social determinants of health introduction 1 n announcing his intention to create the The CSDH conceptual framework synthesizes Commission on Social Determinants many elements from previous models, yet we of Health (CSDH), World Health believe it represents a meaningful advance. We Organization (WHO) Director-General O ground the framework in a theorization of social Lee Jong-wook identified the Commission as power and make clear our debt to the work of part of a comprehensive eff ort to promote greater Diderichsen and colleagues. We present the 1 equity in global health in a spirit of social justice . core components of the framework, including: Th e Commission’s goal, then, is to advance health (1) socioeconomic and political context; (2) equity, driving action to reduce health diff erences structural determinants of health inequities; and among social groups, within and between (3) intermediary determinants of health. Our countries. Getting to grips with this mission answers to the fi rst two questions above will be requires fi nding answers to three fundamental articulated by way of these concepts. In the last problems: section of the paper, we deduce key directions for Where do health diff erences among social 1 pro-equity policy action based on the framework, groups originate, if we trace them back to providing broad elements of a response to the their deepest roots? third question. 2 What pathways lead from root causes to the stark diff erences in health status An important defi nitional issue must be clarifi ed observed at the population level? in advance. Th e CSDH has purposely adopted a In light of the answers to the fi rst two 3 broad initial defi nition of the social determinants questions, where and how should we of health (SDH). Th e concept encompasses the intervene to reduce health inequities? full set of social conditions in which people live and work, summarized in Tarlov’s phrase as This paper seeks to make explicit a shared “the social characteristics within which living 2 . A broad initial defi nition of SDH understanding of these issues to orient the work takes place” is important in order not to foreclose fruitful of the CSDH. We recall the historical trajectory of avenues of investigation; however, within the which the CSDH forms a part; and then we make fi eld encompassed by this concept, not all factors explicit the Commission’s fundamental values, have equal importance. Causal hierarchies will be in particular the concept of health equity and 3 . Much the commitment to human rights. We describe ascertained, leading to crucial distinctions of this paper will be concerned with clarifying the broad outlines of current major theories on these distinctions and making explicit the the social determinants of health, and we review relationships between underlying determinants perspectives on the causal pathways that lead from of health inequities and the more immediate social conditions to diff erential health outcomes. determinants of individual health. Afterwards a new framework for analysis and action on social determinants is presented as a potential contribution of the CSDH to public health - the “CSDH framework”. 9

13 Historical trajectory 2 ealth is a complex phenomenon, and it sector spending, constraining policy-makers’ 7 can be approached from many angles. . capacity to address SDH Over recent decades, international health agendas have tended to oscillate Even as these market-oriented reforms were H between: (1) approaches relying on narrowly being applied in both developing and developed countries, new and more systematic analyses of defi ned, technology-based medical and public health interventions; and (2) an understanding of the powerful impact of social conditions on health began to emerge. A series of prominent studies, health as a social phenomenon, requiring more complex forms of intersectoral policy action, including those of McKeown and Illich, challenged the dominant biomedical paradigm and debunked and sometimes linked to a broader social justice the idea that better medical care alone can generate agenda. 8,9,10,11,12 major gains in population health . The WHO’s 1948 Constitution clearly acknowledges UK’s Black Report on Inequalities in Health the impact of social and political conditions (1980) marked a milestone in understanding on health, and the need for collaboration with how social conditions shape health inequities. sectors such as agriculture, education, housing Black and his colleagues argued that reducing and social welfare to achieve health gains. During health gaps between privileged and disadvantaged the 1950s and 1960s, however, WHO and other social groups in Britain would require ambitious global health actors emphasized technology- interventions in sectors such as education, housing driven, ‘vertical’ campaigns targeting specific and social welfare, in addition to improved clinical 4 13 diseases, with little regard for social contexts care . . A social model of health was revived by the 1978 Th roughout the 1980s and early 1990s, the Black Alma-Ata Declaration on Primary Health Care Report sparked debates and inspired a series and the ensuing Health for All movement, which reasserted the need to strengthen health equity by of national inquiries into health inequities in addressing social conditions through intersectoral other countries, e.g. the Netherlands, Spain and 5 . Sweden. Th e pervasive eff ects of social gradients programmes on health were progressively clarifi ed, in particular Many governments embraced the principle of by the Whitehall Studies of Comparative Health 14, 15 . intersectoral action on SDH, under the banner of Outcomes among British civil servants Important work at WHO’s European Offi ce in the Health for All; however, the neoliberal economic early 1990s laid conceptual foundations for a new models that gained global ascendancy during the 1980s created obstacles to policy action. In the health equity agenda, and the vocabulary of SDH 16, 17 began to achieve wider dissemination . health sector, neoliberal approaches mandated market-oriented reforms that emphasized By the late 1990s and early 2000s, in response efficiency over equity as a system goal and to mounting documentation of the scope of often reduced disadvantaged social groups’ 6 inequities, and evidence that existing health and access to health care services . On the level of 3, social policies had failed to reduce equity gaps macroeconomic policy, the structural adjustment 16, 18, 19 , health equity and the social determinants programmes (SAPs) imposed on many developing countries by the international fi nancial institutions of health had been embraced as explicit policy mandated sharp reductions in governments’ social concerns by a growing number of countries, 10

14 A conceptual framework for action on the social determinants of health commitments to health equity, social justice and particularly but not exclusively in Europe. In the a reinvigoration of the values of Health For All. UK, the arrival in 1997 of a Labour government Lee’s fi rst announcement of his intention to create explicitly committed to reducing health inequalities a Commission on Social Determinants of Health, focused fresh attention on SDH. Australia and at the 2004 World Health Assembly, positioned New Zealand explored options for addressing health determinants, with New Zealand’s 2000 the CSDH as a key component of his equity 20 health strategy refl ecting a strong SDH focus . agenda. Lee welcomed rising global investments In 2002, Sweden approved a new, determinants- in health, but affi rmed that “interventions aimed oriented national public health strategy, arguably at reducing disease and saving lives succeed only the most comprehensive model of national policy when they take the social determinants of health 24 adequately into account” action on SDH. New policies focused on tackling . Lee charged the Commission to mobilize emerging knowledge health inequities were passed in England, Ireland, Italy, the Netherlands, Northern Ireland, Scotland on social determinants in a form that could be 3 and Wales during this period turned swift ly into policy action in the low- and . Meanwhile, in developing regions, including sub-Saharan middle-income countries where needs are greatest. In his speech at the launch of the CSDH in Chile Africa, Asia, the Eastern Mediterranean and Latin America, resurgent critical traditions allying in March 2005, Lee noted that the Commission health and social justice agendas, such as the Latin would deliver its report in 2008 for the thirtieth American social medicine movement, refined anniversary of the Alma-Ata conference and sixty their critiques of market-based, technology-driven years aft er the formal entry into force of the WHO neoliberal health care models and called for action Constitution. He urged the Commission to carry 21, 22, 23 . to tackle the social roots of ill-health forward the values that had informed global public health in its most visionary moments, translating In 2003, Lee Jong-wook took offi ce as Director- them into practical action for a new era. General of WHO, on a platform marked by Key messages from this section: p Over recent decades, international health agendas have tended to oscillate between: (1) a focus on technology-based medical care and public health interventions; 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 movement gave 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 of existing 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 and practical 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 thirtieth anniversary of the Alma-Ata conference and sixty years after the WHO Constitution. He instructed the Commission to carry forward the values that have informed global public health in its most visionary moments, translating them into practical action. p The CSDH revives WHO constitutional commitments to health equity and social justice and reinvigorates the values of Health for All. 11

15 3 Defi ning core values: health equity, human rights, and distribution of power which profoundly compromise freedom. When such olicy choices are guided by values, which may health be implicit or explicit. Th e concept of inequalities arise systematically as a consequence of an individual’s social position, governance has failed is the explicit ethical foundation of equity in one of its prime responsibilities, i.e. ensuring the Commission’s work, while human rights P fair access to basic goods and opportunities that provide the framework for social mobilization and condition people’s freedom to choose among life- political leverage to advance the equity agenda. 30 plans they have reason to value empowering Realizing health equity requires . Ruger argues people, particularly socially disadvantaged groups, similarly for the importance of health equity as a to exercise increased collective control over the goal of public policy, based on “the importance 31 factors that shape their health. of health for individual agency” . Nonetheless, the causal linkages between health and agency are WHO’s Secretariat (the (then) Department of Equity, not uni-directional. Health is a prerequisite for full Poverty and Social Determinants of Health) defi ned individual agency and freedom; yet at the same time, social conditions that provide people with greater health equity (also referred to as socioeconomic agency and control over their work and lives are health equity) as “the absence of unfair and 32 associated with better health outcomes . One can avoidable or remediable diff erences in health among population groups defi ned socially, economically, say that health enables agency, but greater agency 25 . In essence, demographically or geographically” and freedom also yield better health. Th e mutually health inequities are health differences that are reinforcing nature of this relationship has important consequences for policy-making. socially produced, systematic in their distribution 26 . Identifying a across the population, and unfair health diff erence as inequitable is not an objective Th e international human rights framework is the appropriate conceptual structure within which to description, but necessarily implies an appeal to 27 ethical norms . advance towards health equity through action on SDH. Th e framework is based on the 1948 Universal Primary responsibility for protecting and enhancing Declaration of Human Rights (UDHR). Th e UDHR holds that ‘Everyone has the right to a standard of health equity rests in the fi rst instance with national governments. An important strand of contemporary living adequate for the health and well-being of moral and political philosophy was built on the himself and his family, including food, clothing, work of Amartya Sen to link the concepts of housing and medical care and necessary social 33 , and additionally that ‘Everyone services’ (Art. 25) health equity and agency and to make explicit the 28 is entitled to a social and international order in which . Joining Sen, implications for just governance Anand stresses that health is a “special good” whose the rights and freedoms set forth in this Declaration equitable distribution merits the particular concern can be fully realized’ (Art. 28). Th e human rights of political authorities. There are two principal aspects of health, and in particular connections reasons for regarding health as a special good: (1) between the right to health and social and economic health is directly constitutive of a person’s well-being; conditions, were clarifi ed in the 1966 International Covenant on Economic, Social and Cultural Rights and (2) health enables a person to function as an 29 (ICESCR). In ICESCR Article 12, States signatories agent . Inequalities in health are thus recognized acknowledge “the right of everyone to the enjoyment as “inequalities in people’s capability to function” 12

16 A conceptual framework for action on the social determinants of health Over recent years, the work of the United Nations of the highest attainable standard of physical and mental health”; and they commit themselves to Special Rapporteur on the Right to Health has specific measures to pursue this goal, including been instrumental in advancing the political agenda around the right to health at national and improved medical care and also health-enabling 38 measures outside the medical realm per se like the . global levels “improvement of all aspects of environmental and 34 . While human rights have oft en been interpreted industrial hygiene” in individualistic terms in some intellectual and Th e General Comment on the Human Right to Health legal traditions, notably the Anglo-Saxon, human rights guarantees also concern the collective released in 2000 by the UN Committee on Economic, Social and Cultural Rights explicitly affi rms that well-being of social groups and thus can serve to articulate and focus shared claims and an assertion the right to health must be interpreted broadly to of collective dignity on the part of marginalized embrace key health determinants including (but communities. In this sense, human rights not limited to) “food and nutrition, housing, access to safe and potable water and adequate sanitation, principles are intimately bound up with values of solidarity and with historical struggles for the safe and healthy working conditions, and a healthy 21, 39 35 environment” empowerment of the disadvantaged . The General Comment echoes . WHO’s Constitution and the 1978 Declaration of Alma-Ata in asserting a government’s responsibility Alicia Yamin and others have shown that is central to operationalizing the to address social and environmental determinants in empowerment right to health and making it relevant to people’s order to fulfi l citizens’ rights to the highest attainable lives. “A right to health based upon empowerment” standard of health. implies fundamentally that “the locus of decision- making about health shift s to the people whose Human rights offer more than a conceptual armature connecting health, social conditions and health status is at issue”. For Yamin, echoing Sen, broad governance principles. Rights concepts and the full expression of empowerment is people’s eff ective freedom to “decide what the meaning standards provide an instrument for turning diff use of their life will be”. In this light, the right to social demand into focused legal and political claims, as well as a set of criteria by which to evaluate the health aims at the creation of social conditions under which previously disadvantaged and performance of political authorities in promoting people’s well-being and creating conditions for disempowered groups are enabled to “achieve 36 . the greatest possible control over ... their equitable enjoyment of the fruits of development , As Braveman and Gruskin argue health”. Increased control over the major factors that infl uence their health is an indispensable component of individuals’ and communities’ broader capacity to make decisions about how 40 . they wish to live “A human rights perspective removes actions to relieve poverty and ensure equity from the voluntary realm of charity ... to the domain of law”. The health sector can use the “internationally recognized human rights mechanisms for legal accountability” to push for aggressive social policies to tackle health inequities, since international human rights instruments “provide not only a framework but also a legal obligation for policies towards achieving equal opportunity to be healthy, an obligation that necessarily requires consideration of poverty and 37 . social disadvantage” 13

17 KEY MESSAGES OF THIS SECTION: p The guiding ethical principle for the CSDH is health equity, defi ned as the absence of unfair and avoidable or remediable differences in health among social groups. p Primary responsibility for protecting health equity rests with governments. p The international human rights framework is the appropriate conceptual and legal structure within which to advance towards health equity through action on SDH. p The realization of the human right to health implies the empowerment of deprived communities to exercise the greatest possible control over the factors that determine their health. 14

18 A conceptual framework for action on the social determinants of health 4 previous theories and models stress from the ‘social environment’ alters he CSDH does not begin in its conceptual work in a vacuum. Th e concepts presented host susceptibility, aff ecting neuroendocrine function in ways that increase the organism’s here build on the contributions of many prior and contemporary analysts. In this vulnerability to disease. More recent T researchers, most prominently Richard section, we fi rst cite three important directions Wilkinson, have sought to link altered emerging recently in social epidemiology theory. neuroendocrine patterns and compromised Then we review a number of perspectives on health capability to people’s perception and the pathways through which social conditions experience of their place in social hierarchies. influence health outcomes. These discussions According to these theorists, the experience uncover important elements to be included in of living in social settings of inequality forces a framework for action for the CSDH. Finally people constantly to compare their status, we highlight areas that previous theories have possessions and life circumstances with those left insuffi ciently clarifi ed, and upon which, the proposed CSDH framework can shed new light. of others, engendering feelings of shame and worthlessness in the disadvantaged, along with chronic stress that undermines health. At the level of society as a whole, Current directions in SDH 4.1 theory meanwhile, steep hierarchies in income and social status weaken social cohesion, with this disintegration of social bonds also The three main theoretical directions invoked seen as negative for health. Th is research by current social epidemiologists, which are not has generated a substantial literature on the mutually exclusive, can be designated as follows: relationship between (perceptions of ) social (1) psychosocial approaches; (2) social production inequality, psychobiological mechanisms, of disease/political economy of health; and (3) 47, 48, 49, 50, 51, 52 and health status ecosocial theory and related multi-level frameworks. . ∏ A All three approaches seek to elucidate principles social production of disease/political framework explicitly economy of health capable of explaining social inequalities in health, and all represent what Krieger has called theories addresses economic and political of disease distribution that cannot be reduced to determinants of health and disease. Researchers adopting this theoretical mechanism–oriented theories of disease causation. approach also sometimes described as a Where they diff er is in their respective emphasis on diff erent aspects of social and biological conditions materialist or neo-materialist position, do not deny negative psychosocial consequences in shaping population health, how they integrate social and biological explanations, and thus their of income inequality. However, they argue 41, 42, 43 . that interpretation of links between income recommendations for action ∏ Th e fi rst school places primary emphasis inequality and health must begin with the on psychosocial factors , and is associated structural causes of inequalities, and not with the view that people’s “perception and just focus on perceptions of that inequality. experience of personal status in unequal Under this interpretation, the effect of 44, societies lead to stress and poor health” income inequality on health refl ects both 45 . Th is school traces its origins to a classic lack of resources held by individuals and 46 , in which he argued that study by Cassel systematic under-investments across a wide 15

19 53, 54, 55 range of community infrastructure . The basis of this selection is that health exerts a Economic processes and political decisions strong effect on the attainment of social position, condition the private resources available to resulting in a pattern of social mobility through individuals and shape the nature of public which unhealthy individuals drift down the social infrastructure—education, health services, gradient and the healthy move up. Social mobility refers to the notion that an individual’s social transportation, environmental controls, position can change within a lifetime, compared availability of food, quality of housing, either with his or her parents’ social status (inter- occupational health regulations—that forms material” matrix of contemporary the “neo generational mobility) or with himself/herself at an life. Thus income inequality per se is but earlier point in time (intra-generational mobility). It is important to distinguish between inter- and intra- one manifestation of a cluster of material generational health selection, although few studies conditions that affect population health. ∏ “ecosocial” approach and are available that examine selection in both ways. Recently, Krieger’s other emerging multi-level frameworks have The literature on health and social mobility suggests that, in general, health status influences subsequent sought to integrate social and biological 56, 57 factors and a dynamic, historical and social mobility , but evidence is patchy and not ecological perspective to develop new entirely consistent across different life stages. Also, there has been limited and inconclusive evidence on insights into determinants of population the effect that this could have on health gradients distribution of disease and social inequities 41, 42, 43 58, 59, 60 . According to Krieger, multi- . Recently, it was proposed that health-related in health 61 . social mobility does not widen health inequalities level theories seek to “develop analysis of On this interpretation, people who are downwardly current and changing population patterns of health, disease and well-being in relation mobile because of their health still have better to each level of biological, ecological and health than the people in the class of destination, social organization”, all the way from the upgrading this class. Similarly, upwardly mobile people will nonetheless lower the mean health in cell to human social groupings at all levels the higher socio-economic classes into which they of complexity, through the ecosystem as a 62, 57 . Again, the evidence for become incorporated whole. In this context, Krieger’s notion of this is inconsistent, with some studies suggesting “embodiment” describes how “we literally incorporate biological influences from the that health selection acts to reduce the magnitude 68 63, 64, 65, 66, 67 material and social world” and that “no . , whereas others do not of inequalities aspect of our biology can be understood Some studies conclude that health selection cannot be regarded as the predominant explanation for divorced from knowledge of history and 69, 70 41 . health inequalities individual and societal ways of living” . Approaches to studying health Pathways and mechanisms 4.2 selection through which SDH influence Several approaches have been used to study the health role and magnitude of health selection on the social gradient. One approach focuses on the effect Having canvassed major theoretical approaches to of social mobility, that is all social mobility and SDH, we now proceed to review specific models, not just that related to health status, on health or 71, 72 health gradients . A second approach focuses and the supporting evidence, that purport to explain health inequities. We characterize these on the effect of health status at an earlier life 73 models as “perspectives”, adopting Mackenbach’s stage in relation to health gradients later on . A classification. This term underscores that third approach has been suggested to overcome these difficulties by focusing on both prior health the hypotheses examined have a potentially 74, 75 complementary character and, like the theoretical status and social mobility . It has been argued “directions” described in section 4.1, should not be that health selection would have a stronger effect regarded as necessarily mutually exclusive. around the time of labour market entry, when the 57 likelihood of social mobility is greatest . 4.2.1 Social selection perspective It may be fruitful to distinguish between when illness influences the allocation of individuals The social selection perspective implies that health determines socioeconomic position, instead to socioeconomic positions (“direct selection”) and when ill-health has economic consequences of socioeconomic position determining health. 16

20 A conceptual framework for action on the social determinants of health that have their sources in the material world. owing to varying eligibility for and coverage by Meanwhile, material factors and social (dis) social insurance or similar mechanisms (example advantages predictably intertwine, such that indirect selection of “ ”). Blane and Manor argue that “people who have more resources in terms of the effect of the “ direct selection ” mechanism on the social gradient is small, and, therefore, direct social knowledge, money, power, prestige, and social mobility cannot be regarded as a main explanation connections are better able to avoid risk ... and to for inequalities in health. More commonly social adopt the protective strategies that are available at 76 . a given time and a given place” mobility is considered selective on determinants of health (hence “indirect selection”), not on 58 are highlighted Psychosocial factors health itself . It is also important to take into by the psychosocial theory described above. account that the health determinants on which indirect selection takes place could themselves Relevant factors include stressors (e.g. negative life events), stressful living circumstances, lack arise from living circumstances of earlier stages of life. Indirect selection would then be part of a of social support, etc. Researchers emphasizing this approach argue that socioeconomic mechanism of accumulation of disadvantage over inequalities in morbidity and mortality cannot the life course. The process of health selection may, be entirely explained by well-known behavioral therefore, contribute to the cumulative effects of or material risk factors of disease. For example, social disadvantage across the life span, but, to date, the inclusion of health selection into studies in cardiovascular disease outcomes, risk factors of life course relationships is scarce. such as smoking, high serum cholesterol and blood pressure can explain less than half of the socioeconomic gradient in mortality. Marmot, 4.2.2 Social causation perspective 142 have argued that the similarity Shipley and Rose of the risk gradient for a range of diseases could From this perspective, social position determines indicate the operation of factors affecting general health through intermediary factors. Longitudinal susceptibility. Meanwhile, the inverse relation studies in which socioeconomic status has been between height and mortality suggests that factors measured before health problems are present, operating from early life may influence adult death and in which the incidence of health problems 77 rates has been measured during follow-up, show . higher risk of developing health problem in the lower socioeconomic groups, and suggest , such as smoking, diet, Behavioral factors “social causation” as the main explanation for alcohol consumption and physical exercise, 15 . This socioeconomic inequalities in health are certainly important determinants of causal effect of socioeconomic status on health health. Moreover, since they can be unevenly is likely to be mainly indirect, through a number distributed between different socioeconomic positions, they may appear to have important of more specific health determinants that are weight as determinants of health inequalities. differently distributed across socioeconomic Yet this hypothesis is controversial in light of the groups. Socioeconomic health differences occur available evidence. Patterns differ significantly when the quality of these intermediary factors are unevenly distributed between the different from one country to another. For example, smoking is generally more prevalent among lower socioeconomic classes: socioeconomic status socioeconomic groups; however, in Southern determines a person’s behavior, life conditions, etc., and these determinants induce higher or Europe, smoking rates are higher among higher lower prevalence of health problems. The main income groups, and in particular among women. The contribution of diet, alcohol consumption and groups of factors that have been identified as playing an important part in the explanation of physical activities to inequalities in health is less health inequalities are material, psychosocial, and clear and not always consistent. However, there is behavioral and/or biological factors. higher prevalence of obesity and excessive alcohol consumption in lower socioeconomic groups, 19, 78, 79 are linked to conditions . particularly in richer countries Material factors of economic hardship, as well as to health- constitutes an The health system itself damaging conditions in the physical environment, additional relevant intermediary factor, though e.g. housing, physical working conditions, etc. one which has often not received adequate For researchers who emphasize this aspect, health inequalities result from the differential attention in the literature. We will discuss this accumulation of exposures and experiences topic in detail in subsequent sections of the paper. 17

21 effects of childhood social class by identifying 4.2.3 Life course perspective specific aspects of the early physical or psychosocial A life course perspective explicitly recognizes the environment (such as exposure to air pollution or family conflict) or possible mechanisms (such as importance of time and timing in understanding causal links between exposures and outcomes nutrition, infection or stress) that are associated with adult disease will provide further etiological within an individual life course, across generations, and in population-level diseases trends. Adopting insights. Circumstances in early life are seen as the initial stage in the pathway to adult health but with a life course perspective directs attention to how social determinants of health operate at every level an indirect effect, influencing adult health through of development—early childhood, childhood, social trajectories, such as restricting educational adolescence and adulthood—both to immediately opportunities, thus influencing socioeconomic influence health and to provide the basis for health circumstances and health in later life. Risk factors or illness later in life. The life course perspective tend to cluster in socially patterned ways, for example, those living in adverse childhood social attempts to understand how such temporal processes across the life course of one cohort are circumstances are more likely to be of low birth weight, and be exposed to poor diet, childhood related to previous and subsequent cohorts and are manifested in disease trends observed over time at infections and passive smoking. These exposures the population level. Time lags between exposure, may raise the risk of adult respiratory disease, perhaps through chains of risk or pathways over disease initiation and clinical recognition (latency period) suggest that exposures early in life are time where one adverse (or protective) experience involved in initiating disease processes prior to will tend to lead to another adverse (protective) clinical manifestations; however, the recognition experience in a cumulative way. of early-life influences on chronic diseases does not 80 argue that the life course imply deterministic processes that negate the utility Ben-Shlomo and Kuh approach is not limited to individuals within a of later-life intervention. single generation but should intertwine biological 80 and social transmission of risk across generations. In a table produced by Ben-Shlomo and Kuh It must contextualize any exposure both within the authors propose a simply classification of a hierarchical structure as well as in relation to potential life course models of health. Two main geographical and secular differences, which may mechanisms are identified. be unique to that cohort of individuals. Recently The “critical periods” model the potential for a life course approach to aid is when an exposure acting during a specific period has lasting understanding of variations in the health and or lifelong effects on the structure or function disease of populations over time, across countries and between social groups has been given more of organs, tissues and body systems that are not 70 and his colleagues suggest attention. Davey Smith modified in any dramatic way by later experiences. This is also known as “biological programming”, that explanations for social inequalities in cause- Table 1 Conceptual life course models specific adult mortality lie in socially-patterned and it is sometimes referred to as a “latency” model. This conception is the basis of hypotheses exposures at different stages of the life course. on the fetal origins of adult diseases. This approach ∏ Critical period model With or without later-life risk factors. (focus on the importance of timing of does recognize the importance of later life effect ∏ With later- life effect modifiers. exposure) modifiers (e.g. in the linkage of coronary heart ∏ Accumulation of risk model With independent and uncorrelated insults. disease, high blood pressure and insulin resistance (focus on the importance of exposure over ∏ 81 With correlated insults: . with low birth weight) time and the sequence of exposure) Risk clustering • • Chain of risk with additive or trigger effects. The “accumulation of risk” model suggests that factors that raise disease risk or promote Source: Lynch J, Davey-Smith G. A life course approach to chronic disease epidemiology. Annual Review of Public Health, 2005 26:1-35. good health may accumulate gradually over the life course, although there may be developmental periods when their effects have greater impact on later health than factors operating at other times. This idea is complementary to the notion that as the intensity, number and/or duration of exposures increase, there is increasing cumulative damage to biological systems. Understanding the health 18

22 A conceptual framework for action on the social determinants of health KEY MESSAGES OF THIS SECTION: p In contemporary social epidemiology, three main theoretical explanations of disease distribution are: (1) psychosocial approaches; (2) social production of disease/political economy of health; and (3) eco-social and other emerging multi-level frameworks. All represent theories which presume but cannot be reduced to mechanism–oriented theories of disease causation. p The main social pathways and mechanisms through which social determinants affect people’s health can usefully be seen through three perspectives: (1) “social selection”, or social mobility; (2) “social causation”; and (3) life course perspectives. p These frameworks/directions and perspectives are not mutually exclusive. On the contrary, they are complementary. p Certain of these frameworks have paid insuffi cient attention to political variables. The CSDH framework will systematically incorporate these factors. 19

23 5 CSDH conceptual framework 5.1 Purpose of constructing a an existing model of the social production 2 framework for the CSDH of disease developed by Diderichsen and colleagues, from which the CSDH We now proceed to present in detail the specifi c framework draws signifi cantly. conceptual framework developed for the CSDH. This is an action-oriented framework, whose With these background elements in place, we primary purpose is to support the CSDH in proceed to examine the key components of the identifying where CSDH recommendations will CSDH framework in turn, including: seek to promote change in tackling SDH through 1 the socio-political context; policies. A comprehensive SDH framework should structural determinants and socioeconomic 2 achieve the following: position; and ∏ Identify the social determinants of health 3 intermediary determinants. and the social determinants of inequities in health; We conclude the presentation with a synthetic ∏ Show how major determinants relate to review of the framework as a whole. Th e issue each other; of entry points for policy action will be taken up ∏ Clarify the mechanisms by which social explicitly in the next chapter. determinants generate health inequities; ∏ Provide a framework for evaluating which SDH are the most important to address; Theories of power to guide 5.2 action on social determinants and ∏ Map specific levels of intervention and Health inequities flow from patterns of social policy entry points for action on SDH. stratification—that is, from the systematically To include all these aspects in one framework is unequal distribution of power, prestige and resources among groups in society. As a critical diffi cult and may complicate understanding. In an earlier version of the CSDH conceptual framework, factor shaping social hierarchies and thus conditioning health diff erences among groups, draft ed in 2005, we attempted to include all of these elements in a single synthetic diagram; “power” demands careful analysis from researchers however, this approach was not necessarily the concerned with health equity and SDH. most helpful. In the current elaboration of the Understanding the causal processes that underlie framework, we separate out the various major health inequities, and assessing realistically what components. may be done to alter them, requires understanding how power operates in multiple dimensions of We begin by sketching additional important economic, social and political relationships. background elements not covered in the previous The theory of power is an active domain of theoretical frameworks and perspectives as follows: inquiry in philosophy and the social sciences. 1 While developing a full-fledged theory of insights from the theorization of social power lies beyond the mandate of the CSDH, power, which can help to clarify the the Commission can draw on philosophical and dynamics of social stratifi cation; and 20

24 A conceptual framework for action on the social determinants of health political analyses of power to guide its framing of Young terms this “structural oppression”, whose the relationships among health determinants and forms are “systematically reproduced in major 85 its recommendations for interventions . . economic, political and cultural institutions” For all their explanatory value, power theories which tend to equate power with domination leave Power is “arguably the single most important 82 key dimensions of power insuffi ciently clarifi ed. organizing concept in social and political theory” , As Angus Stewart argues, such theories must yet this central concept remains contested and subject to diverse and often contradictory be complemented by alternative readings that interpretations. We review several approaches to emphasize more positive, creative aspects of power. conceptualizing power. A crucial source for such alternative more positive models is the work of philosopher Hannah First, classic treatments of the concept of power have emphasized two fundamental (and largely Arendt. Arendt challenged fundamental aspects of conventional western political theory by negative) aspects: (1) “power to”, i.e. what Giddens stressing the inter-subjective character of power has termed “the transformative capacity of human in collective action. In Arendt’s philosophy, agency”, in the broadest sense “the capability of “power is conceptually and above all politically the actor to intervene in a series of events so as to alter their course”; and (2) “power over”, which distinguished, not by its implication in agency, 83 characterizes a relationship in which an actor or action . but above all by its character as collective group achieves its strategic ends by determining “Power corresponds to the human ability not just to act, but to act in concert. Power is never the the behavior of another actor or group. Power in property of an individual; it belongs to a group this second, more limited but politically crucial sense may be understood as the capability to secure and remains in existence only so long as the group 86 outcomes where the realization of these outcomes keeps together” . From this vantage point, power depends upon the agency of others. “Power over” is can be understood as: closely linked to notions of coercion, domination and oppression; it is this aspect of power which has been at the heart of most infl uential modern 83 theories of power . “a relation in which people are not It is important to observe, meanwhile, that “domination” and “oppression” in the relevant dominated but empowered through senses need not involve the exercise of brute critical refl ection leading to shared 87 physical violence nor even its overt threat. In a action” . classic study, Steven Lukes showed that coercive power can take covert forms. For example, Recent feminist theory has further enriched these power expresses itself in the ability of advantaged 88 groups to shape the agenda of public debate and perspectives. Luttrell and colleagues follow 89 in distinguishing four fundamental decision-making in such a way that disadvantaged Rowlands types of power: constituencies are denied a voice. At a still ∏ Power over (ability to infl uence or coerce) deeper level, dominant groups can mold people’s ∏ Power to (organize and change existing perceptions and preferences, for example through hierarchies) control of the mass media, in such a way that the ∏ Power with (power from collective action) oppressed are convinced they do not have any ∏ Power within (power from individual serious grievances. “Th e power to shape people’s consciousness). thoughts and desires is the most eff ective kind of power, since it pre-empts confl ict and even pre- 84 . Iris Th ey note that these diff erent interpretations of empts an awareness of possible confl icts” Marion Young develops related insights on the power have important operational consequences presence of coercive power even where overt force for development actors’ eff orts to facilitate the is absent. She notes that “oppression” can designate, empowerment of women and other traditionally dominated groups. An approach based on not only “brutal tyranny over a whole people by a few rulers”, but also “the disadvantage and injustice “power over” emphasizes greater participation some people suff er ... because of the everyday of previously excluded groups within existing economic and political structures. In contrast, practices of a well-intentioned liberal society”. 21

25 previously oppressed groups. “Here the paradigm models based on “power to” and “power with”, case is not one of command, but one of enablement emphasizing new forms of collective action, push in which a disorganized and unfocused group towards a transformation of existing structures 88 . acquires an identity and a resolve to act” and the creation of alternative modes of power- However, there can be little doubt that the political sharing: “not a bigger piece of the cake, but a 90 expression of vulnerable groups’ “enablement” . different cake” will generate tensions among those constituencies This emphasis on power as collective action that perceive their interests as threatened. On the other hand, theories that highlight both the connects suggestively with a model of social ethics based on human rights. As one analyst overt and covert forms through which coercive has argued: “Throughout its history, the struggle power operates provide a sobering reminder of the obstacles confronting collective action among for human rights has a constant: in very different oppressed groups. forms and with very different contents, this struggle has consisted of one basic reality: a Theorizing the impact of social power on health demand by oppressed and marginalized social suggests that the empowerment of vulnerable for the exercise of their social groups and classes 91 and disadvantaged social groups will be vital to . Understood in this way, a human rights ” power agenda means supporting the collective action of reducing health inequities. However, the theories reviewed here also encourage us to problematize historically dominated communities to analyze, resist and overcome oppression, asserting their the concept of “empowerment” itself. They point to the different (in some cases incompatible) shared power and altering social hierarchies in the meanings this term can carry. What different direction of greater equity. groups mean by empowerment depends on their underlying views about power. The theories we The theories of power we have reviewed are have discussed acknowledge different forms of relevant to analysis and action on the social determinants of health in a number of ways. First, power and thus, potentially, different kinds and and most fundamentally, they remind us that levels of empowerment. However, these theories any serious effort to reduce health inequities will urge skepticism towards depoliticized models involve changing the distribution of power within of empowerment and approaches that claim to empower disadvantaged individuals and groups society to the benefit of disadvantaged groups. Changes in power relationships can take place at while leaving the distribution of key social various levels, from the “micro-level” of individual and material goods largely unchanged. Those concerned to reduce health inequities cannot households or workplaces to the “macro-sphere” accept a model of empowerment that stresses of structural relations among social constituencies, mediated through economic, social and political process and psychological aspects at the expense institutions. Power analysis makes clear, however, of political outcomes and downplays verifiable change in disadvantaged groups’ ability to exercise that micro-level modifications will be insufficient control over processes that affect their well-being. to reduce health inequities unless micro-level This again raises the issue of state responsibility action is supported and reinforced through in creating spaces and conditions under which structural changes. the empowerment of disadvantaged communities By definition, then, action on the social can become a reality. A model of community or civil society empowerment appropriate for determinants of health inequities is a political action on health inequities cannot be separated process that engages both the agency of disadvantaged communities and the responsibility from the responsibility of the state to guarantee a comprehensive set of rights and ensure the fair of the state. This political process is likely to be distribution of essential material and social goods contentious in most contexts, since it will be seen among population groups. This theme is explored as pitting the interests of social groups against more fully below. each other in a struggle for power and control of resources. Theories of power rooted in collective action, such as Arendt’s, open the perspective of a less antagonistic model of equity-focused politics, emphasizing the creative self-empowerment of 22

26 A conceptual framework for action on the social determinants of health KEY MESSAGES OF THIS SECTION: p An explicit theorization of power is useful for guiding action to tackle SDH to improve 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 with domination and coercion. p Theories that equate power with domination can be complemented by alternative readings that emphasize more positive, creative aspects of power, based on collective action. In this perspective, human rights can be understood as embodying a demand on the part of oppressed and marginalized communities for the expression of their collective social power. p Any serious effort to reduce health inequities will involve changing the distribution of power within society to the benefi t of disadvantaged groups. p Changes in power relationships can range from the “micro- level” of individual households or workplaces to the “macro- sphere” of structural relations among social constituencies, mediated through economic, social and political institutions. Micro-level modifi cations will be insuffi cient to reduce health inequities unless supported by structural changes but structural changes that are 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 a political process that engages both the agency of disadvantaged communities and the responsibility of the state. Relevance of the determine the pattern of social stratifi cation. Th e 5.3 Diderichsen model for the model emphasizes how social contexts create CSDH framework social stratification and assign individuals to diff erent social positions. Social stratifi cation in The CSDH framework for action draws turn engenders diff erential exposure to health- damaging conditions and diff erential vulnerability, substantially on the contributions of many previous researchers, most prominently Finn in terms of health conditions and material Diderichsen. Diderichsen’s and Hallqvist’s 1998 resource availability. Social stratifi cation likewise model of the social production of disease was determines diff erential consequences of ill health subsequently adapted by Diderichsen, Evans and for more and less advantaged groups (including 92 . Th e concept of social position is economic and social consequences, as well as Whitehead at the center of Diderichsen’s interpretation of diff erential health outcomes per se). 93 “the mechanisms of health inequality” . In its initial formulation, the model emphasized the At the individual level, the figure depicts the pathway from society through social position pathway from social position, through exposure and specifi c exposures to health. Th e framework to specifi c contributing causal factors, and on to was subsequently elaborated to give greater health outcomes. As many diff erent interacting emphasis to “mechanisms that play a role in causes in the same pathway might be related to 94 stratifying health outcomes” , including “those social position, the eff ect of a single cause might central engines of society that generate and diff er across social positions as it interacts with 94, 95 . distribute power, wealth and risks” and thereby some other cause related to social position 23

27 Figure 1. Model of the social production of disease Source: Reproduced with permission from Diderichsen et al. (2001) Diderichsen’s most recent version of the model 92, 94 . Both provides some additional insights KEY MESSAGES OF THIS SECTION: differential exposure (Roman numeral I in the diagram above) and diff erential vulnerability (II) p Social position is at the center of Diderichsen’s model of may contribute to the relation between social “the mechanisms of health inequality”. position and health outcomes, as can be tested empirically. In addition, diff erential vulnerability p The mechanisms that play a role in stratifying health is about clustering and interaction between outcomes operate in the following manner : those determinants that mediate the effect of socio-economic health gradient. Ill health has • Social contexts create social stratifi cation and serious social and economic consequences due assign individuals to different social positions. to inability to work and the cost of health care. Social stratifi cation differential in turn engenders • Th ese consequences depend not only on the extent to health-damaging conditions and exposure of disability, but also on the individual’s social , in terms of health differential vulnerability diff erential consequences position (III— ) and on conditions and material resource availability. the society’s environment and social policies. Social stratifi cation likewise determines • Th e social and economic consequences of illness of ill health for more and differential consequences may feed back into the etiological pathways and less advantaged groups (including economic and contribute to the further development of disease in social consequences, as well differential health the individual (IV). Th is eff ect might even, on an outcomes per se). aggregate level, feed into the context of society, as well, and infl uence aggregate social and economic development. Many of the insights from Diderichsen’s model 24 will be taken up into the CSDH framework that

28 A conceptual framework for action on the social determinants of health we will now begin to explain, presenting its key in Kerala for the longest period during those 98 components one by one. . Chung and Muntaner find similarly 40 years that few studies have explored the relationship between political variables and population health at the national level, and none has included a First element of the CSDH 5.4 framework: socio-economic comprehensive number of political variables to and political context understand their effect on population health while simultaneously adjusting for economic 99 determinants . As an illustration of the powerful The social determinants framework developed impact of political variables on health outcomes, by the CSDH differs from some others in the importance attributed to the these researchers concluded in a recent study of 18 socioeconomic- wealthy countries in Europe, North America and . This is a deliberately broad term political context that refers to the spectrum of factors in society the Asia-Pacific region that 20 % of the differences in infant mortality rate among countries could be that cannot be directly measured at the individual explained by the type of welfare state. Similarly, level. “Context”, therefore, encompasses a broad different welfare state models among the countries set of structural, cultural and functional aspects of a social system whose impact on individuals accounted for about 10 % of differences in the rate 99 . of low birth weight babies tends to elude quantification but which exert a powerful formative influence on patterns of social stratification and, thus, on people’s health Raphael similarly emphasizes how policy decisions impact a broad range of factors that influence opportunities. In this stated context, one will the distribution and effects of SDH across find those social and political mechanisms that population groups. Policy choices are reflected, generate, configure and maintain social hierarchies (e.g. the labor market, the educational system and for example, in: family-friendly labor policies; political institutions including the welfare state). active employment policies involving training and support; the provision of social safety nets; One point noted by some analysts, and which we and the degree to which health and social services 44, 45 and other resources are available to citizens wish to emphasize, is the relative inattention to . issues of political context in a substantial portion The organization of healthcare is also a direct of the literature on health determinants. It has result of policy decisions made by governments. become commonplace among population health Public policy decisions made by governments researchers to acknowledge that the health of are themselves driven by a variety of political, individuals and populations is strongly influenced economic and social forces, constituting a complex by SDH. It is much less common to aver that the space in which the relationship between politics, quality of SDH is in turn shaped by the policies policy and health works itself out. that guide how societies (re)distribute material 96 resources among their members It is safe to say that these specifically political aspects . In the growing area of SDH research, a subject rarely studied is the of context are important for the social distribution impact on social inequalities and health of political of health and sickness in virtually all settings, and they have been seriously understudied. On movements and parties and the policies they adopt 97 the other hand, it is also the case that the most . when in government relevant contextual factors (i.e. those that play the greatest role in generating social inequalities) may Meanwhile, Navarro and other researchers 99 . have compiled over the years an increasingly differ considerably from one country to another For example, in some countries religion will be a solid body of evidence that the quality of many decisive factor and less so in others. In general, the social determinants of health is conditioned by construction/mapping of context should include approaches to public policy. To name just one in the broadest at least six points: (1) governance example, the state of Kerala in India has been sense and its processes, including definition of widely studied, showing the relationship between needs, patterns of discrimination, civil society its impressive reduction of inequalities in the participation and accountability/transparence in last 40 years and improvements in the health public administration; (2) macroeconomic policy, status of its population. With very few exceptions, including fiscal, monetary, balance of payments however, these reductions in social inequalities and and trade policies and underlying labour market improvements in health have rarely been traced structures; (3) affecting factors social policies to the public policies carried out by the state’s such as labor, social welfare, land and housing governing communist party, which has governed 25

29 to workers or enhancing workers’ skills and distribution; (4) in other relevant public policy capacities, reducing labour supply, creating jobs or areas such as education, medical care, water and changing the structure of employment in favour of culture and societal values; sanitation; (5) and (6) disadvantaged groups (e.g. employment subsidies epidemiological conditions, particularly in the for target groups). Typical passive programmes case of major epidemics such as HIV/AIDS, which are unemployment insurance and assistance and exert a powerful infl uence on social structures and early retirement; typical active measures are labour must be factored into global and national policy- market training, job creation in form of public and setting. In what follows, we highlight some of these community work programmes, programmes to contextual elements with particular focus on those promote enterprise creation and hiring subsidies. with major importance for health equity. Active policies are usually targeted at specific We have adopted the UNDP definition of groups facing particular labour market integration governance, which is as follows: diffi culties: younger and older people, women and those particularly hard to place such as the disabled.” Th e concept of the “welfare state” is one in which “[the] system of values, policies the state plays a key role in the protection and promotion of the economic and social well-being and institutions by which society of its citizens. It is based on the principles of manages economic, political and equality of opportunity, equitable distribution of social affairs through interactions wealth and public responsibility for those unable within and among the state, civil to avail themselves of the minimal provisions for society and private sector. It is the a good life. Th e general term may cover a variety way a society organizes itself to of forms of economic and social organization. A fundamental feature of the welfare state is social make and implement decisions”. insurance. Th e welfare state also, usually, includes public provision of basic education, health services and housing (in some cases at low cost or without It comprises the mechanisms and processes for charge). Anti-poverty programs and the system of citizens and groups to articulate their interests, personal taxation may also be regarded as aspects mediate their differences and exercise their of the welfare state. Personal taxation falls into legal rights and obligations. Th ese are the rules, this category insofar as it is used progressively institutions and practices that set limits and provide to achieve greater justice in income distribution incentives for individuals, organizations and fi rms. (rather than merely to raise revenue), and also Governance, including its social, political and insofar as it used to finance social insurance economic dimensions, operates at every level of payments and other benefits not completely human enterprise, be it the household, village, 100, 101 fi nanced by compulsory contributions. In more . It municipality, nation, region or globe” socialist countries the welfare state also covers is important to acknowledge, meanwhile, that employment and administration of consumer there is no general agreement on the defi nition of 102, 103 prices . governance, or of good governance. Development agencies, international organizations and academic One of the main functions of the welfare state is institutions defi ne governance in diff erent ways, “income redistribution”; therefore, the welfare this being generally related to the nature of their state framework has been applied to the fi elds interests and mandates. of social epidemiology and health policy as an amendment to the “relative income hypothesis”. Regarding labour market policies, we adopt the Welfare state variables have been added to ideas proposed by the CSDH’s Employment 102 : “Labour measures of income inequality to determine the Conditions Knowledge Network market policies mediate between supply structural mechanism through which economic 104 (jobseekers) and demand (jobs off ered) in the inequality aff ects population health status . labour market, and their intervention can take several forms. Th ere are policies that contribute Chung and Muntaner provide a classifi cation of welfare state types and explore the health eff ects directly to matching workers to jobs and jobs 26

30 A conceptual framework for action on the social determinants of health of their respective policy approaches. Th eir study In constructing a typology of health systems, concludes that countries exhibit distinctive levels Kleczkowski, Roemer and Van der Werff have of population health by welfare regime types, proposed three domains of analysis to indicate even when adjusted by the level of economic how health is valued in a given society: ∏ Th e extent to which health is a priority development (GDP per capita) and intra-country in the governmental /societal agenda, as correlations. Th ey fi nd, specifi cally, that Social Democratic countries exhibit signifi cantly better refl ected in the level of national resources population health status, e.g. lower infant mortality allocated to health (care), with the need for rate and low birth weight rate, compared to other health care signalling a grave ethical basis 99, 105 countries for resource redistribution); . ∏ Th e extent to which the society assumes collective responsibility for fi nancing and Institutions and processes connected with organizing the provision of health services. globalization constitute an important dimension In maximum collectivism (also referred of context as we understand it. “Globalization” is to as a state-based model), the system is defi ned by the CSDH Globalization Knowledge Network, following Jenkins, as: almost entirely concerned with providing collective benefits, leaving little or no choice to the individual. In maximum individualism, ill health and its care are viewed as private concerns; and ∏ The extent of societal distributional “a process of greater integration responsibility. This is a measure of the degree to which society assumes within the world economy responsibility for the distribution of through movements of goods and its health resources. Distributional services, capital, technology and responsibility is at its maximum when the (to a lesser extent) labour, which society guarantees equal access to services 107, 108 lead increasingly to economic . for all decisions being infl uenced by global Th ese criteria are important for health systems conditions”. policy and evaluating systems performance. Th ey are also relevant to assessing opportunities for – in other words, to the emergence of a global action on SDH. 106 . Non-economic aspects of marketplace globalization, including social and cultural aspects, To fully characterize all major components of the socioeconomic and political context is are acknowledged and relevant. However, economic globalization is understood as the force that has beyond the scope of the present paper. Here, we driven other aspects of globalization over recent have considered only a small number of those decades. Th e importance of globalization signifi es components likely to have particular importance that contextual analysis on health inequities will for health equity in many settings. oft en need to examine the strategies pursued by actors such as transnational corporations and Second element: 5.5 supranational political institutions, including the structural determinants and World Bank and International Monetary Fund. socioeconomic position “Context” also includes social and cultural values. Graham observes that the concept of “social Th e value placed on health and the degree to which determinants of health” has acquired a dual health is seen as a collective social concern diff ers meaning, referring both to the social factors greatly across regional and national contexts. We promoting and undermining the health of have argued elsewhere, following Roemer and individuals and populations and to the social Kleczkowski, that the social value attributed to processes underlying the unequal distribution of health in a country constitutes an important and these factors between groups occupying unequal oft en neglected aspect of the context in which positions in society. Th e central concept of “social health policies must be designed and implemented. 27

31 position in the social stratifi cation system can be determinants” thus remains ambiguous, referring summarized as their socioeconomic position. (A simultaneously to the determinants of health and variety of other terms, such as social class, social to the determinants of inequalities in health. Th e stratum and social or socioeconomic status, are author notes that: oft en used more or less interchangeably in the literature, despite their diff erent theoretical bases.) Th e two major variables used to operationalize “using a single term to refer to socioeconomic position in studies of social both the social factors infl uencing social stratifi cation and inequities in health are health and the social processes . The term stratification is used in social class shaping their social distribution sociology to refer to social hierarchies in which would not be problematic if the individuals or groups can be arranged along a ranked order of some attribute. Income or main determinants of health—like years of education provide familiar examples. living standards, environmental Measures of social stratifi cation are important infl uences and health behaviors— predictors of patterns of mortality and morbidity. were equally distributed between However, despite their usefulness in predicting 3 . socioeconomic groups” health outcomes, these measures do not reveal the social mechanisms that explain how individuals arrive at diff erent levels of economic, political and But the evidence points to marked socioeconomic cultural resources. “Social class”, meanwhile, is diff erences in access to material resources, health- defi ned by relations of ownership or control over promoting resources, and in exposure to risk productive resources (i.e. physical, fi nancial and factors. Furthermore, policies associated with 112 organizational) positive trends in health determinants (e.g. a rise . Th is concept adds signifi cant value, in our view, and for that reason we have in living standards and a decline in smoking) have chosen to include it as an additional, distinct also been associated with persistent socioeconomic disparities in the distribution of these determinants component in our discussion of socioeconomic (marked socioeconomic differences in living position. The particularities of the concept of 109, 110 social class will be described in greater detail when standards and smoking rates) .We have we analyze this concept below. attempted to resolve this linguistic ambiguity by introducing additional diff erentiations within the Two central fi gures in the study of socioeconomic fi eld of concepts conventionally included under the position were Karl Marx and Max Weber. For heading “social determinants”. We adopt the term structural determinants Marx, socioeconomic position was entirely “ ” to refer specifi cally to determined by ‘‘social class’’, whereby an individual interplay between the socioeconomic-political context, structural mechanisms generating social is defined by their relation to the ‘‘means of production’’ (for example, factories and land). stratification and the resulting socioeconomic Social class, and class relations, is characterized position of individuals. These structural determinants are what we include when referring by the inherent confl ict between exploited workers to the “ social determinants of health inequities ”. and the exploiting capitalists or those who control Th is concept corresponds to Graham’s notion of the means of production. Class, as such, is not an the “social processes shaping the distribution” of a priori property of individual human beings, but 3 . When referring is a social relationship created by societies. One downstream social determinants to the more downstream factors, we will use the explicit adaptation of Marx’s theory of social class ”. We intermediary determinants of health term “ that takes into account contemporary employment attach to this term specifi c nuances that will be and social circumstances is Wright’s social class spelled out in a later section. classifi cation. In this scheme, people are classifi ed according to the interplay of three forms of Within each society, material and other resources exploitation: (a) ownership of capital assets, (b) are unequally distributed. This inequality can control of organizational assets, and (c) possession 113, 114 be portrayed as a system of social stratifi cation . of skills or credential assets 111, 112 or social hierarchy . People attain diff erent positions in the social hierarchy according, Weber developed a diff erent view of social class. mainly, to their social class, occupational status, According to Weber, diff erential societal position educational achievement and income level. Th eir is based on three dimensions: class, status and 28

32 A conceptual framework for action on the social determinants of health party (or power). Class is assumed to have an these indicators may not be directly available. Information on education, occupation and income economic base. It implies ownership and control of resources and is indicated by measures of may be unavailable, and it may be necessary to use proxy measures of socioeconomic status like income. Status is considered to be prestige or indicators of living standards (for example, car honor in the community. Weber considers status to imply “access to life chances” based on social and ownership or housing tenure). cultural factors like family background, lifestyle Singh-Manoux and colleagues have argued that and social networks. Finally, power is related to the social gradient is sensitive to the proximal/ a political context. In this paper, we use the term “socioeconomic position”, acknowledging the distal nature of the indicator of socioeconomic 116 position employed three separate but linked dimensions of social . The idea is that there is valid basis for causal and temporal ordering in class reflected in the Weberian conceptualization. the various measures of socioeconomic position. Krieger, Williams and Moss highlight that An analysis of the socioeconomic status of individuals at several stages of their lives showed as “socioeconomic position” is an aggregate that socioeconomic origins have enduring effects concept, its use in research needs to be clarified 115 . It includes both resource-based and prestige- on adult mortality through their effect on later socioeconomic circumstances, such as education, based measures, and linked to both childhood occupation and financial resources. This approach and adult social class position. Resource-based is derived from the life course perspective, where measures refer to material and social resources and education is seen to structure occupation and assets, including income, wealth and educational credentials; terms used to describe inadequate income. In this model, education influences resources include “poverty” and “deprivation”. health outcomes both directly and indirectly 116 . Prestige-based measures refer to individuals’ through its effect on occupation and income The disadvantage with education is that it does rank or status in a social hierarchy, typically not capture changes in adult socioeconomic evaluated with reference to people’s access to and circumstances or accumulated socioeconomic consumption of goods, services and knowledge, position. as linked to their occupational prestige, income and educational level. Given distinctions between Reporting that educational attainment, the diverse pathways by which resource-based and occupational category, social class and income prestige-based aspects of socioeconomic position are probably the most often used indicators of affect health across the life cycle, epidemiological current socioeconomic status in studies on health studies need to state clearly how measures of 115 inequalities, Lahelman and colleagues find that . socioeconomic position are conceptualized each indicator is likely to reflect both common Educational level creates differences between people in terms of access to information and impacts of a general hierarchical ranking in the level of proficiency in benefiting from new society and particular impacts specific to the indicator. (1) Educational attainment is usually knowledge, whereas income creates differences in access to scarce material goods. Occupational acquired by early adulthood. The specific nature status includes both these aspects and adds to them of education is knowledge and other non-material resources that are likely to promote healthy benefits accruing from the exercise of specific jobs, lifestyles. Additionally, education provides formal such prestige, privileges, power, and social and technical skills. qualifications that contribute to the socioeconomic status of destination through occupation and Kunst and Mackenbach have argued that there income. (2) Occupation-based social class relates are several indicators for socioeconomic position, people to social structure. Occupational social and that the most important are occupational class positions indicate status and power, and status, level of education and income level. they reflect material conditions related to paid Each indicator covers a different aspect of social work. (3) Individual and household income derive stratification, and it is, therefore, preferable to use primarily from paid employment. Income provides 111 individuals and families necessary material all three instead of only one . They add that the measurement of these three indicators is far from resources and determines their purchasing power. Thus, income contributes to resources needed straightforward, and due attention should be paid to the application of appropriate classifications, in maintaining good health. Following these for example, children, women and economically considerations, education is typically acquired inactive people, for whom one or more of first over the life course. Education contributes 29

33 association with health; it can influence a wide to occupational class position and through this range of material circumstances with direct to income. The effect of education on income 119, 114 implications for health . Income also has a is assumed to be mediated mainly through 117 . cumulative effect over the life course, and it is occupation the socioeconomic position indicator that can Socioeconomic position can be measured change most on a short term basis. It is implausible meaningfully at three complementary levels: individual, household and neighborhood. that money in itself directly affects health, thus it is the conversion of money and assets into Each level may independently contribute to health enhancing commodities and services distributions of exposure and outcomes. Also, socioeconomic position can be measured at via expenditure that may be the more relevant different points of the lifespan (e.g. infancy, concept for interpreting how income affects health. Consumption measures are, however, rarely used childhood, adolescence and adulthood in the in epidemiological studies; and they are, in fact, current, past 5 years, etc.). Relevant time periods depend on presumed exposures, causal pathways seriously flawed when used in health equity research, because high medical costs (an element and associated etiologic periods. Today it is also vital to recognize gender, ethnicity and sexuality of consumption) may make a household appear 120 as social stratifiers linked to systematic forms of . non-poor 118 . discrimination Income is not a simple variable. Components include wage earning, dividends, interest, child structural The CSDH framework posits that support, alimony, transfer payments and pensions. are those that generate or reinforce determinants social stratification in the society and that define Kunst and Mackenbach argued that this is a more proximate indicator of access to scarce material individual socioeconomic position. These resources or of standard of living. It can be mechanisms configure the health opportunities of social groups based on their placement within expressed most adequately when the income level hierarchies of power, prestige is measured by: adding all income components and access to (this yield total gross income); subtracting resources (economic status). We prefer to speak deductions of tax and social contribution (net of structural determinants , rather than “distal income); adding the net income of all household factors”, in order to capture and underscore the members (household income); or adjusting for causal hierarchy of social determinants involved in producing health inequities. Structural the size of the household (household equivalent 111 social stratification mechanisms, joined to and income) . influenced by institutions and processes embedded in the socioeconomic and political context (e.g. While individual income will capture individual redistributive welfare state policies), can together material characteristics, household income may be conceptualized as the social determinants of be a useful indicator, since the benefits of many . health inequities elements of consumption and asset accumulation are shared among household members. This We now examine briefly each of the major variables cannot be presumed, especially in the context used to operationalize socioeconomic position. of gender divisions of labour and power within First we analyse the proxies use to measure the household, in particular for women, who social stratification, including income, education may not be the main earners in the household. and occupation. Income and education can be Using household income information to apply to understood as social outcomes of stratification all the people in the household assumes an even processes, while occupation serves as a proxy for distribution of income according to needs within social stratification. Having reviewed the use of the household, which may or may not be true; these variables, we then turn to analyse social class, however, income is nevertheless the best single gender and ethnicity that operate as important indicator of material living standards. Ideally, structural determinants. data are collected on disposable income (what individuals/households can actually spend); but often data are collected instead on gross incomes 5.5.1 Income or incomes that do not take into account in-kind Income is the indicator of socioeconomic transfers that function as hypothecated income. position that most directly measures the material The meaning of current income for different age resources component. As with other indicators, groups may vary and be most sensitive during the such as education, income has a ‘‘dose-response’’ prime earning years. Income for young and older 30

34 A conceptual framework for action on the social determinants of health Table 1. Explanations for the relationship between income inequality and health Synopsis of the Argument Explanation Income inequality results in “invidious processes of social comparison” Psychosocial (micro): Social status that enforce social hierarchies causing chronic stress leading to poorer health outcomes for those at the bottom. Psychosocial (macro): Income inequality erodes social bonds that allow people to work together, decreases social resources, and results in less trust and civic participation, Social cohesion greater crime and other unhealthy conditions. Neo-material (micro): Income inequality means fewer economic resources among the poorest, Individual income resulting in lessened ability to avoid risks, cure injury or disease, and/or prevent illness. Income inequality results in less investment in social and environmental Neo-material (macro): Social disinvestment conditions (safe housing, good schools, etc.) necessary for promoting health among the poorest. Statistical artifact The poorest in any society are usually the sickest. A society with high levels of income inequality has high numbers of poor and, consequently, will have more people who are sick. Health selection People are not sick because they are poor. Rather, poor health lowers one’s income and limits one’s earning potential. 123 adults may be a less reliable indicator of their true , it determined by parental characteristics can be conceptualized within a life course socioeconomic position, because income typically framework as an indicator that in part follows a curvilinear trajectory with age. Thus, measures early life socioeconomic position. measures at one point in time may fail to capture Education can be measured as a continuous important information about income fluctuations 121, 115 variable (years of completed education) or as . Macinko et al. propose the following summary explanations for the relationship between a categorical variable by assessing educational 122 milestones, such as completion of primary or income inequality and health shown in Table 1 . high school, higher education diplomas, or Galobardes et al. conversely, have argued that degrees. Although education is often used as a generic measure of socioeconomic position, income primarily influences health through a direct effect on material resources that are in turn specific interpretations explain its association with health outcomes: mediated by more proximal factors in the causal 121 ∏ Education captures the transition from . The mechanisms chain, such as behaviours parents’ (received) socioeconomic position through which income could affect health are: ∏ to adulthood (own) socioeconomic Buying access to better quality material position and it is also a strong determinant resources such as food and shelter; ∏ of future employment and income. It Allowing access to services, which may reflects material, intellectual and other improve health directly (such as health resources of the family of origin, it services, leisure activities) or indirectly begins at early ages, it is influenced by (such as education); ∏ Fostering self esteem and social standing access to and performance in primary by providing the outward material and secondary school, and it reaches final characteristics relevant to participation in attainment in young adulthood for most society; and people. Therefore, it captures the long-term ∏ Health selection (also referred to as influences of both early life circumstances “reverse causality”) may also be considered on adult health and the influence of adult as income level can be affected by health resources (e.g. through employment status) status. on health; ∏ The knowledge and skills attained through education may affect a person’s cognitive 5.5.2 Education functioning, make them more receptive to health education messages, or better enable Education is a frequently used indicator in them to communicate with and access epidemiology. As formal education is frequently appropriate health services; and completed in young adulthood and is strongly 31

35 ∏ Ill health in childhood could limit predictive of inequalities in morbidity or mortality, 124, 125 educational attendance and/or attainment especially among employed men . The model has five categories based on a graded hierarchy of and predispose a person to adult disease, occupations ranked according to skill (I Professional, generating a health selection influence on II Intermediate, IIIa Skilled non-manual IIIb Skilled health inequalities. manual, IV Partly skilled, V Unskilled). Importantly, these occupational categories are not necessarily Finally, measuring the number of years of education or levels of attainment may contain no reflective of class relations. information about the quality of the educational Most studies use the current or longest held experience, which is likely to be important if conceptualizing the role of education in health occupation of a person to characterize their adult outcomes specifically related to knowledge, socioeconomic position. However, with increasing interest in the role of socioeconomic position cognitive skills and analytical abilities; but it may across the life course, some studies include be less important if education is simply used as a parental occupation as an indicator of childhood broad indicator of socioeconomic position. socioeconomic position in conjunction with individuals’ occupations at different stages in adult 5.5.3 Occupation life. Some of the more general mechanisms that Occupation-based indicators of socioeconomic may explain the association between occupation position are widely used. Kunst and Mackenbach and health-related outcomes are as follows: ∏ emphasize that this measure is relevant, because it Occupation (parental or own adult) is determines people’s place in the societal hierarchy strongly related to income and, therefore, and not just because it indicates exposure to specific the association with health may be one 111 occupational risk, such as toxic compounds of a direct relation between material . resources—the monetary and other Galobardes et al. suggest that occupation can be seen as a proxy for representing Weber’s notion tangible rewards for work that determines material living standards—and health. of socioeconomic position, as a reflection of a ∏ Occupations reflect social standing and person’s place in society related to their social 121 standing, income and intellect . Occupation can may be related to health outcomes because of certain privileges—such as easier access also identify working relations of domination and subordination between employers and employees to better health care, access to education and more salubrious residential facilities— or, less frequently, characterize people as exploiters or exploited in class relations. that are afforded to those of higher standing. ∏ The main issue, then, is how to classify people with Occupation may reflect social networks, work based stress, control and autonomy, a specific job according to their place in the social hierarchy. The most usual approach consists of and, thereby, affect health outcomes classifying people based on their position in the through psychosocial processes. ∏ Occupation may also reflect specific toxic labour market into a number of discreet groups or social classes. People can be assigned to social classes environmental or work task exposures, by means of a set of detail rules that use information such as physical demands (e.g. transport driver or labourer). on such items as occupational title, skills required, income pay-off and leadership functions. For One of the most important limitations of example, Wright’s typology distinguishes among occupational indicators is that they cannot four basic class categories: wage laborers, petty bourgeois (self-employed with no more than one be readily assigned to people who are not employee; small employers with 2-9 employees currently employed. As a result, if used as the only source of information on socioeconomic and capitalist with 10 or more employees). Also, other classifications - called “social class” but more position, socioeconomic differentials may be accurately termed “occupational class”- have been underestimated through the exclusion of retired used in European public health surveillance and people, people whose work is inside the home research. Among the best known and longest lived (mainly affecting women), disabled people (including those disabled by work-related illness of these occupational class measures is the British Registrar General’s social class schema, developed and injury), the unemployed, students, and people 121 in 1913. This schema has proven to be powerfully working in unpaid, informal, or illegal jobs . 32

36 A conceptual framework for action on the social determinants of health Given the growing prevalence of insecure and French industrial sociologists called this “l’usure precarious employment, knowing a person’s de travai”—the usury of work. At the most obvious occupation is of limited value without further level, the manager sits in an office while the routine information about the individual’s employment workers are exposed to all the dangers of heavy 127 . history and the nature of the current employment loads, dusts, chemical hazards and the like relationship. Furthermore, socioeconomic indicators based on occupational classification The task of class analysis is precisely to understand not only how macro structures (e.g. class relations may not adequately capture disparities in working and living conditions across divisions of race/ at the national level) constrain micro processes 115 ethnicity and gender (e.g. interpersonal behavior), but also how . micro processes (e.g. interpersonal behavior) can affect macro structures (e.g. via collective 5.5.4 Social Class 128 action) . Social class is among the strongest known predictors of illness and health and yet Social class is defined by relations of ownership is, paradoxically, a variable about which very or control over productive resources (i.e. physical, little research has been conducted. Muntaner financial and organizational). Social class provides and colleagues have observed that, while there an explicit relational mechanism (property, is substantial scholarship on the psychology of management) that explains how economic inequalities are generated and how they may affect racism and gender, little research has been done on the effects of class ideology (i.e. classism). health. Social class has important consequences for This asymmetry could reflect that in most the lives of individuals. The extent of an individual’s legal right and power to control productive assets wealthy democratic capitalist countries, income determines an individual’s strategies and practices inequalities are perceived as legitimate while 128 devoted to acquire income and, as a result, gender and race inequalities are not . determines the individual’s standard of living. Thus the class position of “business owner” compels its 5.5.5 Gender members to hire “workers” and extract labour from them, while the “worker” class position “Gender” refers to those characteristics of compels its members to find employment and women and men which are socially constructed, perform labour. Most importantly, class is an whereas “sex” designates those characteristics 129 inherently relational concept. It is not defined . Gender that are biologically determined according to an order or hierarchy, but according involves “culture-bound conventions, roles and to relations of power and control. Although there behaviors” that shape relations between and have been few empirical studies of social class among women and men and boys and girls. In and health, the need to study social class has been many societies, gender constitutes a fundamental 126 noted by social epidemiologists basis for discrimination, which can be defined as . the process by which members of a socially defined Class, in contrast to stratification, indicates group are treated differently especially unfairly 41 because of their inclusion in that group the employment relations and conditions of . Socially each occupation. The criteria used to allocate constructed models of masculinity can have deleterious health consequences for men and occupations into classes vary somewhat between the two major systems presently in widespread use: boys (e.g. when these models encourage violence the Goldthorpe schema and the Wright schema. or alcohol abuse). However, women and girls bear According to Wright, power and authority are the major burden of negative health effects from “organizational assets” that allow some workers gender-based social hierarchies. to benefit from the abilities and energies of other In many societies, girls and women suffer workers. The hypothetical pathway linking class systematic discrimination in access to power, (as opposed to prestige) to health is that some prestige and resources. Health effects of members of a work organization are expending discrimination can be immediate and brutal (e.g. in less energy and effort and getting more (pay, cases of female infanticide, or when women suffer promotions, job security, etc.) in return, while genital mutilation, rape or gender-based domestic others are getting less for more effort. So the less violence). Gender divisions within society powerful are at greater risk of running down their stocks of energy and ending up in some also affect health through less visible biosocial processes, whereby girls’ and women’s lower social kind of physical or psychological “health deficit”. 33

37 social, not biological, category”. The term refers to status and lack of control over resources exposes social groups, often sharing cultural heritage and them to health risks. Disproportionately high ancestry, whose contours are forged by systems in levels of HIV infection among young women in which “one group benefits from dominating other some sub-Saharan African countries are fueled by groups, and defines itself and others through this patterns of sexual coercion, forced early marriage domination and the possession of selective and and economic dependency among women and 130 . Widespread patterns of underfeeding arbitrary physical characteristics (for example, girls 42 skin colour)” girl children, relative to their male siblings, . provide another example of how gender-based In societies marked by racial discrimination and discrimination undermines health. As Doyal exclusion, people’s belonging to a marginalized argues, “A large part of the burden of preventable racial/ethnic group affects every aspect of their morbidity and mortality experienced by women is related directly or indirectly to the patterning status, opportunities and trajectory throughout the life-course. Health status and outcomes of gender divisions. If this harm is to be avoided, among oppressed racial/ethnic groups are often there will need to be significant changes in related significantly worse than those registered in more aspects of social and economic organization. In privileged groups or than population averages. particular, strategies will be required to deal with the damage done to women’s health by men, Thus, in the United States, life expectancy for 131 masculinities and male institution” African-Americans is significantly lower than . for whites, while an African-American woman Gender-based discrimination often includes is twice as likely as a white woman to give birth 134, 135 . Indigenous groups to an underweight baby limitations on girls’ and women’s ability to obtain endure racial discrimination in many countries education and to gain access to respected and well- and often have health indicators inferior to those remunerated forms of employment. These patterns of non-indigenous populations. In Australia, the reinforce women’s social disadvantages and, in average life expectancy of Aboriginal and Torres consequence, their health risks. Gender norms Strait Islanders lags 20 years behind that of non- and assumptions define differential employment Aboriginal Australians. Perhaps as a result of the conditions for women and men and fuel differential compounded forms of discrimination suffered exposures and health risks linked to work. Women by members of minority and oppressed races/ generally work in different sectors than men and ethnicities, the “biological expressions of racism” occupy lower professional ranks. “Women are more are closely intertwined with the impact of other likely to work in the informal sector, for example in 132 determinants associated with disadvantaged social . Broadly, domes¬tic work and street vending” positions (low income, poor education, poor gender disadvantage is manifested in women’s housing, etc.). often fragmented and economically uncertain work trajectories: domestic responsibilities disrupt career paths, reducing lifetime earning capacity 5.5.7 Links and influence amid and increasing the risks of poverty in adulthood sociopolitical context and structural 133 . For these reasons, Doyal argues and old age determinants that “the removal of gender inequalities in access A close relationship exists between the to resources” would be one of the most important policy steps towards gender equity in health. sociopolitical context and what we term the “Since it is now accepted that gender identities are structural determinants of health inequities. The CSDH framework posits that structural essentially negotiated, policies are needed which will enable people to shape their own identities are those that generate or reinforce determinants and actions in healthier ways. These could include stratification in the society and that define a range of educational strategies, as well as ... individual socioeconomic position. In all cases, structural determinants present themselves in employment policies and changes in the structure 131 . of state benefits” a specific political and historical context. It is not possible to analyze the impact of structural determinants on health inequities or to assess 5.5.6 Race/ethnicity policy and intervention options, if contextual aspects are not included. As we have noted, key Constructions of racial or ethnic differences are the basis of social divisions and discriminatory elements of the context include: governance practices in many contexts. As Krieger observes, patterns; macroeconomic policies; social policies; and public policies in other relevant sectors, it is important to be clear that “race/ethnicity is a 34

38 A conceptual framework for action on the social determinants of health socioeconomic position. among other factors. Contextual aspects, including Moving to the right, in the next column of the education, employment and social protection policies, act as modifiers or buffers influencing diagram, we have situated the main aspects of the effects of socioeconomic position on health social hierarchy, which define social structure and outcomes and well-being among social groups. social class relationships within the society. These At the same time, the context forms part of the features are given according to the distribution of power, prestige and resources. The principal “origin” and sustenance of a given distribution of power, prestige and access to material resources domain is social class / position within the social structure, which is connected with the economic in a society and thus, in the end, of the pattern of social stratification and social class relations base and access to resources. This factor is also linked with people’s degree of power, which is in existing in that society. The positive significance turn is again influenced by the political context of this linkage is that it is possible to address the effects of the structural determinants of health (functioning democratic institutions or their absence, corruption, etc.). The other key domain inequities through purposive action on contextual in this area encompasses systems of prestige and features, particularly the policy dimension. discrimination that exist in the society. 5.5.8. Diagram synthesizing the Again moving to the right, in the next column, we major aspects of the framework have described the main aspects of socioeconomic shown thus far position. Studies and evaluations of equity In this diagram we have summarized the main frequently use income, education and occupation elements of the social and political context that as proxies for these domains (power, prestige and model and directly influence the pattern of economic status). When we refer to the domains of social stratification and social class existing in prestige and discrimination, we find them strongly a country. We have included in the diagram, in related to gender, ethnicity and education. Social the far left column, the main contextual aspects class also has a close connection to these different that affect inequities in health, e.g. governance, domains, as previously indicated. As an inherently macroeconomic policies, social policies, public relational variable, class is able to provide greater policies in other relevant areas, culture and understanding of the mechanisms associated with societal values, and epidemiological conditions. the social production of health inequities. The context exerts an influence on health through Figure 2. Structural determinants: the social determinants of health inequities SOCIOECONOMIC AND POLITICAL Social Hierarchy Socioeconomic Social Structure/ CONTEXT Position Social Class Governance has Class: Macroeconomic an economic Social Class Policies base and access Gender Labour Market resources SOCIAL Ethnicity Structure IMPACT ON DETERMINANTS EQUITY IN OF HEALTH is Power HEALTH AND Social Policies related to a (INTERMEDIARY WELL-BEING Education Labour Market, political FACTORS) Housing, Land context Occupation Public Policies or Prestige Health, Education honor in the Social Protection Income community Culture and Discrimination Societal Values STRUCTURAL DETERMINANTS SOCIAL DETERMINANTS OF HEALTH INEQUITIES 35

39 KEY MESSAGES OF THIS SECTION: p The CSDH framework is distinguished from some others by its emphasis on the socioeconomic and political context and the structural determinants of health inequity. p “Context” is broadly defi ned to include all social and political mechanisms that generate, confi gure and maintain social hierarchies, including: the labour market; the educational system political institutions and other cultural and societal values. p Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies). p In the CSDH framework, the structural mechanisms are those that interplay between context and socio-economic position: generating and reinforcing class divisions that defi ne individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and policies of the socioeconomic and political context. The most important structural stratifi ers and the proxy indicators include: Income • Education • Occupation • • Social Class • Gender Race/ethnicity. • p Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” We began this study by asking the question of where health inequities come from. The answer to that question lies here. The structural mechanisms that shape social hierarchies, according to these key stratifi ers, are the root cause of inequities in health. Meanwhile, the patterns according to which Together, context, structural mechanisms and people are assigned to socioeconomic positions socioeconomic position constitute the social can turn back to infl uence the broader context (e.g. determinants of health inequities, whose eff ect is by generating momentum for or against particular to give rise to an inequitable distribution of health, social welfare policies, or aff ecting the level of well-being and disease across social groups. participation in trade unions). 5.6 Third element of the Proceeding again to the next column to the right framework: intermediary (blue rectangle), we see that it is socioeconomic determinants position as assigned within the existing social hierarchy that determines diff erences in exposure Th e structural determinants operate through a and vulnerability to intermediary health-aff ecting intermediary social series of what we will term factors, (what we call the ‘social determinants Th e social factors or social determinants of health. of health’ in the limited and specific sense), determinants of health inequities are causally depending on people’s positions in the hierarchy. antecedent to these intermediary determinants, which are linked, on the other side, to a set of 36

40 A conceptual framework for action on the social determinants of health 136 individual-level influences, including health- . In addition to household risk of infection amenities, household conditions like the presence related behaviors and physiological factors. The of damp and condensation, building materials, intermediary factors flow from the configuration rooms in the dwelling and overcrowding are of underlying social stratification and, in turn, housing-related indicators of material resources. determine differences in exposure and vulnerability to health-compromising conditions. At the These are used in both industrialized and non- 136, 137 most proximal point in the models, genetic and . Crowding is industrialized countries calculated as the number of persons living in biological processes are emphasized, mediating 3 the household per number of rooms available the health effects of social determinants . The in the house. Overcrowding can plausibly affect main categories of intermediary determinants of health outcomes through a number of different health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; mechanisms: overcrowded households are often households with few economic resources and the health system itself as a social determinant. We once again review these elements in turn. and there may also be a direct effect on health through facilitation of the spread of infectious diseases. Galobardes et al. add that recent efforts 5.6.1 Material circumstances to better understand the mechanisms underlying socioeconomic inequalities in health have lead This includes determinants linked to the physical environment, such as housing (relating to both to the development of some innovative area level 121 indicators that use aspects of housing the dwelling itself and its location), consumption . For potential, i.e. the financial means to buy healthy example, a ‘‘broken windows’’ index measured food, warm clothing, etc., and the physical working housing quality, abandoned cars, graffiti, trashand and neighborhood environments. Depending on public school deterioration at the census block 137 their quality, these circumstances both provide . level in the USA resources for health and contain health risks. An explicit definition incorporating the causal Differences in material living standards are relationship between work and health is given by probably the most important intermediary the Spanish National Institute of Work, Health and factor. The material standards of living are Safety: “The variables that define the making of any probably directly significant for the health status given task, as well as the environment in which it of marginalized groups; and also for the lower is carried out, determine the health of the workers socioeconomic position, especially if we include in a threefold sense: physical, psychological and 102 environmental factors. Housing characteristics social” . There are clear social differences in measure material aspects of socioeconomic physical, mental, chemical and ergonomic strains 109 circumstances in the workplace. The accumulation of negative . A number of aspects of housing environmental factors throughout working life have direct impact on health: the structure of probably has a significant effect on variations in dwellings; and internal conditions, such as damp, the general health of the population, especially cold and indoor contamination. Indirect housing when people are exposed to such factors over a effects related to housing tenure, including long period of time. Main types of hazards at the wealth impacts and neighborhood effects, are workplace include physical, chemical, ergonomic, seen as increasingly important. Housing as a neglected site for public health action include biological and psychosocial risk factors. General indoor and outdoor housing condition, as well conditions of work define, in many ways, peoples’ experience of work. Minimum standards for as, material and social aspects of housing, and local neighborhoods have an impact on health of working conditions are defined in each country, but the large majority of workers, including many occupants. Galobardes et al. propose a number of household amenities including access to hot and of those whose conditions are most in need of cold water in the house, having central heating improvement, are excluded from the scope of existing labour protection measures. In many and carpets, sole use of bathrooms and toilets, whether the toilet is inside or outside the home, countries, workers in cottage industries, the urban informal economy, agricultural workers (except and having a refrigerator, washing machine, or 121 . These household amenities are telephone for plantations), small shops and local vendors, markers of material circumstances and may domestic workers and home workers are outside also be associated with specific mechanisms of the scope of protective legislation. Other workers disease. For example, lack of running water and a are deprived of effective protection because of household toilet may be associated with increased weaknesses in labour law enforcement. This is 37

41 between the social strata. Social interaction is thus particularly true for workers in small enterprises, characterized by less solidarity and community which account for over 90 per cent of enterprises 138 . The people who lose most are those spirit in many countries, with a high proportion of at the bottom of the income hierarchy, who are women workers. particularly affected by psychosocial stress linked to social exclusion, lack of self-respect and more 5.6.2 Social-environmental or or less concealed contempt from the people psychosocial circumstances around them. Secondly, there are significant social This includes psychosocial stressors (for example, differences in the prevalence of episodes of stress negative life events and job strain), stressful living occurrence of short-term and long-term episodes of mental stress, linked to uncertainty about the circumstances (e.g. high debt) and (lack of ) social support, coping styles, etc. Different social groups financial situation, the labor market and social are exposed in different degrees to experiences and relations. The same applies to the probability of experiencing violence or threats of violence. life situations that are perceived as threatening, Disadvantaged people have experienced far more frightening and difficult for coping in the everyday. insecurity, uncertainty and stressful events in This partly explains the long-term pattern of social their life course, and this affects social inequalities inequalities in health. in health. This is illustrated in Table 2 published in the Norwegian Action Plan to Reduce Social Stress may be a causal factor and a trigger that 139 . directs many forms of illness; and detrimental, Inequalities in Health 2005-06 long-term stress may also be part of the causal Some studies refer to the association between complex behind many somatic illnesses. A person’s socio-economical status and health locus socioeconomic position may itself be a source control. This concept refers to the way people of long-term stress, and it will also affect the perceive the events related to their health — as opportunities to deal with stressful and difficult controllable (internal control) or as controlled by situations. However, there are also other, more others (external control). People with education indirect explanations of the pathway from stress below university level more frequently identified to social inequalities in health. Firstly, there is an an external locus of control. Other important on-going international debate on what is often challenges arise from increased incidence called Wilkinson’s «income inequality and social and prevalence of precarious and informal cohesion» model. The model states that, in rich employments; consequently, changes in the labor societies, the size of differences in income is more market raise many issues and challenges for health important from a health point of view than the care providers, organizational psychologists, size of the average income. Wilkinson’s hypothesis personnel and senior managers, employers and is that the greater the income disparities are trade union representatives, and workers and their in a society, the greater becomes the distance Table 2. Social inequalities affecting disadvantaged people 1 Social Status: Low: High: Percentages who have experienced in their adult life: - serveral episodes of 3+ months of unemployment 1% 11 % - lost their job several times (involuntarily) 7% 2% - received social security benefits 11 % 2% - had a serious accident 6% 21% - been unemployed at the age of 55 29% 7% - been unmarried/had no cohabitant at the age of 55 26% 14% - had low income at the age of 53 20% 2% 1 Low status = the third with the lowest occupational prestige, high status = the third with the highest occupational prestige. Source: Reproduced with permission from the Norwegian Action Plan to Reduce Social Inequalities in Health 2005-2006 38

42 A conceptual framework for action on the social determinants of health was related to SEP. Significant employment grade families. Job insecurity and non-employment are differences in smoking were found in the Whitehall also matters of concern to the wider community. II study, which examined a new cohort of 10,314 subjects from the British Civil Service beginning in 5.6.3 Behavioral and biological 15, 143 . Moving from the lowest to the highest 1985 factors. employment grades, the prevalence of current smoking among men was 33.6%, 21.9%, 18.4%, This includes smoking, diet, alcohol consumption and lack of physical exercise, which again can 13.0%, 10.2% and 8.3%, respectively. For women, the comparable figures were 27.5%, 22.7%, 20.3%, be either health protecting and enhancing (like exercise) or health damaging (cigarette smoking 15.2%, 11.6% and 18.3%, respectively. Social class differences in smoking are likely to continue, and obesity); in between biological factors we because rates of smoking initiation are inversely are including genetics factors, as well as from the related to SEP and because rates of cessation are perspective of social determinants of health, age positively related to SEP. and sex distribution. Social inequalities in health have also been Lifestyle factors are relatively accessible for associated with social differences in lifestyle or research, so this is one of the causal areas we know a good deal about. Although descriptions behaviors. Such differences are found in nutrition, physical activity, and tobacco and alcohol of the correlation of lifestyle factors with social consumption. This indicates that differences in status are relatively detailed and well-founded, this lifestyle could partially explain social inequalities should not be taken to indicate that these factors in health, but researchers do not agree on are the most important causes of social inequalities in health. Other, more fundamental, factors may their importance. Some regard differences cause variations in both lifestyle and health. Some in lifestyle as a sufficient explanation without surveys indicate that differences in lifestyle can only further elaboration, while others regard them explain a small proportion of social inequalities in as contributory factors that in turn result from 14, 142 health more fundamental causes. For example, Margolis . For instance, material factors may act et al. found that the prevalence of both acute and as a source of psychosocial stress and psychosocial persistent respiratory symptoms in infants showed stress may influence health-related behaviors. Each dose response relationships with SEP. When risk of them can influence health through specific factors such as crowding and exposure to smoking biological factors. A diet rich in saturated fat, for in the household were adjusted for this condition, example, will lead to atherosclerosis, which will relative risk associated with SEP was reduced but increase the risk of a myocardial infarction. Stress still remained significant. The data further suggest will activate hormonal systems that may increase that risk factors operated differently for different blood pressure and reduce the immune response. SEP levels; being in day care was associated with Adoption of health-threatening behaviors is somewhat reduced incidence in lower SEP families a response to material deprivation and stress. but with increased incidence among infants from Environments determine whether individuals 140 high SEP families take up tobacco, use alcohol, have poor diets and . Health risk behaviors such engage in physical activity. Tobacco and excessive as cigarette smoking, physical inactivity, poor diet alcohol use, and carbohydrate-dense diets, are and substance abuse are closely tied to both SEP 100 and health outcomes. Despite the close ties, the . means of coping with difficult circumstances association of SEP and health is reduced, but not eliminated, when these behaviors are statistically 5.6.4 The health system as a social 141, 142, 143 . controlled determinant of health. Cigarette smoking is strongly linked to SEP, As discussed, various models that have tried to explain the functioning and impact of SDH including education, income and employment status, and it is significantly associated with have not made sufficiently explicit the role of the health system as a social determinant. The role of morbidity and mortality, particularly from 15, 144, 145, 146 . A cardiovascular disease and cancer the health system becomes particularly relevant linear gradient between education and smoking through the issue of access, which incorporates prevalence was also shown in a community sample differences in exposure and vulnerability. On of middle-aged women. Additionally, among the other hand, differences in access to health current smokers the number of cigarettes smoked care certainly do not fully account for the social 39

43 disabilities, in particular, is often overlooked as patterning of health outcomes. Adler et al. for a potential contributor to the reduction of health instance, have considered the role of access to inequalities); (4) strengthening policies that care in explaining the SEP-health gradient and reproduce contextual factors such as social capital concluded that access alone could not explain the 146 that might modify the health effects of poverty; . gradient and (5) protecting against social and economic consequences of ill health though health insurance In a comprehensive model, the health system 92 . itself should be viewed as an intermediary sickness benefits and labor market policies determinant. This is closely related to models for the organization of personal and non-personal Even if there were some dispute as to whether the health service delivery. The health system can health system can itself be considered an indirect determinant of health inequities, it is clear that the directly address differences in exposure and vulnerability not only by improving equitable system influences how people move among the social strata. Benzeval, Judge and Whitehead argue access to care, but also in the promotion of that the health system has three obligations in intersectoral action to improve health status. confronting inequity: (1) to ensure that resources Examples would include food supplementation are distributed between areas in proportion to through the health system and transport policies their relative needs; (2) to respond appropriately and intervention for tackling geographic barrier to access health care. A further aspect of great to the health care needs of different social groups; and (3) to take the lead in encouraging a wider importance is the role the health system plays in mediating the differential consequences of illness and more strategic approach to developing healthy public policies at both the national and local level, in people’s lives. The health system is capable of 147 to promote equity in health and social justice ensuring that health problems do not lead to a . further deterioration of people’s social status and On this point the UK Department of Health has of facilitating sick people’s social reintegration. argued that the health system should play a more Examples include programmes for the chronically active role in reducing health inequalities, not ill to support their reinsertion in the workforce, as only by providing equitable access to health well as appropriate models of health financing that care services but also by putting in place public can prevent people from being forced into (deeper) health programmes and by involving other policy poverty by the costs of medical care. Another bodies to improve the health of disadvantaged 147 important component to analyze relates to the way . communities in which the health system contributes to social participation and the empowerment of the people, 5.6.5. Summarizing the section on if in fact this is defined as one of the main axes intermediary determinants for the development of pro-equity health policy. In this context, we can reflect on the hierarchical Socioeconomic-political context directly affects and authoritarian structure that predominates in intermediary factors, e.g. through kind, magnitude the organization of most health systems. Within and availability. But for the population, the health systems, people enjoy little participatory more important path of influence is through space through which to take part in monitoring, socioeconomic position. Socioeconomic evaluation and decision-making about system position influences health through more specific, priorities and the investment of resources. intermediary determinants. Those intermediary factors include: material circumstances, such as Diderichsen suggests that services through which neighborhood, working and housing conditions; the health sector deals with inequalities in health psychosocial circumstances, and also behavioral can be of five different types: (1) reducing the and biological factors. The model assumes that inequality level among the poor with respect to the members of lower socioeconomic groups live in causal factors that mediate the effects of poverty less favorable material circumstances than higher on health in such areas as nutrition, sanitation, socioeconomic groups, and that people closer to housing and working conditions; (2) reinforcing the bottom of the social scale more frequently factors that might reduce susceptibility to health engage in health-damaging behaviors and less effects from inequitable exposures, using various frequently in heath-promoting behaviors than means including vaccination, empowerment and do the more privileged. The unequal distribution social support; (3) treating and rehabilitating the of these intermediary factors (associated with health problems that constitute the socioeconomic differences in exposure and vulnerability to gap of burden of disease (the rehabilitation of health-compromising conditions, as well as 40

44 A conceptual framework for action on the social determinants of health Figure 3. Intermediary determinants of health Differential social, SOCIO- economic and health ECONOMIC consequences CONTEXT Unequal Socioeconomic distribution Position of these Social Structure/ factors Material Circumstances Social Class IMPACT ON (Living and Working EQUITY IN Conditions, Food Differences in HEALTH AND Availability, etc. ) exposure and WELL-BEING to vulnerability Behaviors and health- Biological Factors compromising conditions Psychosocial Factors Health System INTERMEDIARY DETERMINANTS POLITICAL CONTEXT OF HEALTH The and resource distribution approaches. with differential consequences of ill-health) communitarian approach defines social capital constitutes the primary mechanism through as a psychosocial mechanism, corresponding to which socioeconomic position generates health a neo-Durkheimian perspective on the relation inequities. The model includes the health system between individual health and society. This as a social determinant of health and illustrates school includes influential authors such as Robert the capacity of the heath sector to influence the Putnam and Richard Wilkinson. Putnam defines process in three ways, by acting upon: differences social capital as “features of social organization, in exposures, differences in vulnerability and such as networks, norms and social trust, that differences in the consequences of illness for facilitate coordination and cooperation for mutual people’s health and their social and economic 152 benefit” circumstances. . Social capital is looked upon as an extension of social relationships and the norms 154 of reciprocity , influencing health by way of the 5.6.6 A crosscutting determinant: 149, 150 social support mechanisms that these relationships social cohesion / social capital provide to those who participate on them. The The concepts of social cohesion and “social network approach considers social capital in terms capital” occupy an unusual (and contested) of resources that flow and emerge through social place in understandings of SDH. Over the past networks. It begins with a systemic relational decade, these concepts have been among the perspective; in other words, an ecological vision most widely discussed in the social sciences is taken that sees beyond individual resources and and social epidemiology. Influential researchers additive characteristics. This involves an analysis of have proclaimed social capital a key factor in the influence of social structure, power hierarchies 155 151, 152, 153, 154 shaping population health . . However, and access to resources on population health controversies surround the definition and This approach implies that decisions that groups or importance of social capital. individuals make, in relation to their lifestyle and In the most influential recent discussions, three behavioral habits, cannot be considered outside the social context where such choices take place. Two broad approaches to the characterization and of the most outstanding conceptualisations in this analysis of social capital can be distinguished: communitarian approaches, network approaches regard have been elaborated by James Coleman 41

45 of social capital has not infrequently been deployed and Pierre Bourdieu, whose work has focused as part of a broader discourse promoting reduced primarily on notions of social cohesion. Finally, state responsibility for health, linked to an emphasis resource distribution approach the , adopting a on individual and community characteristics, materialistic perspective, suggests that there is a values and lifestyles as primary shapers of health danger in promoting social capital as a substitute outcomes. Logically, if communities can take care for structural change when facing health inequity. of their own health problems by generating “social Some representatives of this group openly criticize capital”, then government can be increasingly psychosocial approaches that have suggested discharged of responsibility for addressing health social capital and cohesion as the most important and health care issues, much less taking steps mediators of the association between income and 156 to tackle underlying social inequities. Navarro . The resource distribution health inequality suggests that foundational work on social capital, approach insists that psychosocial aspects affecting including Putnam’s, “reproduced the classical ... population health are a consequence of material 157, 158 dichotomy between civil and political society, in . life conditions which the growth of one (civil society) requires the contraction of the other (political society— Recent work by Szreter and Woolcock has enriched the debates around social capital and the state)”. From this perspective, the adoption 155 its health impacts . These authors distinguish of social capital as a key for understanding and promoting population health is part of a broader, between bonding, bridging and linking social 160 . Bonding social radically depoliticizing trend capital. capital refers to the trust and cooperative relationships between members of On the other hand, however, it can be argued that a network that are similar in terms of their social the recognition of linking social capital through identity. Bridging social capital , on the other hand, Szreter’s and Woolcock’s work has contributed refers to respectful relationships and mutuality to a higher consideration of the dimension of between individuals and groups that are aware power and of structural aspects in tackling social that they do not possess the same characteristics capital as a social determinant of health. This may linking social in socio-demographic terms. Finally, help move discussions of social capital resolutely capital corresponds with the norms of respect beyond the level of informal relationships and and trust relationships between individuals, social support. The idea of linking social capital groups, networks and institutions that interact has also been fundamental as a new element from different positions along explicit gradients 153 . when discussing the role that the state occupies of institutionalised power or should occupy in the development of strategies Some scholars have critiqued what they see as that favour equity. Linking social capital offers the opportunity to analyse how relationships the faddish, ideologically driven adoption of the that are established with institutions in general, term “social capital”. Muntaner, for example, has and with the state in particular, affect people’s suggested that the term serves primarily as a quality of life. Such discussions highlight the “comforting metaphor” for those in public health role of political institutions and public policy in who wish to maintain that “capitalism ... and social shaping opportunities for civic involvement and cohesion/social integration are compatible”. Beyond 161, 162 . The CSDH adopts the democratic behaviour such ideological reassurance, Muntaner argues, position that the state possesses a fundamental role the vocabulary of social capital provides few if any in social protection, ensuring that public services fresh insights, and may in fact provoke confusion. are provided with equity and effectiveness. The Those innovations that have been achieved by researchers investigating social capital could just as welfare state is characterized as systematic defense against social insecurity, this being understood as well “have been carried out under the label of ‘social individuals’, groups’ or communities’ vulnerability integration’ or ‘social cohesion’. Indeed, it would be 163 more adequate to use terms such as ‘cohesion’ and . In this context, to diverse environmental threats while remaining alert to ways in which notions of ‘integration’ to avoid the confusion and implicit ‘social capital’ or community may be deployed to endorsement of [a specific] economic system that 159 . excuse the state from responsibility for the well- the term [social capital] conveys” 166, 165, 166 We share with Muntaner the concern that the being of the population , we can also look for aspects of these concepts that shed fresh light current interest in “social capital” may further on key state functions. encourage depoliticized approaches to population health and SDH. Indeed, it is clear that the concept 42

46 A conceptual framework for action on the social determinants of health The notion of linking social capital speaks to are found for rates of mortality and morbidity 167 the idea that one of the central points of from almost every disease and condition . SEP is also linked to prevalence and course of health politics should be the configuration of disease and self-rated health. Socioeconomic cooperative relationships between citizens and health inequalities are evident in specific causes of institutions. In this sense, the state should assume disease, disability and premature death, including the responsibility of developing more flexible lung cancer, coronary heart disease, accidents and systems that facilitate access and develop real participation by citizens. Here, a fundamental suicide. Low birth weight provides an additional aspect is the strengthening of local or regional important example. This is a sensitive measure of child health and a major risk factor for impaired governments so that they can constitute concrete 162 spaces of participation . The development of development through childhood, including 168 . There are marked intellectual development social capital, understood in these terms, is based differences in national rates of low birth weight, on citizen participation. True participation implies with higher rates in the US and UK and lower a (re)distribution of empowerment, that is to rates in Nordic countries like Sweden, Norway say, a redistribution of the power that allows the and the Netherlands. These rates vary in line with community to possess a high level of influence in the proportion of the child population living in decision-making and the development of policies poverty (in households with incomes below 50% affecting its well-being and quality of life. The competing definitions and approaches of average income): at their lowest in low-poverty suggest that “social capital” cannot be regarded countries like Sweden and Norway, and at their as a uniform concept. Debate surrounds whether highest in relatively high-poverty countries like 169 . it should be as seen a property of individuals, the UK and US groups, networks, or communities, and thus where it should be located with respect to other features 5.7.1 Impact along the gradient of the social order. It is unquestionably difficult There is evidence that the association of SEP and to situate social capital definitively as either a health occurs at every level of the social hierarchy, structural or an intermediary determinant of not simply below the threshold of poverty. Not health, under the categories we have developed only do those in poverty have poorer health than here. It may be most appropriate to think of this those in more favored circumstances, but those component as “cross-cutting” the structural and at the highest level enjoy better health than do intermediary dimensions, with features that link 142 those just below . The effects of severe poverty it to both. on health may seem obvious through the impact of poor nutrition, crowded and unsanitary 5.7 living conditions and inadequate medical care. Impact on equity in health and well-being Identifying factors that can account for the link to health all across the SEP hierarchy may shed light on new mechanisms that have heretofore been This section summarizes some of the outcomes that emerge at the end of the social “production chain” ignored because of a focus on the more readily of health inequities depicted in the framework. apparent correlates of poverty. The most notable of At this stage (far right side of the framework the studies demonstrating the SEP-health gradient is the Whitehall study of mortality (Marmot et al), diagrams), we find the measurable impacts of social factors upon comparative health status and which covered British civil servants over a period outcomes among different population groups, of 10 years. Similar findings emerge from census e.g. health equity. According to the analysis we data in the United Kingdom (Susser, Watson and 170, 171 Hopper) . Surprisingly, we know rather little have developed, the structural factors associated about how SEP operates to influence biological with the key components of socioeconomic functions that determine health status. Part of position (SEP) are at the root of health inequities measured at the population level. This relationship the problem may be the way in which SEP is is confirmed by a substantial body of evidence. conceptualized and analyzed. SEP has been almost universally relegated to the status of a control Socioeconomic health differences are captured in variable and has not been systematically studied general measures of health, like life expectancy, all- as an important etiologic factor in its own right. 100 . Differences cause mortality and self-rated health It is usually treated as a main effect, operating independently of other variables to predict health. correlated with people’s socioeconomic position 43

47 mental retardation were at higher risk of sensory 5.7.2 Life course perspective on the impairments and emotional difficulties; they were impact also more likely to be in contact with psychiatric Children born into poorer circumstances are at services. In adulthood, mild mental retardation greater risk of the forms of developmental delay was associated with limiting long-term illness associated with intellectual disability, including and disability, and, particularly for women, with depressed mood. speech impairments, cognitive difficulties 172, 173 . Some other and behavioral problems One might assume such effects to be inevitable. But conditions, like stroke and stomach cancer, they are in part due to discriminatory practices, appear to depend considerably on childhood in part also to failures to adapt educational circumstances, while for others, including deaths institutions and working life to special needs. To from lung cancer and accidents/violence, adult circumstances play the more important role. the extent that this is the case, social selection is In another group are health outcomes where neither necessary, nor inevitable, nor fair. This it is cumulative exposure that appears to be phenomenon particularly affects persons with disabilities, persons from immigrant backgrounds important. A number of studies suggest that 3 and, to a certain extent, women this is the case for coronary heart disease and . 174 respiratory disease, for example . 5.7.4 Impact on the socioeconomic 5.7.3 Selection processes and health- and political context related mobility From a population standpoint, we observe that the magnitude of certain diseases can translate into As discussed above, people with weaker health resources, allegedly, have a tendency to end up direct effects on features of the socioeconomic or remain low on the socioeconomic ladder. and political context, through high prevalence According to some analysts, the status of research rates and levels of mortality and morbidity. The on selection processes and health-related mobility HIV/AIDS pandemic in sub-Saharan Africa can within the socioeconomic structure can be be seen in this light, with its associated plunge summarized in three points: (1) variations in health in life expectancy and stresses on agricultural in youth have some significance for educational productivity, economic growth, and sectoral capacities in areas such as health and education. paths and for the kind of job a person has at the The magnitude of the impact of epidemics and beginning of his or her working career; (2) for emergencies will depend on the historical, political those who are already established in working life, variations in health have little significance for the and social contexts in which they occur, as well as on the demographic composition of the societies overall progress of a person’s career; and (3) people who develop serious health problems in adult life affected. These are aspects that must be considered are often excluded from working life, and often when analyzing welfare state structures, in particular models of health system organization long before the ordinary retirement age. that might respond to such challenges. Graham argues that people with intellectual disabilities are more exposed to the social 5.8 Summary of the conditions associated with poor health and have 175 mechanisms and pathways . She poorer health than the wider population represented in the framework adds that, for example, those with mild disabilities are more likely than non-disabled people to have In this section, we summarize key features of the employment histories punctured by repeated periods of unemployment. Women with mild CSDH framework (or model) and begin to sketch some of the considerations for policy-making to intellectual disabilities are further disadvantaged 175 . In both which the model gives rise. The next chapter will by high rates of teenage motherhood explore policy implications and entry points in childhood and adulthood, co-morbidity – the experience of multiple illnesses and functional greater depth. limitations – disproportionately affects people with intellectual disabilities. For example, in the British 1958 birth cohort study, children with mild 44

48 A conceptual framework for action on the social determinants of health KEY MESSAGES OF THIS SECTION: p The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of ‘structural determinants’ and ‘intermediary determinants’ underscores the causal priority of the structural factors. p The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant p Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the fi nancial means to buy healthy food, warm clothing, etc.), and the physical work environment. p Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof). p Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors. p The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health. The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people’s lives. p The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both. p Focus on social capital risks reinforcing depoliticized approaches to public health and SDH; however, certain interpretations, including Szreter’s and Woolcock’s notion of “linking social capital”, have spurred new thinking on the role of the state in promoting equity. p A key task for health politics is nurturing cooperative relationships between citizens and institutions. The state should take responsibility for developing fl exible systems that facilitate access and participation on the part of the citizens. p The social, economic and other consequences of specifi c forms of illness and injury vary signifi cantly, depending on the social position of the person who falls sick. p Illness and injury have an indirect impact in the socioeconomic position of individuals. From the population perspective, the magnitude of certain illnesses can directly impact key contextual factors (e.g. the performance of institutions). p Looking at the ultimate impact of social processes on health equity, we fi nd that the structural factors associated with the key components of socioeconomic position (SEP) are at the root of health inequities at the population level. This relationship is confi rmed by a substantial body of evidence. p Differences correlated with people’s socioeconomic position are found for rates of mortality and morbidity from almost every disease and condition. SEP is also linked to prevalence and course of disease and self-rated health. p The magnitude of certain diseases can directly affect features of the socioeconomic and political context, through high prevalence rates and levels of mortality and morbidity. The HIV/AIDS pandemic in sub-Saharan Africa provides one example, with its impact on agriculture, economic growth and sectoral capacities in areas such as health and education. 45 45

49 Figure 4 illustrates the main processes captured in but that this effect is not direct. Socioeconomic the CSDH framework, as we have explored them, position influences health through more specific, intermediary determinants. step by step, in the present chapter. The diagram Based on their respective social status, individuals also highlights the reverse or feedback effects through which illness may affect individual social experience differences in exposure and vulnerability to health-compromising conditions. Socioeconomic position, and widely prevalent diseases may affect position directly affects the level or frequencies of key social, economic and political institutions. exposure and the level of vulnerability, in connection Reading the diagram from left to right, we see with intermediary factors. Also, differences in the social (socioeconomic) and political context, which gives rise to a set of unequal socioeconomic exposure can generate more or less vulnerability in the population after exposure. positions or social classes. (Phenomena related to socioeconomic position can also influence aspects Once again, a distinctive element of this model of the context, as suggested by the arrows pointing is its explicit incorporation of the health system. back to the left.) Groups are stratified according Socioeconomic inequalities in health can, in fact, be to the economic status, power and prestige they partly explained by the “feedback” effect of health enjoy, for which we use income levels, education, occupation status, gender, race/ethnicity and other on socioeconomic position, e.g. when someone factors as proxy indicators. This column of the experiences a drop in income because of a work- diagram (Social Hierarchy) locates the underlying induced disability or the medical costs associated with major illness. Persons who are in poor health mechanisms of social stratification and the creation of social inequities. less frequently move up and more frequently move down the social ladder than healthy persons. This Moving to the right, we observe how the resultant implies that the health system itself can be viewed as a social determinant of health. This is in addition socioeconomic positions then translate into specific determinants of individual health status to the health sector’s key role in promoting and coordinating SDH policy, as regards interventions reflecting the individual’s social location within the stratified system. The model shows that a person’s to alter differential exposures and differential vulnerability through action on intermediary socioeconomic position affects his/her health, Figure 4. Summary of the mechanisms and pathways represented in the framework Differential social, economic and health consequences SOCIOECONOMIC POLITICAL CONTEXT Social Hierarchy Social Structure/ Governance Social Class Class: has Macroeconomic Differences in IMPACT ON an economic Policies Exposure to EQUITY IN base and access intermediary HEALTH AND resources Social Policies factors WELL-BEING Labour Market, Housing, Land is Power related to a political context Public Policies Health, Education Differences in Social Protection Health or Prestige Vulnerability to System honor in the health- community compromising Culture and conditions Societal Values Discrimination STRUCTURAL DETERMINANTS INTERMEDIARY DETERMINANTS SOCIAL DETERMINANTS SOCIAL DETERMINANTS OF HEALTH OF HEALTH INEQUITIES 46

50 A conceptual framework for action on the social determinants of health factors (material circumstances, psychosocial in determinants are not factored into the models, factors and behavioral/biological factors). It may their central role in driving inequalities in health may not be recognized. They are designed to be noted, in addition, that some specifi c diseases can impact people’s socioeconomic position, not capture schematically the distinction between health determinants and health inequality determinants, only by undermining their physical capacities, but which can be obscured in the translation of research also through associated stigma and discrimination into policy. Evidence points to the importance of (e.g. in the case of HIV/AIDS). Because of their representing the concept of social determinants to magnitude, certain diseases, such as HIV/AIDS and malaria, can also impact key contextual policymakers in ways that clarify the distinction between the social causes of health and the factors components directly, e.g. the labour market and governance institutions. Th e whole set of “feedback” determining their distribution between more and mechanisms just described is brought together less advantaged groups. Our CSDH framework under the heading of “diff erential social, economic attempts to fulfi ll this objective. Indeed, this is one of its most important intended functions. and health consequences”. We have included the impact of social position on these mechanisms, Graham argues that what is obscured in many indicating that path with an arrow. previous treatments of these topics: We have repeatedly referred to Hilary Graham’s warning about the tendency to confl ate the social determinants of health and the social processes that shape these determinants’ unequal distribution, by lumping the two phenomena together under a “is that tackling the determinants of single label. Maintaining the distinction is more than a matter of precision in language. As Graham health inequalities is about tackling argues, blurring these concepts may lead to seriously the unequal distribution of health misguided policy choices. “Th ere are drawbacks 175 . determinants” to applying health-determinant models to health inequalities.” To do so may “blur the distinction between the social factors that infl uence health and Focusing on the unequal distribution of the social processes that determine their unequal determinants is important for thinking about distribution. Th e blurring of this distinction can feed policy. Th is is because policies that have achieved the policy assumption that health inequalities can be overall improvements in key determinants such diminished by policies that focus only on the social as living standards and smoking have not reduced determinants of health. Trends in older industrial inequalities in these major infl uences on health. societies over the last 30 years caution against When health equity is the goal, the priority of assuming that tackling ‘the layers of influence’ a determinants-oriented strategy is to reduce on individual and population health will reduce inequalities in the major infl uences on people’s health inequalities. Th is period has seen signifi cant health. Tackling inequalities in social position improvements in health determinants (e.g. rising is likely to be at the heart of such a strategy. For, living standards and declining smoking rates) according to Graham, social position is the pivotal and parallel improvements in people’s health (e.g. point in the causal chain linking broad (“wider”) higher life expectancy). But these improvements determinants to the risk factors that directly have broken neither the link between social damage people’s health. disadvantage and premature death nor the wider link between socioeconomic position and health. As Graham emphasizes that policy objectives will be this suggests, those social and economic policies that defi ned quite diff erently, depending on whether have been associated with positive trends in health- our aim is to address determinants of health or determining social factors have also been associated determinants of health inequities: with persistent inequalities in the distribution of 3, 175 ∏ Objectives for health determinants are these social infl uences.” likely to focus on reducing overall exposure Many existing models of the social determinants to health-damaging factors along the causal of health may need to be modified in order to pathway. Th ese objectives are being taken help the policy community understand the social forward by a range of current national causes of health inequalities. Because inequalities and local targets: for example, to raise 47

51 Final form of the CSDH 5.9 educational standards and living standards conceptual framework (important constituents of socioeconomic position) and to reduce rates of smoking (a The diagram below brings together the key major intermediary risk factor). ∏ elements of the account developed in successive Objectives for health inequity determinants stages throughout this chapter. This image seeks are likely to focus on leveling up the to summarize visually the main lessons of the distribution of major health determinants. How these objectives are framed will preceding analysis and to organize in a single depend on the health inequities goals that comprehensive framework the major categories are being pursued. For example, if the goal of determinants and the processes and pathways that generate health inequities. is to narrow the health gap, the key policies will be those which bring standards of living and diet, housing and local services The framework makes visible the concepts and in the poorest groups closer to those categories discussed in this paper. It can also serve to situate the specific social determinants on which enjoyed by the majority of the population. the Commission has chosen to focus its efforts, If the health inequities goal is to reduce the wider socioeconomic gradient in health, and it can provide a basis for understanding how then the policy objective will be to lift these choices were made (balance of structural and the level of health determinants across intermediary determinants, etc.). society towards the levels in the highest socioeconomic group. Figure 5. Final form of the CSDH conceptual framework SOCIOECONOMIC AND POLITICAL CONTEXT Governance Socioeconomic Material Circumstances Macroeconomic Position (Living and Working, Policies IMPACT ON Conditions, Food EQUITY IN Availability, etc. ) Social Policies Social Class HEALTH Labour Market, Gender Behaviors and AND Housing, Land Ethnicity (racism) Biological Factors WELL-BEING Psychosocial Factors Public Policies Education Education, Health, Social Protection Social Cohesion & Social Capital Occupation Culture and Income Societal Values Health System STUCTURAL DETERMINANTS INTERMEDIARY DETERMINANTS SOCIAL DETERMINANTS OF SOCIAL DETERMINANTS HEALTH INEQUITIES OF HEALTH 48

52 A conceptual framework for action on the social determinants of health KEY MESSAGES OF THIS SECTION: p This section recapitulates key elements of the CSDH conceptual framework and begins to explore implications for policy. p The framework shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratifi ed according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specifi c determinants of health status (intermediary determinants) refl ective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. p Illness can “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions. p Confl ating the social determinants of health and the social processes that 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 factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups. p Policy objectives will be defi ned quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities. p Thus, Graham argues for the importance of representing the concept of social determinants to policy-makers in ways that clarify the distinction between the social causes of health and the factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework attempts to fulfi ll this objective. 49

53 policies and interventions policies and interventions 6 6 6 n this section, we draw upon the conceptual n this section, we draw upon the conceptual n this section, we draw upon the conceptual significantly in their underlying values and framework elaborated above to derive lessons framework elaborated above to derive lessons framework elaborated above to derive lessons implications for programming. Each off ers specifi c for policy action on SDH. First, we consider for policy action on SDH. First, we consider for policy action on SDH. First, we consider advantages and raises distinctive problems. the issue of conceptualizing health inequities I the issue of conceptualizing health inequities I the issue of conceptualizing health inequities and their distribution across the population in and their distribution across the population in and their distribution across the population in Programmes to improve health among low SEP terms of “gaps” or of a continuous social gradient terms of “gaps” or of a continuous social gradient terms of “gaps” or of a continuous social gradient populations have the advantage of targeting a in health. We then present two policy analysis in health. We then present two policy analysis in health. We then present two policy analysis clearly defined, fairly small segment of the frameworks informed by the work of Stronks et al. frameworks informed by the work of Stronks et al. frameworks informed by the work of Stronks et al. population and of allowing for relative ease in and Diderichsen et al. respectively that are useful and Diderichsen et al. respectively that are useful and Diderichsen et al. respectively that are useful monitoring and assessing results. Targeted to illustrate the type of processes that can guide to illustrate the type of processes that can guide to illustrate the type of processes that can guide programmes to tackle health disadvantage may policy decision-making on SDH. Th en we review a policy decision-making on SDH. Th en we review a policy decision-making on SDH. Th en we review a align well with other targeted interventions in a number of key directions, which the CSDH model number of key directions, which the CSDH model number of key directions, which the CSDH model governmental anti-poverty agenda, for example suggests should guide policy choices as decision- suggests should guide policy choices as decision- suggests should guide policy choices as decision- social welfare programmes focused on particular makers seek to tackle health inequities through makers seek to tackle health inequities through makers seek to tackle health inequities through disadvantaged neighborhoods. On the other hand, SDH action. SDH action. SDH action. such an approach may be politically weakened precisely by the fact that it is not a population- wide strategy but instead benefits sub-groups 6.1 6.1 Gaps and gradients 6.1 Gaps and gradients that make up only a relatively small percentage of the population, thus undermining the politics Today, health equity is increasingly embraced Today, health equity is increasingly embraced Today, health equity is increasingly embraced of solidarity that are important to maintaining 177 . Furthermore, as a policy goal by international health agencies as a policy goal by international health agencies as a policy goal by international health agencies support for public provision 176 . However, political this approach does not commit itself to bringing and national policy-makers and national policy-makers and national policy-makers levels of health in the poorest groups closer to leaders’ commitment to “tackle health inequities” leaders’ commitment to “tackle health inequities” leaders’ commitment to “tackle health inequities” can be interpreted diff erently to authorize a variety national averages. Even if a targeted programme can be interpreted diff erently to authorize a variety can be interpreted diff erently to authorize a variety of distinct policy strategies. of distinct policy strategies. of distinct policy strategies. is successful in generating absolute health gains among the disadvantaged, stronger progress Three broad policy approaches to reducing Three broad policy approaches to reducing Three broad policy approaches to reducing among better-off groups may mean that health health inequities can be identifi ed: (1) improving health inequities can be identifi ed: (1) improving inequalities widen. health inequities can be identifi ed: (1) improving the health of low SEP groups through targeted the health of low SEP groups through targeted the health of low SEP groups through targeted programmes; (2) closing the health gaps between programmes; (2) closing the health gaps between An approach targeting health gaps directly programmes; (2) closing the health gaps between those in the poorest social circumstances and those in the poorest social circumstances and those in the poorest social circumstances and confronts the problem of relative outcomes. Th e better off groups; and (3) addressing the entire better off groups; and (3) addressing the entire better off groups; and (3) addressing the entire UK’s current health inequality targets on infant health gradient, that is, the association between health gradient, that is, the association between mortality and life expectancy are examples of such health gradient, that is, the association between socioeconomic position and health across the socioeconomic position and health across the a gaps-focused approach. However, this model, socioeconomic position and health across the whole population. whole population. too, brings problems. For one thing, its objectives whole population. will be technically more challenging than those To be successful, all three of these options would To be successful, all three of these options would associated with strategies conceived only to To be successful, all three of these options would require action on SDH. All three constitute require action on SDH. All three constitute improve health status among the disadvantaged. require action on SDH. All three constitute potentially effective ways to alleviate the potentially effective ways to alleviate the “Movement towards the [gap reduction] targets potentially effective ways to alleviate the unfair burden of illness borne by the socially unfair burden of illness borne by the socially requires both absolute improvements in the levels unfair burden of illness borne by the socially disadvantaged. Yet the approaches differ disadvantaged. Yet the approaches differ of health in lower socioeconomic groups and a rate disadvantaged. Yet the approaches differ 50

54 A conceptual framework for action on the social determinants of health of improvement which outstrips that in higher country-level contextual analysis and a pragmatic 175 . Meanwhile, gaps- socioeconomic groups” mapping of policy options and sequencing. oriented approaches share some of the ambiguities underlying the focus on health disadvantage. 6.2 Frameworks for policy Health-gaps models continue to direct efforts to analysis and decision-making minority groups within the population (they are concerned with the worst-off, measured against the best-off ). By adopting this stance, “a health- Our review of the literature has identified gaps approach can underestimate the pervasive several suggestive analytic frameworks for policy development on SDH. One of the proposals most effect which socioeconomic inequality has on relevant to current purposes was elaborated health, not only at the bottom but also across 175 in the context of the Dutch national research the socioeconomic hierarchy” . By focusing 177 programme on inequalities in health too narrowly on the worst-off, gaps models can . The obscure what is happening to intermediary groups, programme report highlights phases of analysis for the implementation of interventions and policies including “next to the worst-off ” groups that may also be facing major health difficulties. on SDH. The first phase involves filling in the social background on health inequalities in the Tackling the socioeconomic gradient in health specific country or socioeconomic context. The right across the spectrum of social positions impact of each social determinant on health varies within a given country according to different constitutes a much more comprehensive model socioeconomic contexts. Four intervention areas for action on health inequities. With a health- are identified: gradient approach, “tackling health inequalities ∏ becomes a population-wide goal: like the goal The first and the most fundamental of improving health, it includes everyone”. On option is to reduce inequalities in the the other hand, this model must clearly contend distribution of socioeconomic factors or with major technical and political challenges. , like income and structural determinants Health gradients have persisted stubbornly education. An example would be reducing across epidemiological periods and are evident the prevalence of poverty. ∏ for virtually all major causes of mortality, raising The second option relates to the specific doubts about the feasibility of significantly or intermediary determinants that mediate reducing them even if political leaders have the the effect of socioeconomic position will to do so. Public policy action to address on health, such as smoking or working gradients may prove complex and costly and, in conditions. Interventions at this level will addition, yield satisfactory results only in a long aim to change the distribution of such timeframe. Yet it is clear that an equity-based specific or intermediary determinants approach to social determinants, carried through across socioeconomic groups, e.g. by 175 consistently, must lead to a gradients focus reducing the number of smokers in lower . socioeconomic groups, or improving the working conditions of people in lower Strategies based on tackling health disadvantage, status jobs. health gaps and gradients are not mutually ∏ A third option addresses the exclusive. The approaches are complementary reverse effect and can build on each other. “Remedying health of health status on socioeconomic position. If bad health status leads to a worsening disadvantages is integral to narrowing health gaps, and both objectives form part of a comprehensive of people’s socioeconomic position, inequalities in health might partly be strategy to reduce health gradients”. Thus a sequential pattern emerges, with “each goal diminished by preventing ill people from 175. Of add[ing] a further layer to policy impact” experiencing a fall in income, such as course the relevance of these approaches and a consequence of job loss. An example would be strategies to maintain people with their sequencing will vary with countries’ levels of economic development and other contextual chronic illness within the workforce. ∏ factors. A targeted approach may have little The fourth policy option concerns the It becomes delivery of curative healthcare. relevance in a country where 80% of the population relevant only after people have fallen is living in extreme poverty. Here the CSDH can contribute by linking a deepened reflection on ill. One might offer people from lower the values underpinning an SDH agenda with socioeconomic positions extra healthcare 51

55 and not central to health policy per se, or another type of healthcare, in other to Diderichsen and colleagues argue that achieve the same effects as among people addressing stratification is in fact “the in higher socioeconomic positions. most critical area in terms of diminishing disparities in health”. They propose two This and other policy frameworks should be general types of policies in this entry point: seen in the light of the preceding discussion first the promotion of policies that diminish on health disadvantage, gaps and gradients. social inequalities, e.g. labor market, Following Graham, we argued that improving education and family welfare policies; and the health of poor groups and narrowing health second a systematic impact assessment of gaps are necessary but not sufficient objectives. A social and economic policies to mitigate commitment to health equity ultimately requires their effects on social stratification. In the a health-gradients approach. A gradients model figure below, this approach is represented locates the cause of health inequalities not only line A. by in the disadvantaged circumstances and health- ∏ to health- specific exposure Decreasing the damaging behaviors of the poorest groups, but damaging factors suffered by people in in the systematic differences in life chances, disadvantaged positions. The authors living standards and lifestyles associated with indicate that most health policies do not people’s unequal positions in the socioeconomic 178. While interventions targeted at the differentiate exposure or risk reduction hierarchy strategies according to social position. most disadvantaged may appeal to policymakers on Earlier anti-tobacco efforts constitute cost grounds or for other reasons, an unintended one illustration. Today there is increasing effect of targeted interventions may be to legitimize experience with health policies aiming economic disadvantage and make it both more tolerable for individuals and less burdensome for to combat inequities in health that 178, 179, 180 . Health programmes (including society target the specific exposures of people in SDH programmes) targeted at the poor have a disadvantaged positions, including aspects constructive role in responding to acute human like unhealthy housing, dangerous working suffering. Yet the appeal to such strategies must conditions and nutritional deficiencies. not obscure the need to address the structured Children living in extreme poverty (below social inequalities that create health inequities in US$1 per day, according to the World Bank’s 181 . the first place contentious and problematic definition) have very different mortality rates in In another approach, Diderichsen and colleagues different countries; this shows that the propose a typology or mapping of entry points for national policy context modifies the effect 182 policy action on SDH that is very closely aligned ). Living in a society of poverty (Wagstaff to theories of causation, as was mapped out for with strong safety nets, active employment policies, or strong social cohesion may the Commission’s Framework. They identify social stratification; differential make day-today life less threatening and actions related to: relieve some of the social stress involved exposure/differential vulnerability; differential consequences and macro social conditions. The in having very little money or being 96, 183 ). Below, figure elaborated by Diderichsen and colleagues unemployed (Whitehead et al. 94 that illustrates these ideas is shown in Figure 6 line B. this approach is represented by . ∏ The following entry points are identified: vulnerability Lessening the of disadvantaged ∏ people to the health-damaging itself, by social stratification First, altering reducing “inequalities in power, prestige, conditions they face. An alternative way of thinking about modifying the effect income and wealth linked to different 93 . For example, socioeconomic positions” of exposures is through the concept of policies aimed at diminishing gender differential vulnerability. Intervention disparities will influence the position of in a single exposure may have no effect women relative to men. In this domain, on the underlying vulnerability of the one could envisage an impact assessment disadvantaged population. Reduced vulnerability may only be achieved when of social and economic policies to mitigate their effects on social stratification. While interacting exposures are diminished or relative social conditions improve social stratification is often seen as the responsibility of other policy sectors significantly. An example would be the 52

56 A conceptual framework for action on the social determinants of health Figure 6. Typology of Entry Points for Policy Action on SDH Social Position Social Context A B Causes (Exposure) E C Disease / injury D Policy Context Social and economic consequences Source: Reproduced with permission from Diderichsen et al. (2001) benefits of female education as one of the implications of various public and private financing mechanisms and their use most effective means of mediating women’s differential vulnerability. This entry point by disadvantaged populations. In poor . This line is line C is shown below by countries, the impoverishing effects of bifurcated to emphasize that conditions of user fees play an increasing role in the differential vulnerability exist previous to economic consequences of illness. Social specific exposures. consequences of diseases have a much ∏ steeper socioeconomic gradient than the Intervening through the health system to incidence and prevalence of the same reduce the unequal consequences of ill- health diseases. The entry point appears below as and prevent further socioeconomic degradation among disadvantaged line D. ∏ conditions Policies influencing macro-social people who become ill. Examples would (context). Social and economic policies include additional care and support to disadvantaged patients; additional may influence social cohesion, integration resources for rehabilitation programmes and social capital of communities. to reduce the effects of illness on people’s Channels of influence and intervention earning potential; and equitable health care can be defined for the development of redistributive policies, strengthening social financing. Policy options should marshal policies, in particular for the neediest and evidence for the range of interventions most vulnerable social groups. This entry (both disease-specific and related to line E. the broader social environment) that point appears in the figure as will reduce the likelihood of unequal consequences of ill health. For instance, additional resources for rehabilitation 6.3 Key dimensions and directions for policy might be allocated to reduce the social consequences of illness. Equitable health care financing is a critical component at On the basis of the model developed in the this level. It involves protection from the preceding chapter and the policy analysis impoverishment arising from catastrophic frameworks just reviewed, we can identify illness, as well as an understanding of the fundamental orientations for policy action to 53

57 (for example, models of governance, labour market reduce health inequities through action on SDH. structures or the education system) may appear We do not attempt here to recommend specific too vast and intractable to be realistic targets for policies and interventions, which will be the task concerted action to bring change. The CSDH of the Commission in its final report; rather, may hesitate to recommend ambitious forms of our aim is to highlight broad policy directions policy action (particularly expanded redistributive that the CSDH conceptual framework suggests policies) that could be considered quixotic. Yet must be considered as decision-makers weigh significant aspects of the context in our sense -- options and develop more specific strategies. the established institutional landscape and broad The directions we take up here are the following: governance philosophies -- can be (and historically (1) the importance of context-specific strategies have been) changed. Such changes have taken and tackling structural as well as intermediary place through political action, often spurred by determinants; (2) intersectoral action; and (3) organized social demand. The contextual factors social participation and empowerment as crucial that powerfully shape social stratification and, in components of a successful policy agenda on SDH turn, the distribution of health opportunities are and health equity. not (entirely) beyond people’s collective control. This is among the important implications of recent 6.3.1 Context strategies tackling 98, 105 . analyses of welfare state policies and health structural and intermediary Social policies (covering the areas of “public” and determinants “social” policies from the conceptual framework) A key implication of the CSDH framework, with matter for health and for the degree of social and its emphasis on the impact of socio-political health equity that exists in society. Evidence-based context on health, is that SDH policies must not action to alter key determinants of health inequities pin their hopes on a “one-size-fits-all” approach, is by no means politically unachievable. Notably, in but should instead be crafted with careful attention a 2005 strategy document named The Challenge of to contextual specificities. Since the mechanisms , the Norwegian Directorate for Health the Gradient producing social stratification will vary in different and Social Affairs argues that health inequities settings, certain interventions or policies are will probably be most effectively reduced through likely to be effective for a given socio-political “social equalization policies”, though the authors context but not for all. Meanwhile, the timing of acknowledge the political challenges involved in 139 interventions with respect to local processes must . Indeed, the most significant implementation lesson of the CSDH conceptual framework may be considered, as well as partnerships, availability of resources, and how the intervention and/or be that interventions and policies to reduce policy under discussion is conceptualized and health inequities must not limit themselves to understood by participants at national and local intermediary determinants; but they must include 184 . policies specifically crafted to tackle the underlying levels structural determinants of health inequities. In addition to specificities related to sub-national, national and regional factors, context also includes a Not all major determinants have been targeted for interventions. In particular, social factors rarely global component which is of growing importance. appear to have been the object of interventions The actions of rich and powerful countries, in particular, have effects far outside their borders. aimed at reducing inequity. In contrast, Global institutions and processes increasingly interventions are more frequently aimed at the influence the socio-political contexts of all countries, accessibility of health care and at behavioral risk in some cases threatening the autonomy of national factors. Regarding the accessibility of health care, a majority of policies are concerned with financing. actors. International trade agreements, the A notably high proportion of interventions are deployment of new communications technologies, aimed at those determinants that fall within the the activities of transnational corporations and domain of regular preventative care, including other phenomena associated with globalization behavioral factors (individual health promotion impact health determinants (in)directly through and education). Indeed, interventions and policies multiple pathways; hence, the importance of the that address structural determinants of health findings and recommendations of the CSDH constitute orphan areas in the determinants Knowledge Network on globalization for countries field. More work has been done on intermediary seeking to frame effective SDH policies. Some of the major institutions and processes determinants (decreasing vulnerability and exposure); but interventions at this level frequently situated in the socioeconomic and political context 54

58 A conceptual framework for action on the social determinants of health target only one determinant, without relation causes, so as to allow evaluation of their diff erent to other intermediary factors or to the deeper roles in mediating the eff ect of social position and poverty on health. structural factors. National policies in Sweden have recently given Recent discussions on resource allocation formulas in England have introduced the issue of reducing strong priority to psychosocial working conditions as well as tobacco smoking and alcohol abuse inequalities in health, not only in access to medical care. Growing political concern about as major causes mediating the effect of social position on health. A similar British overview the persistence of social inequalities in health has led the government to add a new resource put strong emphasis on living conditions and 185, 187 allocation objective for the NHS: to contribute . health behaviors of mothers and children Th e World Health Report 2002 emphasized the to the reduction in avoidable health inequalities 183, 185 enormous potential impact of improvements . Th e review is not yet fi nalized, and as an interim solution an index of mortality (years of in nutrition and vaccination programs on the 187 . Common to poverty-related burden of disease life lost under age 75) has been proposed. Resource proposals in both rich and poor countries is the allocation to disease prevention to improve health equity has to be based on an understanding of emphasis on strong coordination between social some of the causal relationships outlined above. policies and health policies in any eff ort to mitigate social inequalities in health. Eff orts should, therefore, be made to break-up socioeconomic inequality in health into its diff erent Dahlgren and Whitehead on policy approaches 188 Dahlgren and Whitehead have produced a list of broad recommendations for policy approaches to reduce underlying social inequities. Their primary focus is on income inequalities, but the principles apply to other structural determinants. Their recommendations for national policy directions include the following: ∏ Describe present and future possibilities to reduce social inequalities in income through cash benefi ts, taxes and subsidized public services. The 186 magnitude of these transfers can be illustrated by an example from the United Kingdom : “Before redistribution the highest income quintile earn 15 times that of the lowest income quintile. After distribution of government cash benefi ts this ratio is reduced to 6 to 1, and after direct and local taxes the ratio falls further to 5 to 1. Finally, after adjustment for indirect taxes and use of certain free government services such as health and education, the highest income quintile enjoys a fi nal income 4 times higher than the lowest income quintile”. ∏ Regulate the invisible hand of the market with a visible hand, promoting equity-oriented and labour-intensive growth strategies. A strong labour movement is important for promoting such policies, and it should be coupled with a broad public debate with strong links to the democratic or political decision-making process. Within this policy framework, the following special efforts should be made: • Maintain or strengthen active wage policies, where special efforts are made to secure jobs with adequate pay for those in the weakest position in the labour market. Secure minimum wage levels through agreements or legislation that are adequate and that eliminate the risk of a population of working poor. • Introduce or maintain progressive taxation, related both to income and to different tax credits, so that differences in net income are reduced after tax. • Intensify efforts to eliminate gender differences in income, by securing equal pay for equal jobs – regardless of sex. Some gender differences in income are also brought about when occupations that are typically male receive greater remuneration than occupations that are seen as female, because women are concentrated in them. These differences also need to be challenged. • Increase or maintain public fi nancing of health, education and public transport. The distributional effects of these services are signifi cant – in 188 particular for health services – in universal systems fi nanced according to ability to pay and utilized according to need . 55

59 political factors (e.g. political backing, political 6.3.2 Intersectoral action style, values and ideology), policy issues (such as As the preceding discussion has begun to suggest, consensus on the nature of problems and their solutions), and specifi c technical factors related to a commitment to tackle structural, as well as 192 the policy fi eld(s) in question intermediary, determinants has far-reaching . implications for policy. Th is focus notably requires intersectoral action, because structural determinants Shannon and Schmidt propose a “conceptual 193 of health inequities can only be addressed by policies framework for emergent governance” that suggests how levels of decision-making from global to local that reach beyond the health sector. If the aim is attacking the deepest roots of health inequities, an can be brought into fl exible but coherent connection intersectoral approach is indispensable. (“loose coupling”) by linking intersectoral policy-making and participatory approaches. “Participatory approaches” in this context means Intersectoral action for health has been defi ned as: “political processes that self-consciously and directly engage the people interested in and affected by [policy] choices”, as well as the offi cials charged with making and carrying out policy. Th ese authors argue that intersectoral action and participation A recognized relationship between can work together to enable more collaborative, responsive modes of governance. Specifi c elements part or parts of the health sector of collaboration in governance include “sharing and part or parts of another sector, resources (including staff and budgets), working that has been formed to take action to craft joint decisions, engaging the opposition in on an issue or to achieve health creative solutions to shared problems, and building 194 outcomes in a way that is more . new relationships as needs and problems arise” effective, effi cient or sustainable Three frequent approaches to intersectoral than could be achieved by the 189 action involve policies and interventions defi ned . health sector working alone according to: (1) specifi c issues; (2) designated target groups within the population; and (3) Since the Alma-Ata era, WHO has recognized a particular geographical areas (‘area-based wide range of sectors with the potential to infl uence strategies’). Th ese approaches can be implemented the determinants of health and, in some cases, the separately or combined in various forms. 188 underlying structures responsible for determinants’ have stressed Dahlgren and Whitehead 1 inequitable distribution among social groups. the importance of intersectoral approaches Relevant sectors include agriculture, food and for reducing health inequities and provided illustrative intersectoral strategies focused on nutrition; education; gender and women’s rights; the specifi c issue of improving health equity labour market and employment policy; welfare and social protection; fi nance, trade and industrial through education. Policies approaching health from the angle of education can be policy; culture and media; environment, water universal in scope (addressed to the whole and sanitation; habitat, housing, land use and 190 population), for example a nationwide . urbanization Healthy Schools programme or a universal programme to provide greater support Collaboration with these and other relevant sectors off ers distinctive opportunities, while also raising in the transition from school to work. On the other hand, thematically defi ned specific challenges. Numerous approaches to planning and implementing intersectoral action intersectoral policies can be linked with social or geographical targeting. Examples exist, and a substantial literature has grown up around the facilitators and inhibitors of such action would include introducing comprehensive 192 191 support programmes for children from less divide potential facilitating and . Challis et al. obstructing factors into two categories: behavioral privileged families, to promote preschool 188 . and structural. Behavioral elements concern development individual attitudes and comportments among Some intersectoral strategies are built around 2 the needs of specific vulnerable groups those being asked to work collaboratively across sectoral boundaries. Structural infl uences include within the population. Th is is the case of 56

60 A conceptual framework for action on the social determinants of health redefine health care result had been to: “ Chile’s “Puente” programme, for example, less as a social right and more as a market which seeks to provide a personalized commodity ”. Muntaner et al. argue that benefits package to the country’s poorest “popular resistance to neoliberalism” helped families to help them assume increased drive the creation of Barrio Adentro and the control of their own lives and enjoy array of innovative social welfare measures measurably improved life quality across 53 with which the programme is intertwined. indicators of social well-being. The Puente They suggest that Barrio Adentro “not only programme, aimed at the “hard core” of provides a compelling model of health care Chilean families living in long-term poverty, reform for other low- to middle-income is constructed to coordinate support services countries, but also offers policy lessons to from multiple sectors, including health, 197 wealthy countries” . education, employment and social welfare, while strengthening families’ social networks and their planning, conflict resolution, Of course, the intersectoral nature of SDH challenges adds considerably to their complexity. While WHO relational and life-management skills. A 2005 evaluation of the Puente programme found and other health authorities have long recognized mixed results after Puente’s first three years of the importance of intersectoral action for health, operation, revealing both successful aspects effective implementation of intersectoral policies has often proven elusive, and the Commission does not and limitations of the effort to construct 190 . Stronks a network model of integrated service underestimate the challenges involved 198 argue that: “Although and Gunning-Schepers provision at the local level. Effectiveness there is great potential for improving the distribution of service networking was inconsistent and of health through intersectoral action ... there very highly dependent on the quality of local often will be a conflict of interest with other societal leadership within the municipalities where goals. ... The major constraint in trying to redress the programme operates. The evaluation socio-economic health differences results from concluded that despite its problems, the the fact that interventions on most determinants Puente model “stands out through its of health will have to come from [government] requirement that services connect up in departments other than the department of public networks to coordinate provision to very 194 health. ... Whereas the primary goal of health . Another example of poor sectors” intersectoral action crafted to meet the policy is (equality in) health, other policy fields needs of specific groups is the New Zealand have other primary goals.” (For example, in the area government’s programming for health of employment and workforce policies, loosening regulation in the hope of raising the number of improvement among the country’s Maori 195 new jobs may take precedence over concerns for . minority A third form of intersectoral policy-making maintaining a living wage or for workplace safety). 3 is oriented to designated geographical areas. ...“In intersectoral action, conflicts between the goal A widely discussed (and contested) recent of equity in health and goals in other policy fields, especially economic policies, are to be expected”. example is provided by the United Kingdom’s 196 In light of such concerns, important tasks for the Health Action Zones (HAZ) . Venezuela’s CSDH will be: (1) to identify successful examples Barrio Adentro (“Inside the Neighborhood”) programme offers a very different model of intersectoral action on SDH at the national and sub-national level in jurisdictions with different of an area-focused healthcare programme incorporating intersectoral elements. Barrio levels of resources and administrative capacity; (2) to characterize in detail the political and management Adentro forms part of a multi-dimensional national policy effort introduced by the mechanisms that have enabled effective intersectoral government of President Hugo Chavez to programmes to function sustainably; and (3) to improve health and living conditions for identify key examples of intersectoral action, and residents of fragile, historically marginalized needs for future action, in the international frame urban neighborhoods. Barrio Adentro of reference. These will often require initiatives by was consciously constructed as an equity- several countries acting jointly, within or outside the framework provided by existing multilateral focused response to the neoliberal health institutions. care reforms implemented throughout Latin . America during the 1980s and 90s, whose 57

61 ∏ To obtain feedback from Consulting: 6.3.3 Social participation and affected communities on analysis, empowerment alternatives and/or decisions. ∏ To work directly with Involving: A final crucial direction for policy to promote communities throughout the process health equity concerns the participation of to ensure that public concerns and civil society and the empowerment of affected aspirations are consistently understood communities to become active protagonists in shaping their own health. and considered. ∏ To partner with affected Collaborating: communities in each aspect of the decision, Broad social participation in shaping policies to including the development of alternatives advance health equity is justified on ethical and and the identification of the preferred human rights grounds, but also pragmatically. solution. Human rights norms concern processes as well ∏ To ensure that communities Empowering: as outcomes. They stipulate that people have the have “the last word” – ultimate control over right to participate actively in shaping the social and health policies that affect their lives. This the key decisions that affect their well- being. principle implies a particular effort to include groups and communities that have tended Policy-making on social determinants of health to suffer acute forms of marginalization and equity should work towards the highest form of disempowerment. Meanwhile, from a strategic point of view, promoting civil society ownership participation as authentic empowerment of civil society and affected communities. of the SDH agenda is vital to the agenda’s long- term sustainability. The task of implementing the Commission’s recommendations and advancing As noted above, of course, definitions of “empowerment” are diverse and contested. To action for health equity must be taken up by some, empowerment is a “political concept that governments. In turn, governments’ commitment in pursuing this work will depend heavily on the involves a collective struggle against oppressive social relations” and the effort to gain power degree to which organized demand from civil over resources. To others, it “refers to the society holds political leaders accountable. By consciousness of individuals, or the power to nurturing civil society participation in action 88 on SDH during its lifetime, the Commission is express and act on one’s desires” . When laying the groundwork for sustained progress promoting “empowerment” and “participation” in health equity in the long term. The Cuenca as key aspects of policy strategies to tackle heath Declaration, adopted at the Second People’s inequities, we must be aware of the historical Health Assembly, rightly states that the best and conceptual ambiguities that surround these hope for equitable health progress comes when terms. The concept of empowerment in particular empowered communities ally with the state has generated a voluminous and often polemical 84, 201 in action against the economic and political . Here, we cannot hope to recent literature interests currently tending to undermine the reflect all the nuances of these debates. However, 199 public sector we can highlight relevant aspects that clarify . our interpretation of these concepts and their implications for policy-making. While the primary responsibility for promoting health equity and human rights lies with Historically, key sources of the concept of governments, participation in decision-making empowerment include the Popular Education processes by civil society groups and movements is “vital in ensuring people’s power and control movement and the women’s movement. The 200 . As proposed by the in policy development” Popular Education approach gained prominence International Association for Public Participation in Latin America and elsewhere in the 1970s. (IAP2), when governments solicit social It is based on the pioneering work of Paulo participation, this term can have a wide range of Freire in the education of oppressed people, and 201 meanings : notably on Freire’s model of consciencization ∏ To provide people with Informing: (conscientisaçao). In the 1980s, movements balanced and objective information inspired by Popular Education played an important to assist them in understanding the role in progressive political struggles and resistance problem, alternatives, opportunities and/ against authoritarian governments in Latin 202 . The actual term “empowerment” first or solutions. America 58

62 A conceptual framework for action on the social determinants of health 90 achieved wide usage in the women’s movement, . Indeed, the increased ability of ” control on oppressed and marginalized communities to which drew inspiration from Freire’s work. Luttrell and colleagues argue that, in contrast to other control key processes that affect their lives is the essence of empowerment as we understand it. progressive intellectual currents dominated by Their capacity to promote such control should be voices from the global north, groundbreaking work on empowerment and gender emerged from a significant criterion in evaluating policies on the social determinants of health. the south, for example through the movement of Development Alternatives from Women from 203 a New Era (DAWN), which shaped grassroots A framework originally developed by Longwe analysis and strategies for women challenging provides a useful way of distinguishing among 90 . Subsequently, notions of collective inequalities different levels of empowerment, while also empowerment became central to the liberation suggesting the step-wise, progressive nature of empowerment processes. The framework describes movements of ethnic minorities, including indigenous groups in Latin America and African- the following levels: Americans in the United States. The 1 level: where basic needs are welfare satisfied. This does not necessarily require structural causes to be addressed and tends During the 1990s, the association between to assume that those involved are passive empowerment and progressive politics tended to break down. In the context of neoliberal economic recipients. level: where equal access to access 2 The and social policies and the rolling-back of the education, land and credit is assured. state, “notions of participation and empowerment, The 3 conscientisation and awareness- previously reserved to social movements and level: where structural and raising NGOs, were reformulated and became a central 90 ; a substantially institutional discrimination is addressed. part of the mainstream discourse” depoliticized model of empowerment emerged. The 4 participation and mobilisation level: Whereas it was linked to progressive political where the equal taking of decisions is agendas, empowerment now came increasingly enabled. to appear as a substitute for political change. control The 5 level: where individuals can During this same period, the vocabulary of make decisions and are fully recognized empowerment was being adopted by mainstream and rewarded. international development agencies, including the World Bank. Thus, empowerment came to suffer This framework stresses the importance of gaining ambiguities similar to those surrounding social over decisions and resources that control of 90 . Today, critics argue that the embrace of capital determine the quality of one’s life and suggests empowerment by leading development actors has that “lower” degrees of empowerment are a pre- not led to any meaningful changes in development requisite for achieving higher ones . practice. Some critiques go further to suggest that the use of the term allows organisations to say they Importantly, the empowerment of disadvantaged are “tackling injustice without having to back any communities, as we understand it, is inseparably political or structural change, or the redistribution intertwined with principles of state responsibility. 90 of resources” (Fiedrich et al., 2003) . This point has fundamental implications for policy-making on SDH. The empowerment of In contrast to this depoliticized understanding, we marginalized communities is not a psychological follow recent critics in adopting a political model process unfolding in a private sphere separate of the meaning and practice of empowerment. from politics. Empowerment happens in ongoing Empowerment, as we understand it, is inseparably engagement with the political, and the deepening of linked to marginalized and dominated that engagement is an indicator that empowerment communities gaining effective control over the is real. The state bears responsibility for creating political and economic processes that affect their spaces and conditions of participation that can well-being. Like these critics, we value participation enable vulnerable and marginalized communities but question whether participation alone can to achieve increased control over the material, be considered genuinely empowering, without social and political determinants of their own attention to outcomes, namely, the redistribution well-being. Addressing this concern defines a of resources and power over political processes. crucial direction for policy action on health equity. We endorse the call to “mov[e] beyond mere It also suggests how the policy-making process participation in decision-making to an emphasis itself, structured in the right way, might open space 59

63 communities. These broad directions for policy for the progressive reinforcement of vulnerable action can utilize various entry points or levels people’s collective capacity to control the factors of engagement, represented in the image by the that shape their opportunities for health. cross-cutting horizontal bars. 6.3.4 Diagram summarizing key Moving from the lower to the higher bars policy directions and entry points (from more “downstream” to more structural approaches), these entry points include: seeking The diagram below summarizes the main ideas presented in the preceding sections and to palliate the differential consequences of illness; seeking to reduce differential vulnerabilities attempts to clarify their relationships via a visual and exposures for disadvantaged social groups; representation. It recalls that the Commission’s and, ultimately, altering the patterns of social broad aim, politically speaking, is to promote context-specific strategies to address structural, stratification. At the same time, policies and interventions can be targeted at the “micro” level as well as intermediary determinants. Such strategies will necessarily include intersectoral of individual interactions; at the “meso” level of policies, through which structural determinants community conditions; or at the broadest “macro” can be most effectively addressed, and will aim level of universal public policies and the global to ensure that policies are crafted so as to engage environment. and ultimately empower civil society and affected Figure 7. Framework for tackling SDH inequities Context-specific Key dimensions and directions for policy strategies tackling both structural and intermediary Intersectoral Social Participation determinants and Empowerment Action Globalization Environment Policies on to reduce inequalities, stratification mitigate effects of stratification Macro Level: Policies to reduce exposures of disadvantaged Public Policies people to health-damaging factors Mesa Level: of Policies to reduce vulnerabilities Community disadvantaged people of unequal consequences Policies to reduce illness in social, economic and health terms Micro Level: Individual interaction 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 60

64 A conceptual framework for action on the social determinants of health He continues: “Each of the core concerns of social The CSDH and policy partners must also be concerned with an additional set of issues relevant policy—need, deserts and citizenship—are social to all these types of policies (summarized in the box at constructs that derive full meaning from the cultural and ideological definition of ‘deserving the lower right): monitoring of the eff ects of policies and interventions on health equity and determinants; poor’, ‘entitlement’ and ‘citizens’ rights’. Although in current parlance, the choice between targeting and assembling and disseminating evidence of eff ective universalism is couched in the language of effi cient interventions, including intersectoral strategies; and advocating for the incorporation of health equity allocation of resources subject to budget constraints as a goal into the formulation and evaluation of and the exigencies of globalization, what is actually health and all social policies (covering the areas at stake is the fundamental question about a polity’s labelled “public” and “social” policies identifi ed in values and its responsibilities to all its members. Th e technical nature of the argument cannot conceal the conceptual framework). the fact that, ultimately, value judgments matter not 204 As Stewart-Brown only with respect to determining the needy and how points out, to date, public health research has focused more on the impact of social they are perceived, but also in attaching weights to inequalities than on their causes, or a fortiori on the types of costs and benefi ts of approaches chosen. realistic political strategies to address underlying Such a weighting is oft en refl ective of one’s ideological causes. Studies of interventions to mitigate the impact predisposition. In addition, societies chose either targeting or universalism in conjunction with other of social inequalities have tended to focus on methods policies that are ideologically compatible with the of reducing the level of disease at the lower end of the income distribution. Th e application of public choice, and that are deemed constitutive of the 205 . health theory, however, suggests that the causes of desired social and economic policy regime” social inequalities are likely to lie as much with the Mkandawire highlights the contradictions of attributes of high-income groups as with those of 204 . Th is insight sharpens our dominant approaches: “One remarkable feature low-income groups of the debate on universalism and targeting is the sense of the political challenges. Solutions such as redistribution of income that may appear simple in disjuncture between an unrelenting argumentation for targeting, and a stubborn slew of empirical the abstract are anything but simple to achieve in evidence suggesting that targeting is not eff ective in re a l it y. addressing issues of poverty (as broadly understood). Many studies clearly show that identifying the poor Fundamental to formulating eff ective policy in this area is the vexed problem of universal vs. targeted with the precision suggested in the theoretical models involves extremely high administrative approaches. Th andika Mkandawire, while director of the United Nations Research Institute for Social costs and an administrative sophistication and 205 capacity that may simply not exist in developing : Development, summarized the issue as follows countries. An interesting phenomenon is that while the international goals are stated in international conferences, in universalistic terms (such as “For much of its history, social policy ‘education for all’ and ‘primary health care for all’), has involved choices about whether the means for reaching them are highly selective and the core principle behind social targeted. Th e need to create institutions appropriate for targeting has, in many cases, undermined the provisioning will be ‘universalism’ or capacity to provide universal services. Social policies selectivity through ‘targeting’. Under not only defi ne the boundaries of social communities ‘universalism’ the entire population is and the position of individuals in the social order of the benefi ciary of social benefi ts as things, but also aff ect people’s access to material well- a basic right; while under ‘targeting’, being and social status. Th is follows from the very eligibility to social benefi ts involves process of setting eligibility criteria for benefi ts and some kind of means-testing to rights. Th e choice between universalism and targeting determine the “truly deserving”. Policy is therefore not merely a technical one dictated by the regimes are hardly ever purely universal need for optimal allocation of limited resources. or purely based on targeting, however; Furthermore, it is necessary to consider the kind of they tend to lie somewhere between political coalitions that would be expected to make the two extremes on a continuum and such policies politically sustainable. Consequently, there is a lot of reinvention of the wheel, and wasteful are often hybrid, but where they lie and socially costly experimentation with ideas that on this continuum can be decisive in 61 spelling out individuals’ life chances and 205 in characterizing the social order.”

65 ‘targeting within universalism’, in which extra benefits have been clearly demonstrated to be the wrong ones for the countries in which they are being imposed. are directed to low-income groups within the context of a universal policy design (Skocpol 1990) and There is ample evidence of poor countries that have significantly reduced poverty through universalistic involves the fine-tuning of what are fundamentally 205 approaches to social provision, and from whose universalist policies” . experiences much can be learnt (Ghai 1999; Mehrotra and Jolly 1997a, 1997b). Although we have posed the We now present a summary of examples of SDH issue in what Atkinson calls ‘gladiator terms’, in reality interventions, organized according to the most governments tend to have a mixture of both framework for action developed in this paper. This summary draws, among other sources, on universal and targeted social policies. However, in the the policy measures discussed in the Norwegian more successful countries, overall social policy itself Health Directorate’s 2005 publication named has been universalistic, and targeting has been used 139 . as simply one instrument for making universalism The Challenge of the Gradient effective; this is what Theda Skocpol has referred as Table 3. Examples of SDH interventions Strategies Entry Point Universal Selective ∏ ∏ Social Stratification: Active policies to reduce income inequality Social security schemes for specific population Policies to reduce through taxes and subsidized public services. groups in disadvantaged positions. inequalities and ∏ ∏ Child welfare measures: Implement Early Child Free and universal services such as health, mitigate effects of education, and public transport. Development programmes including the provision stratification. of nutritional supplements, regular monitoring ∏ Active labour market policies to secure jobs with of child development by health staff. Promotion adequate payment. Labour intensive growth of cognitive development of children at pre- strategies. schooling age. Promote pre-school development. ∏ Social redistribution policies and improved mechanisms for resource allocation in health care and other social sectors. ∏ Promote equal opportunities for women and gender equity. ∏ Promote the development and strengthening of autonomous social movements. ∏ ∏ Exposure: Policies and programs to address exposures for Healthy and safe physical neighbourhood Policies to reduce specific disadvantaged groups at risk (cooking environments. Guaranteed access to basic exposure of fuels, heating, etc). neighbourhood services. disadvantaged ∏ ∏ Healthy and safe physical and social living Policies on subsidized housing for disadvantaged people to health people. environments. Access to water and sanitation. damaging factors. ∏ Healthy and safe working environments. ∏ Policies for health promotion and healthy lifestyle (e.g. smoking cessation, alcohol consumption, healthy eating and others). ∏ ∏ Vulnerability: Employment insurance and social protection Extra support for students from less privileged Policies to reduce policies for the unemployed. families facilitating their transition from school to vulnerability of work. ∏ Social protection policies for single mothers specific groups. ∏ and programs for access to work and education Free healthy school lunches. opportunities. ∏ Additional access and support for health ∏ Policies and support for the creation and promotion activities. ∏ development of social networks in order to Income generation, employment generation increase community empowerment. activities through cash benefits or cash transfers. ∏ ∏ Unequal Policies Additional care and support for disadvantaged Equitable health care financing and protection to reduce from impoverishment for people affected by patients affected by chronic, catastrophic illness the unequal catastrophic illness. and injuries. consequences of ∏ ∏ Support workforce reintegration of people affected Additional resources for rehabilitation programs social, economic, by catastrophic or chronic illness. for disadvantaged people. and ill-health for ∏ Active labour policies for incapacitated people. disadvantaged ∏ Social and income protection for people affected people. with chronic illness and injuries. 62

66 A conceptual framework for action on the social determinants of health KEY MESSAGES OF THIS SECTION: p Three broad approaches to reducing health inequities can be identifi ed, based on: (1) targeted programmes for disadvantaged populations; (2) closing health gaps between worse-off and better-off groups; and (3) addressing the social health gradient across the whole population. p A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other. p Policy development frameworks, including those from Stronks et al. and Diderichsen, can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. p The CSDH framework suggests a number of broad directions for policy action. We highlight three: • Context-specifi c strategies to tackle both structural and intermediary determinants • Intersectoral action • Social participation and empowerment. p SDH policies must be crafted with careful attention to contextual specifi cities, which should be rigorously characterized using methodologies developed by social and political science. p Arguably the single most signifi cant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifi cally crafted to tackle underlying structural determinants through addressing structural mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. These mechanisms are rooted in the key institutions and policies of the socioeconomic and political context. p To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches. A key task for the CSDH will be: (1) to identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and (2) to characterize in detail the political and management mechanisms that have enabled effective intersectoral policy-making and programmes to function sustainably. p Participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success. Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward after the Commission has completed its work. 63

67 Conclusion Conclusion 7 7 7 features of the socioeconomic and political context features of the socioeconomic and political context features of the socioeconomic and political context his paper has sought to clarify shared his paper has sought to clarify shared his paper has sought to clarify shared that mediate their impact, and constitute the understandings around a series of understandings around a series of social that mediate their impact, and constitute the understandings around a series of that mediate their impact, and constitute the determinants of health inequities foundational questions. The architects foundational questions. The architects . Th e structural determinants of health inequities foundational questions. The architects determinants of health inequities T mechanisms that shape social hierarchies, mechanisms that shape social hierarchies, of the CSDH gave it the mission of T of the CSDH gave it the mission of of the CSDH gave it the mission of mechanisms that shape social hierarchies, helping to reduce health inequities, understood as helping to reduce health inequities, understood as helping to reduce health inequities, understood as according to key stratifi ers, are the root cause of according to key stratifi ers, are the root cause of according to key stratifi ers, are the root cause of health inequities. avoidable or remediable health diff erences among avoidable or remediable health diff erences among health inequities. health inequities. avoidable or remediable health diff erences among population groups defi ned socially, economically, population groups defi ned socially, economically, population groups defi ned socially, economically, demographically or geographically. Getting to Our answer to the second question, about demographically or geographically. Getting to demographically or geographically. Getting to Our answer to the second question, about Our answer to the second question, about grips with this mission requires fi nding answers pathways from root causes to observed inequities grips with this mission requires fi nding answers grips with this mission requires fi nding answers pathways from root causes to observed inequities pathways from root causes to observed inequities to three basic problems: in health, was elaborated by tracing how the in health, was elaborated by tracing how the in health, was elaborated by tracing how the to three basic problems: to three basic problems: underlying social determinants of health inequities If we trace health diff erences among social 1 If we trace health diff erences among social 1 underlying social determinants of health inequities If we trace health diff erences among social underlying social determinants of health inequities intermediary operate through a set of what we call groups back to their deepest roots, where groups back to their deepest roots, where groups back to their deepest roots, where operate through a set of what we call operate through a set of what we call do they originate? determinants of health to shape health outcomes. determinants of health do they originate? do they originate? determinants of health Th e main categories of intermediary determinants What pathways lead from root causes to the 2 Th e main categories of intermediary determinants What pathways lead from root causes to the What pathways lead from root causes to the 2 Th e main categories of intermediary determinants of health are: material circumstances; psychosocial stark diff erences in health status observed of health are: material circumstances; psychosocial stark diff erences in health status observed of health are: material circumstances; psychosocial stark diff erences in health status observed circumstances; behavioral and/or biological at the population level? at the population level? at the population level? circumstances; behavioral and/or biological circumstances; behavioral and/or biological In light of the answers to the first two 3 factors; and the health system itself as a social factors; and the health system itself as a social factors; and the health system itself as a social In light of the answers to the first two 3 In light of the answers to the first two determinant. We argued that the important questions, where and how should we determinant. We argued that the important questions, where and how should we determinant. We argued that the important questions, where and how should we complex of phenomena toward which the intervene to reduce health inequities? intervene to reduce health inequities? complex of phenomena toward which the complex of phenomena toward which the intervene to reduce health inequities? unsatisfactory term “social capital” directs our unsatisfactory term “social capital” directs our unsatisfactory term “social capital” directs our The framework presented in these pages has attention cannot be classifi ed defi nitively under attention cannot be classifi ed defi nitively under The framework presented in these pages has attention cannot be classifi ed defi nitively under The framework presented in these pages has the headings of either structural or intermediary been developed to provide responses to these the headings of either structural or intermediary the headings of either structural or intermediary been developed to provide responses to these been developed to provide responses to these questions and to buttress those responses with determinants of health. “Social capital” cuts across determinants of health. “Social capital” cuts across determinants of health. “Social capital” cuts across questions and to buttress those responses with questions and to buttress those responses with the structural and intermediary dimensions, with solid evidence, canvassing a range of views among the structural and intermediary dimensions, with the structural and intermediary dimensions, with solid evidence, canvassing a range of views among solid evidence, canvassing a range of views among features that link it to both. Th e vocabulary of theorists, researchers and practitioners in the fi eld features that link it to both. Th e vocabulary of features that link it to both. Th e vocabulary of theorists, researchers and practitioners in the fi eld theorists, researchers and practitioners in the fi eld of SDH and other relevant disciplines. To the fi rst “structural determinants” and “intermediary of SDH and other relevant disciplines. To the fi rst “structural determinants” and “intermediary “structural determinants” and “intermediary of SDH and other relevant disciplines. To the fi rst determinants” underscores the causal priority of question, on the origins of health inequities, we question, on the origins of health inequities, we determinants” underscores the causal priority of question, on the origins of health inequities, we determinants” underscores the causal priority of the structural factors. have answered as follows. Th e root causes of health the structural factors. the structural factors. have answered as follows. Th e root causes of health have answered as follows. Th e root causes of health inequities are to be found in the social, economic inequities are to be found in the social, economic inequities are to be found in the social, economic This paper provides only a partial answer to and political mechanisms that give rise to a set of This paper provides only a partial answer to and political mechanisms that give rise to a set of This paper provides only a partial answer to and political mechanisms that give rise to a set of the third and most important question: what hierarchically ordered socioeconomic positions hierarchically ordered socioeconomic positions hierarchically ordered socioeconomic positions the third and most important question: what the third and most important question: what we should do to reduce health inequities. Th e within society, whereby groups are stratified Commission’s fi nal report will bring a robust set according to income, education, occupation, gender, race/ethnicity and other factors. The of responses to this problem. However, we believe fundamental mechanisms that produce and the principles sketched here to be of importance in suggesting directions for action to improve health maintain (but that can also reduce or mitigate equity. We derive three key policy orientations effect) this stratification include: governance; from the CSDH framework: the education system; labour market structures; and redistributive welfare state policies (or their Arguably the single most signifi cant lesson 1 of the CSDH conceptual framework is absence). We have referred to the component that interventions and policies to reduce structural factors of socioeconomic position as . Structural determinants, include the health inequities must not limit themselves determinants 64

68 A conceptual framework for action on the social determinants of health to intermediary determinants, but must and management mechanisms that have enabled effective intersectoral policy- include policies crafted to tackle structural determinants. In conventional usage, the making and programmes to function sustainably. term “social determinants of health” has often encompassed only intermediary 3 Participation of civil society and affected communities in the design and determinants. However, interventions implementation of policies to address SDH addressing intermediary determinants can improve average health indicators while is essential to success. Social participation is an ethical obligation for the CSDH leaving health inequities unchanged. For and its partner governments. Moreover, this reason, policy action on structural determinants is necessary. To achieve solid the empowerment of civil society and communities and their ownership results, SDH policies must be designed with attention to contextual specificities; of the SDH agenda is the best way to build a sustained global movement for this should be rigorously characterized health equity that will continue after the using methodologies developed by social and political science. Commission completes its work. 2 Intersectoral policy-making and The broad policy directions mapped by this implementation are crucial for progress on SDH. This is because structural framework are empty unless translated into determinants can only be tackled through concrete action. To be effective, however, action strategies that reach beyond the health in the complex field of health inequities must be sector. Key tasks for the CSDH will be guided by careful theoretical analysis grounded to: (1) identify successful examples in explicit value commitments. The framework of intersectoral action on SDH in offered here proposes basic conceptual foundations jurisdictions with different levels of for the Commission’s work in, we hope, a clear resources and administrative capacity; form, so that they can be subjected to examination and (2) characterize in detail the political and reasoned debate. 65

69 list of abbreviations Commission on Social Determinants of Health CSDH SDH Social determinants of health UNDP United Nations Development Programme SEP Socioeconomic position 66

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79 Social Determinant H t Heal of S of conditions and resources — and money , power to access the life daily the age and , work , live , grow , born are people which in circumstances [energy] [justice] [investment] [water] [community/gov.] [food] [accessible & safe] [supply & safety] [providers of services, education, etc.] or A Con C e P tu A l Fr A mework F A C tion on t H e So C i A l Determin A nt S H F He A l t o Social Determinants of Health Discussion Paper 2 ISBN 978 92 4 150085 2 H World Healt or G a NIZ at I o N ve a a N ue a pp I ev N 1211 Ge a 27 P , CASE STUDIES DEBATES, e oli CY & P r AC ti C d WI Z erla N t S IN a N t IN WWW . o. WH t/ S S I al_determ oc

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