Jeanette Vega1; Alec Irwin
Equity Team, Office of the Assistant Director-General, Evidence and Information for Policy, World Health Organization, 1211 Geneva 27, Switzerland
That social and environmental factors account for a substantial portion of health inequalities between and within countries has long been recognized (1). Much less is understood about how these determinants can be tackled. A multisectoral approach to policy design and implementation is urgently needed to confront persisting infectious epidemics and rising noncommunicable disease burdens in developing countries.
The mainstream policy response to socially determined health inequalities is "pro-poor" strategies: interventions targeted on low-income groups. While often important, such strategies are insufficient, as they focus only on a specific population subset defined by income level. In countries characterized by pervasive widespread deprivation, access to health-enabling conditions and a broad scaling-up of health services are required (2). Factors other than income powerfully shape the social hierarchy that determines chances to be healthy. Pro-poor approaches limit intervention to the end of the social production chain that creates health or sickness: they tend to leave untouched the core social processes that generate health inequities, including gender and ethnicity (3).
Genuinely pro-equity health policy is needed, considering not only income but all "systematic disparities in health between more and less advantaged social groups" (4) and intervening on the social factors that influence health. The pro-equity agenda demands an evolution in the delivery of clinical services, in health information systems, and in the relationship between the health sector and other policy areas.
A few countries have moved towards a pro-equity approach. Sweden's new national public health policy, for example, focuses on "determinants of health mainly at the societal level". Government departments and social sectors including education, transport, environmental protection and labour policy assume explicit responsibility for improving population health and narrowing health equity gaps (5). In the United Kingdom, one aspect of a sustained policy effort to get to grips with health inequalities has been the fostering of intersectoral action to deal with the social determinants of health through innovative programmes at local, regional and national levels. Strong emphasis has been placed on initiatives that integrate early education, child care, family assistance and health services to support children's early development (6, 7). Promoting such collaborative intersectoral action should be seen as part of government's fundamental stewardship responsibility in health.
Some developing countries have also implemented promising pro-equity programmes involving intersectoral collaboration. In Chile, health system reform is based on an integrative primary health care approach using a family-centred model of care. Chile's national health objectives for the decade include explicit equity targets related to outcomes and processes (8).
In some countries, targeted interventions have improved income levels, school attendance and health indicators among vulnerable populations. Mexico introduced a programme in 1997 to combat poverty through coordinated intersectoral action. The programme provides regular cash payments to women beneficiaries in the country's poorest households, to be used for education, health and nutritional improvement within the family (9). A randomized trial found that children under 5 years of age had a 12% lower incidence of illness than children from similar families that did not participate in the programme (10).
To improve the social and environmental conditions that create differential opportunities to be healthy is today's most far-reaching health policy challenge. A recent study stresses how little has yet been done, even in wealthy countries, to measure the specific impact of public health policies on disadvantaged groups or to test options for reducing health gaps (6). Moreover, public sector administrative and budgeting structures in most countries continue to discourage intersectoral cooperation.
A major initiative is needed to support innovation in this critical domain. Knowledge sharing must be strengthened among countries working to promote health equity. New forms of collaboration between health experts and decision-makers should be explored, so as to turn evidence on social and environmental determinants into effective public policy. Gaps in the existing evidence base should not halt the introduction of innovative programmes: the evidence on what works best to narrow health inequalities will become more robust once more results are generated. A rapid cycle of policy innovation, monitoring and evaluation and knowledge sharing is needed to reduce global health inequalities in the years ahead (11). WHO can support this process as part of its commitment to strengthen health systems, which must be linked to multisectoral action for equity in health.
1. Evans R, Barer M, Marmor T. Why are some people healthy and others not? The determinants of health of populations. Hawthorne (NY): Aldine de Gruyter; 1994.
2. The world health report 2003 Shaping the future. Geneva: World Health Organization; 2003. p. 123.
3. Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, editors. Challenging inequities in health: from ethics to action. New York: Oxford University Press; 2001.
4. Braveman P, Starfield S, Geiger HJ. World Health Report 2000: how it removes equity from the agenda for public health monitoring and policy. BMJ 2001;323:678-81.
5. Östlin P, Diderichsen F. Equity-oriented national strategy for public health in Sweden: a case study. Brussels: European Centre for Health Policy; 2001. Policy Learning Curve Series, No. 1:21-2.
6. Wanless D. Securing good health for the whole population: final report. London: Stationery Office; 2004.
7. Department of Health. Tackling health inequalities: a programme for action. London: Department of Health; 2003.
8. See: http://www.minsal.cl/
9. Coady D. Alleviating structural poverty in developing countries: the approach of PROGRESA in Mexico. Washington (DC): World Bank; 2003. Available from: http://econ.worldbank.org/files/27999_Coady.pdf
10. Gertler P. Final report: the impact of PROGRESA on health. Washington (DC): International Food Policy Research Institute; 2000.
11. Mackenbach JP, Bakker MJ. Tackling socioeconomic inequalities in health: analysis of European experiences. Lancet 2003;362:1409-14.