The Commission on Social Determinants of Health (CSDH, 2008) explained in their final report that health inequity is represented by the systematic differences in health which could be avoided through both global action and action taken within society. The inequitable distribution of wealth is one of the social determinants of health, but so are the conditions in which people are born, live their lives, work and age. All of these are impacted upon by poor social policies, programmes, by bad economic arrangements and poor politics.
The CSDH argues that in order to achieve health equity it is necessary for this to become a central aim of most social policies and of health policy. They advise that whereas the health sector has an important role to play and significant responsibility to assume, the sector should contribute by working together with other sectors of society, given that there are social determinants of health which go beyond the medical sector.
According to the CSDH, achieving health equity should be guided by two objectives: (1) To improve the health of countries and (2) To eliminate inequalities which can be avoided within countries. The Commission point out that if all countries experienced the infant mortality rate of Iceland, then the global rate of infant mortality would be 2%, implying that there would be 6.6 million fewer infant deaths. Other aspects in which health inequity is prominent, depending on various conditions (e.g. socio-economic status, level of education, income, race etc.) are: life expectancy at birth (LEB), risk of dying among middle-aged adults, prevalence of long-term disabilities among older people, mortality rates among African Americans, cardiovascular disease, diabetes, mental health, maternal death etc. (2008).
CSDH suggest that there is a social gradient in health which shows that there is a graded relationship between socioeconomic level and the health of the population. This is not only relevant for poorer societies, but also for rich ones. According to CSDH, the social gradient is a consequence of policies which promote the interests of a powerful minority over those of a powerless majority. Life expectancy and health represent a social gradient as these are considerably lower in poorer countries. They are also lower for those who belong to the poorer strata of the society in which they live, regardless of the wider economic profile of these societies. Fewer financial resources are more commonly associated with a higher incidence of illness and premature death (WHO, 2009). In addition, the social and economic status within communities impacts upon the respective health and life expectancy outcomes. As demonstrated by Navarro (2007), being poor in a wealthy society may be more detrimental to health than being an above average earner in a poor society, even when the former has greater access to resources than the latter.
It is also important to note that there are health aspects which need to be addressed similarly in both poor and rich countries. Poor countries are confronted with communicable, non-communicable disease and injury, whereas richer countries more often face the challenge of dealing with non-communicable disease. Whatever the case, the global incidence of communicable and non-communicable disease implies that a coherent global framework for health needs to be developed and implemented.
An examination of the situation of both high and low income countries with a good level of health revealed that there are five main contributing factors: (1) Setting health as a social goal for the long term, (2) Acknowledging development as a means of achieving social welfare, (3) Involving the community in decision-making relevant to health, (4) Making health services available for all social groups and (5) Intersectoral cooperation for health. These factors may inspire the development of future health policies by indicating the aims that such policies should set. However, it is important to consider that, qua the conclusions of the CSDH, there are social determinants of health which emerge outside the health sector. The health sector needs to be involved in developing health systems and disease control programmes, as well as leading and guiding the development of policies directed at social determinants of health, but their effort should only be a part of a cross-sectorial contribution.
Thompson et al. (2017) show that the structural adjustment programmes managed by international financial institutions (IFIs) have set the fiscal limits within which health policies may be implemented in developing countries. The IFIs argue that the programmes they propose set the premise for enhancing health among vulnerable populations by increasing the amount spent for health as a consequence of economic growth. Bhutta (2001) indicates that for structural adjustment policies to achieve their desired aims it would be necessary for these to be implemented in a context in which the following pre-requisites exist: social justice, good governance, true democracy and gender equity. The level of corruption, reliable monitoring of welfare programmes and implementing an effective system for addressing grievances also contribute to achieving a just distribution of benefits and burdens associated with social and economic change (Bhutta, 2001). Critics argue that the rigid fiscal targets associated with structural adjustment loans result in the usage of funds otherwise destined for health and social interventions for repaying debt and for increasing reserves (Thompson et al., 2017). Since UNICEF pointed out that structural adjustment policies (SAPs) may have negative effects on the most vulnerable, social safety nets were introduced to control these effects. However, there is too little effective monitoring of these nets as control is mainly remote, and the effectiveness of interventions is dependent on the integrity of reporting mechanisms (Bhutta, 2001). Thompson et al. (2017) explored the effect of SAP on child and maternal health by looking at SAPs direct and indirect effects on health systems, and at their effects on social determinants. Among the direct effects on health systems, Thompson et al. (2017) found that SAPs impacted upon government health expenditure which may result in medical supply shortage, human capital shortage and insufficient funding for maternity services. Indirect effects include: currency devaluation which may result in increasing the cost of pharmaceutical products and health equipment, privatisation outside the medical sector which may lead to loss of jobs in the public sector not otherwise met by the opening of similar positions in the private sector, and subsequently to less health subsidies for mothers and children. SAPs also impact upon social determinants of health. One example is that of how, by encouraging privatisation, they may lead to increased reliance on unsanitary water. If water and sanitation facilities are under private ownership then this may mean that access to sanitised water may become too expensive for the poor, who will therefore be forced to resort to unsanitary sources, therefore endangering their health (Thompson et al., 2017).
The criticism directed at SAPs has determined the implementation of the Poverty Strategy Reduction Papers (PRSP) process. The PSRP present partner countries macroeconomic, structural and social programmes were developed with the purpose of promoting growth and reducing poverty (IMF, 2016). These papers typically refer to a period of three years or more and are prepared in a participative process by domestic stakeholders in member countries and representatives of IFIs, who are development partners (IMF, 2016). Critics (Welch, 2005) argue that this process has also failed to help IFIs to demonstrate how their interventions will help poor people to achieve sustainable development. One problem with the process is that governments have excluded civil voices (e.g. trade unions) from the negotiation and taken on the responsibility of producing the PSRPs themselves, a task which they complete in full awareness of the limits of IFIs approval. This renders the process futile and ineffective.
Butha, Z. (2001). Structural adjustments and their impact on health and society: a perspective from Pakistan. International Journal of Epidemiology, (30), 712-716. [Online] Available at: https://academic.oup.com/ije/article/30/4/712/705900 [Accessed on 15 December 2018]
CSDH. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organisation.
International Monetary Fund. (2016). Poverty Reduction Strategy Papers (PRSP).[Online] Available at: https://www.imf.org/external/np/prsp/prsp.aspx [Accessed on 15 December 2018]
Thomson, M., Kentikelenis, A. and Stubbs, T. (2017). Structural adjustment programmes adversely affect vulnerable populations: a systematic-narrative review of their effect on child and maternal health. Public Health Reviews. 38:13.
Welch, C. (2005). Structural Adjustment Programs & Poverty Reduction Strategy. Institute for Policy Studies. [Online] Available at: https://ips-dc.org/structural_adjustment_programs_poverty_reduction_strategy/ [Accessed 15 December 2018]