Equity, social determinants and the ‘usual’ public health suspects

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WHO Publication I’ve just familiarised myself with WHO’s publication “Equity, social determinants and public health programmes“.  It was written in 2010 with a view to drawing lessons from the WHO Global Commission on Social Determinants in order to think further upstream than the traditional public health programmes.

I have to say I struggled to start with.  I always groan a little when I see documents about ‘public health’ where the chapter headings are the ‘usual’ suspects – diseases such as cardiovascular disease; diabetes; mental disorders and ‘lifestyle behaviours’ such as alcohol; tobacco; diet.  My worry is always that this silos people into thinking of the determinants of each of these ‘usual’ suspects without considering the crossovers between them – what you then get is practitioners fighting for the attention of different stakeholders on a disease by disease or risk by risk basis.  Just recently I was at a WHO European Healthy Cities Network conference where there were calls to move away from that perspective to think more holistically about what creates health.

But I thought I’d persevere, after all – equity and social determinants were in the title.  And I’m glad I did.  In essence the introductory chapter introduces a common analytical framework to consider inequities in major public health priorities i.e. usual suspects (more later).  Then this framework is applied in each of 11 chapters to all those ‘usual’ suspects.  Then in the final chapter – yeah – they synthesise the findings across the whole lot and highlight those social determinants that should be addressed in order to have an effect across a substantial number of all those ‘usual’ suspects.  In other words, they recommend working upstream in an integrated, holistic way – rather than a disease by disease or risk by risk way.

The introductory chapter introduces a framework to help with analysing inequities (mostly explained pages 6-8, with diagram on page 7).  There are five levels of this framework – the top three operate at the population level and the lower two at the individual level.  The ‘higher levels’ influence and impact on those below them not in a linear, ladder like influence but in a complex, dynamic one.

The five levels are:

  • Socio economic context and position – societal level where control of the distribution of power and resources leads to stratification in society
  • Differential exposure – highlighting how your social position gives you different levels of exposure to material, psychosocial and behavioral risk
  • Differential vulnerability – highlighting how the same level of exposure can actually have a different scale of impact on different socio-economic groups.  This can be particularly the case when exposure to multiple risks reinforce each other.
  • Differential health outcomes – highlighting how health services may not be as accessible to, or effective for, different parts of the population
  • Differential consequences – highlighting how ill-health can disproportionately lead to more difficult social circumstances – such as loss of income; inability to work; stigma and so on.

The report also offered a way of considering the different types of intervention that need to be considered for these levels (page 8).  At the population level, three different types of intervention could be considered:

  • seeking to influence the distribution of power and resources
  • seeking to address deficiencies in behaviours, settings or availability of products
  • seeking to change social ‘norms’

Whereas at the bottom two levels, need to think more about the design characteristics of services – both in terms of their access and their effectiveness.  People with lower social position potentially benefit less from health care if these design characteristics are not right for them.

As mentioned above the final chapter draws together the determinants that are involved in the causal pathways of multiple public health concerns.  It presents them at each of the five levels and considers relevant entry points and feasible actions.  The recommendations are aimed at those working in ‘public health programmes’, rather than social policy itself but they do draw attention to familiar issues – social exclusion, settings, poverty and unemployment, low education and knowledge, quality of family and community life and crucially that health services themselves can be a social determinant of inequity.

All in all an interesting read.


Blas, E. and Karup, A.S. (Editors) (2010), Equity, Social Determinants and Public Health Programmes, World Health Organisation, Geneva [Available at http://whqlibdoc.who.int/publications/2010/9789241563970_eng.pdf, accessed 11 Oct 2013].


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