The Root Causes of Health Inequalities

Excerpts from the Introduction of A Conceptual Framework for Action on the Social Determinants of Health by the World Health Organization (2010)

Complexity defines health. Now, more than ever, in the age of globalization, is this so. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization (WHO) to get to the heart of this complexity. They were tasked with summarizing the evidence on how the structure of societies, through myriad social interactions, norms and institutions, are affecting population health, and what governments and public health can do about it.

 

To guide the Commission in its mammoth task, the WHO Secretariat conducted a review and summary of different frameworks for understanding the social determinants of health. This review was summarized and synthesized into a single conceptual framework for action on the social determinants of health which was proposed to and, largely, accepted by, the CSDH for orienting their work.

 

A key aim of the framework is to highlight the difference between levels of causation, distinguishing between the mechanisms by which social hierarchies are created, and the conditions of daily life which then result. This paper describes the review, how the proposed conceptual framework was developed, and identifies elements of policy directions for action implied by the proposed conceptual framework and analysis of policy approaches.

 

Having health framed as a social phenomenon emphasizes health as a topic of social justice more broadly. Consequently, health equity (described by the absence of unfair and avoidable or remediable differences in health among social groups) becomes a guiding criterion or principle. Moreover, the framing of social justice and health equity, points towards the adoption of related human rights frameworks as vehicles for enabling the realization of health equity, wherein the state is the primary responsible duty bearer.

 

In spite of human rights having been interpreted in individualistic terms in some intellectual and legal traditions, notably the Anglo-Saxon, the frameworks and instruments associated with human rights guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having been associated with historical struggles for solidarity and the empowerment of the deprived they form a powerful operational framework for articulating the principle of health equity.

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With this general framing in mind, developing a conceptual framework on social determinants of health (SDH) for the CSDH needs to take note of the specific theories of the social production of health. Three main theoretical non-mutually exclusive explanations were reviewed:

  • psychosocial approaches

  • social production of disease/political economy of health 

  • eco-social frameworks

All three of these theoretical traditions, use the following main pathways and mechanisms to explain

causation:

  • social selection, or social mobility

  • social causation 

  • life course perspectives

Each of these theories and associated pathways and mechanisms strongly emphasize the concept of
“social position”, which is found to play a central role in the social determinants of health inequities.

A very persuasive account of how differences in social position account for health inequities is found
in the Diderichsen’s model of “the mechanisms of health inequality”. Didierichsen’s work identifies how
the following mechanisms stratify health outcomes:

  • Social contexts, which includes the structure of society or the social relations in society, create social stratification and assign individuals to different social positions.

  • Social stratification in turn engenders differential exposure to health-damaging conditions and differential vulnerability, in terms of health conditions and material resource availability.

  • Social stratification likewise determines differential consequences of ill health for more and less advantaged groups (including economic and social consequences, as well differential health outcomes).

 

The role of social position in generating health inequities necessitates a central role for a further two
conceptual clarifications. First, the central role of power. In this context, human rights embody a demand on the part of oppressed and marginalized communities for the expression of their collective social power. The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state. 

 

Second, it is important to clarify the conceptual and practical distinction between the social causes of health and the social factors determining the distribution of these causes between more and less advantaged groups. The CSDH framework makes a point of making clear this distinction.On this second point of clarification, conflating the social determinants of health and the social processes

that shape these determinants’ unequal distribution can seriously mislead policy.

 

Over recent decades, social and economic policies that have been associated with positive aggregate trends in health determining social factors (e.g. income and educational attainment) have also been associated with persistent inequalities in the distribution of these factors across population groups. Furthermore, policy objectives are defined quite differently, depending on whether the aim is to address determinants of health or determinants of health inequities.

The CSDH Conceptual Framework

Bringing these various elements together, the CSDH framework, summarized in Figure A, shows how social, economic and political mechanisms give rise to a set of socioeconomic positions, whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; these socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. Illness can “feed back” on a given individual’s social position, e.g. by compromising employment opportunities and reducing income; certain epidemic diseases can similarly “feed back” to affect the functioning of social, economic and political institutions.
 

“Context” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labor market; the educational system, political institutions and other cultural and societal values. Among the contextual factors that most powerfully affect health are the welfare state and its redistributive policies (or the absence of such policies). In the CSDH framework, structural mechanisms are those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources. Structural mechanisms are rooted in the key institutions and processes of the socioeconomic and political context. The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity.

The most important structural stratifiers and their proxy indicators include: Income, Education,
Occupation, Social Class, Gender, Race/ethnicity. Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of “structural determinants” and “intermediary determinants” underscores the causal priority of the structural factors.


The main categories of intermediary determinants of health are: material circumstances; psychosocial
circumstances; behavioral and/or biological factors; and the health system itself as a social determinant:

  • Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment.

  • Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof).Psychosocial circumstances include psychosocial stressors, stressful living circumstances and

  • Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.

The concepts of social cohesion and social capital occupy a conspicuous (and contested) place in discussions of SDH. Social capital cuts across the structural and intermediary dimensions, with features that link it to both. Yet focus on social capital, depending on interpretation, risks reinforcing depoliticized approaches to public health and the SDH, when the political nature of the endeavor needs to be an explicit part of any strategy to tackle the SDH.

 

Certain interpretations have not depoliticized social capital, notably the notion of “linking social capital”, which have spurred new thinking on the role of the state in promoting equity, wherein a key task for health politics is nurturing cooperative relationships between citizens and institutions. According to this literature, the state should take responsibility for developing flexible systems that facilitate access and participation on the part of the citizens.

Policy Action  

Finally, in turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified. These may be based on:

  • Targeted programs for disadvantaged populations

  • Closing health gaps between worse-off and better-off groups

  • Addressing the social health gradient across the whole population 

 

A consistent equity-based approach to SDH must ultimately lead to a gradients focus. However, strategies based on tackling health disadvantage, health gaps and gradients are not mutually exclusive. They can complement and build on each other.
 

Policy development frameworks can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. The review showed the framework that Diderichsen and colleagues proposed- a typology or mapping of entry points for policy action on SDH inequities - to be very useful in the way it is very closely aligned to theories of causation. They identify actions related to: social stratification; differential exposure/ differential vulnerability; differential consequences and macro social conditions.


Considerations of these policy action frameworks lead to discussion of three key strategic directions for
policy work to tackle the SDH, with a particular emphasis on tackling health inequities:

  • The need for strategies to address context

  • Intersectoral action

  • Social participation and empowerment

Policy Action Challenges for the CSDH

Arguably the single most significant lesson of the CSDH conceptual framework is that interventions and policies to reduce health inequities must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups (see Figure B). To tackle structural, as well as intermediary, determinants requires intersectoral policy approaches.

Theories on the Social Production of Health and Disease

A key task for the CSDH will be:

  • To identify successful examples of intersectoral action on SDH in jurisdictions with different levels of resources and administrative capacity; and to characterize in detail the political and management mechanisms that have enabled effective intersectoral programs to function sustainably.

  • To demonstrate how participation of civil society and affected communities in the design
    and implementation of policies to address SDH is essential to success. Empowering social
    participation provides both ethical legitimacy and a sustainable base to take the SDH agenda
    forward after the Commission has completed its work.

    Empowering social and implementation of policies to address SDH is essential to success.

  • Finally, SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science.