Since the August launch of the report of the three year Commission on Social Determinants of Health titled ‘Closing the gap in a generation: Health equity through action on the social determinants of health’, a flurry of activities have taken place. These have included lectures, conferences and articles to discuss the themes explored in the 250 plus page document. These events are set to continue, and include a three day conference in the UK, where key figures from the health world will air their views on the report.
First and foremost, in our view this report should be applauded for highlighting a set of issues that are rarely discussed in global health and development debates. Amartya Sen put it succinctly when he commented on the report; ‘this WHO Commission has concentrated on the badly neglected causal linkages that have to be adequately understood and remedied’.
Global health debates too often focus on biomedical aspects of health and those working in this area rarely have space, place, opportunity or desire to link up with those working on the social science aspects. This topic will be discussed further at the conference hosted by ODI, Goldsmiths College and the International HIV/AIDS Alliance early next year.
The report introduces a more inclusive approach to health policy. Following consultation with a variety of stakeholders, including civil society, the report explores a range of factors affecting health outcomes across many sectors. These include early childhood development (a topic often overlooked in wider discourses, beyond those with a particular interest in children), education, water and sanitation environment, urbanisation, climate change, labour and employment. It also discusses a set of critical issues that are even less likely to be seen on a biomedical agenda; issues of empowerment, social cohesion, gender, power and control of resources and governance.
By putting health equity firmly at the forefront of development debates, this report goes beyond mainstream arguments that economic growth alone will improve health outcomes. Rather it emphasises how inequitable distribution of benefits, economic growth and power can aggravate inequities. For example, it addresses the differentials between rural and urban populations and analyses their differential health needs, outcomes and challenges – focusing more on urban than rural issues. This is welcome as issues on urbanisation have been relatively neglected in global development debates.
Despite the report’s achievements in broadening the conception of health linkages and equitable distribution, we believe that five key questions have emerged – questions that will certainly be discussed during the weeks and months to come.
Question 1: What can be done to keep focus on equity amid financial turmoil?
As governments focus on kick-starting economic growth, the importance of equity and the distributional aspects of resources and power, so effectively portrayed in the report, are likely to be forgotten. How will policy shapers be convinced that an equity focus is critical for an inclusive growth path? Consequences of non-action include the perpetuation of a vicious spiral of poverty and ill-health.
The report highlights the key role of the public sector, saying that ‘health is a matter of right and public sector duty’. With available funding in both developed and developing nations shrinking, how will funding on social sectors be affected? How will the commitments made by donors be met in this changing environment? This theme will be discussed further at an ODI hosted World AIDS Day event.
Question 2: Who has the motivation and capacity to push this agenda forward?
Although the report calls for action from several stakeholders, who will prioritise this agenda and push it forward? The Determine consortium is leading the way in the EU, but who will act to prioritise this agenda in the South? Do the UN and WHO have sufficient capacity and resources to take this lead, and are they sufficiently empowered to do so? What learning from other global organisations and partnerships (e.g. the Global Fund and GAVI Alliance) could assist in this process?
Question 3: Will President Obama be on our side?
One ray of hope is offered by the election of Obama as US President. Although he is unlikely to change the affect of the damaging health policies overnight, he has made commitments in a number of under resourced and vitally important equity-related areas that are often subsumed by more prominent concerns. During his campaign, for example, Obama pledged to increase spending on child and maternal health, and not at the expense of related important areas like HIV and AIDS. These policies are reinforced by a focus on health infrastructure (see the policy for Global Health Infrastructure by 2020), which will be vital to ensure equitable and context-specific service delivery. Another area in which the Obama administration is singing in tune with the Commission’s report is the focus on improving health-care systems to prevent the ‘brain drain’ of health human resources i.e. health professionals leaving the South for better pay in richer countries.
However, it is important that this vision is well supported by USAID and its partners within the South, given concerns over the capacity and resources of other organisations. It is also essential that sufficient resources are allocated over a substantial period of time (and will not be jeopardised by financial instability) if these policies are to translate into sustainable change.
Question 4: To what end is the call for a multi-sectoral approach to health?
While issues of inequity may be similar across all nations, the starting points are very different. A multi-sectoral approach to health (and indeed a range of other issues) is critical, and has been called for over decades. Nevertheless, to date calls for multi-sectoral approaches have not been turned into practical action. The recommendations of this report will reinforce the necessity for a multi-sectoral approach in high-level discussion but the rhetoric needs to be matched with tangible policies. Discussion over the report will do much to put various stakeholders on a level-playing field and perhaps pave the way for greater cross-sectoral cooperation, but how can this approach be supported in the long term? And who will establish and reinforce this commitment among health professionals, in the North and the South?
Question 5: Closing the gap in a generation: an unrealistic ambition?
Successful change requires a balance between ambition and realism. This report errs on the side of ambition. Addressing inequities in health involve slow processes of affecting political, social and structural changes. Quick and dirty change undermines sustainability of progress. Raising expectations that will be left unfulfilled in a generation is likely to generate cynicism, or worse silence on the issue.
The next few months are pivotal in shaping the global health equity agenda - in particular issues around health policy and implementation. To ensure the continued focus on equity in health it is essential that these questions are addressed in future discussions.
"