EDITORIALS
Implementing equity: the Commission on Social Determinants of Health
Marion Birch*
Medact, The Grayston Centre, 28 Charles Square, London N1 6HT, England
Civil society groups are "powerful protagonists in the global health equity agenda" according to the final report of the Commission on Social Determinants of Health (CSDH).1 Initiatives designed to reduce health inequities need strong support from civil society. In some cases, civil society plays a key role as a complementary force to government action to crack the root causes of health inequity in what has been described as the "nutcracker" effect.2
There are clear examples of civil society applying pressure for change, whether protesting against water privatization in Guatemala or taking part in the "Nine is Mine" campaign in New Delhi (calling for 9% of India's gross domestic product to be committed to health and education). The 40% of the world's population that live on less than US$ 2 a day - with their experience at the receiving end of inequitable policies - will be key partners in the implementation of the report's recommendations. Even those whose income is considerably higher can offer insights on how their national social gradient impacts their own mental and physical health.
The CSDH report recognizes that identifying the structural drivers of health inequity will be challenging in terms of attributing causality and demonstrating effectiveness.1 Civil society will be key to assisting with this process and in many instances has clearly identified these structural drivers. In the Niger delta, the environmental, social and security consequences of oil extraction and the lack of local investment have resulted in a situation where most primary health care centres lack basic medicines, water and electricity,3 and there is only one doctor for every 150 000 residents.4 Civil society protesters clearly recognize the exploitative links that have created this situation.
Global civil society networks can also be important players. The People's Health Movement is described as a key actor in ensuring that "action on the social determinants of health is developed, implemented and evaluated."1 The People's Health Movement is also behind Global Health Watch 2 - the recently released "alternative world health report" that was written by more than 130 individuals from six continents, describing the structural drivers of inequity.5
The CDSH is very clear that those in power will need to make a significant investment for its recommendations to be successful. A glance at recent World Bank figures indicates considerable investment, with development assistance for health increasing from US$ 2.5 billion to almost US$ 14 billion between 2000 and 2005.6 At the same time there has been a proliferation of global health actors resulting in 40 bilateral donors, 26 UN agencies, 20 global and regional funds and more than 90 global health initiatives.7 However, this does not appear to have translated into greater equity, when considering the gap between average life expectancy at birth in low-income countries and in OECD members between 1985 and 2005. An important step in addressing this is to ensure that international bodies responsible for global health are sufficiently influential and powerful to be accountable to those with the greatest health needs.
In several of its recommendations, the CSDH recognizes the key role of WHO - "the nearest thing we have to a ministry of health at the global level".5 Recommendation 12.1 states that "WHO, in collaboration with other relevant multilateral agencies, supporting Member States, institutionalize health equity impact assessment, globally and nationally, of major global, regional and bilateral economic agreements". It is vital that donors allow WHO to pursue such important goals unhindered. A positive first step would be to reverse the trend that, since 1990, has seen donors contribute proportionally more funds to extra-budgetary - and potentially earmarked - funds than to WHO's core budget.5
Global health actors include the increasingly influential "new philanthropists" who have made huge contributions to the global health budget in recent years. While in no way denying the benefits of such generosity, there are legitimate concerns that philanthropy has a strong influence on international health policy, while often lacking democratic or public accountability, and that this influence can drive an overly technical and vertical approach to health improvement. It is vital that such powerful actors recognize that reducing inequity and paying sufficient attention to the social determinants of health will be crucial in achieving health for all. 
References
1. Closing the gap in a generation. Geneva: World Health Organization & Commission on Social Determinants of Health; 2008.
2. Baum F. Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health. Promot Educ 2007;14:90. doi:10.1177/10253823070140022002 PMID:17665710
3. Human Rights Watch. Chop fine: the human rights impact of local government corruption and mismanagement in Rivers State, Nigeria. New York, NY: Human Rights Watch; 2007.
4. Zalik A, Watts M. Imperial oil: petroleum politics in the Nigerian delta and the new scramble for Africa. New Socialist Review 2006. Available from: http://www.socialistreview.org.uk/article.php?articlenumber=9712 [accessed on 5 December 2008] .
5. Global Health Watch 2, 2008. Available from: www.ghwatch.org [accessed on 5 December 2008] .
6. Health development. The World Bank strategy for health, nutrition, and population results. Washington, DC: The World Bank; 2007.
7. The international health partnership launched today [media release]. London: Department for International Development; 5 September 2007. Available from: www.dfid.gov.uk/news/files/ihp/default.asp [accessed on 5 December 2008] .
* Correspondence to Marion Birch (e-mail: marionbirch@medact.org).
doi:10.2471/BLT.08.061978