Ted Schrecker

Addressing social determinants of health inequities: what can the state and civil society do?

In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.

Canada: a land of missed opportunity for addressing the social determinants of health.

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organizations Commission on Social Determinants of Health. In this regard, Canadas recent performance suggests a bleak prognosis. Canadas track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canadas capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.

Globalization and social determinants of health: The role of the global marketplace (part 2 of 3).

Globalization is a key context for the study of social determinants of health (SDH): broadly stated, SDH are the conditions in which people live and work, and that affect their opportunities to lead healthy lives.In the first article in this three part series, we described the origins of the series in work conducted for the Globalization Knowledge Network of the World Health Organizations Commission on Social Determinants of Health and in the Commissions specific concern with health equity. We identified and defended a definition of globalization that gives primacy to the drivers and effects of transnational economic integration, and addressed a number of important conceptual and methodological issues in studying globalizations effects on SDH and their distribution, emphasizing the need for transdisciplinary approaches that reflect the complexity of the topic.In this second article, we identify and describe several, often interacting clusters of pathways leading from globalization to changes in SDH that are relevant to health equity. These involve: trade liberalization; the global reorganization of production and labour markets; debt crises and economic restructuring; financial liberalization; urban settings; influences that operate by way of the physical environment; and health systems changed by the global marketplace.

Priorities for research on equity and health: towards an equity-focused health research agenda.

Piroska Östlin and colleagues argue that a paradigm shift is needed to keep the focus on health equity within the social determinants of health research agenda.

The Growing Impact of Globalization for Health and Public Health Practice

In recent decades, public health policy and practice have been increasingly challenged by globalization, even as global financing for health has increased dramatically. This article discusses globalization and its health challenges from a vantage of political science, emphasizing increased global flows (of pathogens, information, trade, finance, and people) as driving, and driven by, global market integration. This integration requires a shift in public health thinking from a singular focus on international health (the higher disease burden in poor countries) to a more nuanced analysis of global health (in which health risks in both poor and rich countries are seen as having inherently global causes and consequences). Several globalization-related pathways to health exist, two key ones of which are described: globalized diseases and economic vulnerabilities. The article concludes with a call for national governments, especially those of wealthier nations, to take greater account of global health and its social determinants in all their foreign policies.

Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3)

This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and metholodogical issues. In the second article, we identified and described seven key clusters of pathways relevant to globalizations influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection, economic management and development strategy.Reflecting this insight, and against the background of the Millennium Development Goals (MDGs), we focus on the asymmetrical distribution of gains, losses and power that is characteristic of globalization in its current form and identify a number of areas for innovation on the part of the international community: making more resources available for health systems, as part of the more general task of expanding and improving development assistance; expanding debt relief and taking poverty reduction more seriously; reforming the international trade regime; considering the implications of health as a human right; and protecting the policy space available to national governments to address social determinants of health, notably with respect to the hypermobility of financial capital. We conclude by suggesting that responses to globalizations effects on social determinants of health can be classified with reference to two contrasting visions of the future, reflecting quite distinct values.

Globalisation and health: the need for a global vision

The reduction of health inequities is an ethical imperative, according to the WHO Commission on Social Determinants of Health (CSDH). Drawing on detailed multidisciplinary evidence assembled by the Globalization Knowledge Network that supported the CSDH, we define globalisation in mainly economic terms. We consider and reject the presumption that globalisation will yield health benefits as a result of its contribution to rapid economic growth and associated reductions in poverty. Expanding on this point, we describe four disequalising dynamics by which contemporary globalisation causes divergence: the global reorganisation of production and emergence of a global labour-market; the increasing importance of binding trade agreements and processes to resolve disputes; the rapidly increasing mobility of financial capital; and the persistence of debt crises in developing countries. Generic policies designed to reduce health inequities are described with reference to the three Rs of redistribution, regulation, and rights. We conclude with an examination of the interconnected intellectual and institutional challenges to reduction of health inequities that are created by contemporary globalisation.

Committed to health for all? How the G7/G8 rate

Abstract The G7/G8 group of nations dominate the world political and economic order. This article reports selected results from an investigation of the health implications of commitments made at the 1999, 2000 and 2001 Summits of the G7/G8, with special reference to the developing world. We emphasize commitments that relate to the socioeconomic determinants of health (primarily to reducing poverty and economic insecurity) and to the ability of national governments to make necessary basic investments in health systems, education and nutrition. We conclude that without a stronger commitment to redistributive policy measures on the part of the G7/G8, historic commitments on the part of the international community to providing health for all are likely not to be fulfilled.

Foreign policy matters: a normative view of the G8 and population health

The Group of Eight (G8) countries occupy a dominant position in the international economic and political order. Given what is known about influences on the social determinants of health in an interconnected world, the G8 are a logical starting point for any enquiry into the relations between foreign policy and health. We first make five arguments for adopting an explicitly normative, equity-oriented perspective on the performance of G8 policy in areas related to population health. We then examine G8 performance with respect to the crucial policy triad of development assistance, debt relief and trade, finding that neither rhetoric nor promising institutional innovation has been matched by resources commensurate with demonstrated levels of need. We conclude that it is necessary to pursue advocacy efforts based on the normative perspective we have put forward and that doing so effectively requires further investigation of why some policies are more receptive than others to policies of redistribution both within and outside their borders.

A global health equity agenda for the G8 summit

The G8 summit in July could be used to enable developing countries to meet the millennium development goals. What should world leaders commit to?