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DEBATES,POLICY & PRACTICE, CASE STUDIES

ACTION ON THE SOCIAL DETERMINANTSOF HEALTH: LEARNING FROM PREVIOUSEXPERIENCESSocial Determinants of Health Discussion Paper 1

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World Health OrganizationGeneva

2010

ACTION ON THE SOCIAL

DETERMINANTS OFHEALTH:LEARNING FROMPREVIOUS EXPERIENCES

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Te Series:Te Discussion Paper Series on Social Determinants of Health provides a forum for sharing knowledge on how to tackle the socialdeterminants of health to improve health equity. Papers explore themes related to questions of strategy, governance, tools, andcapacity building. Tey aim to review country experiences with an eye to understanding practice, innovations, and encouragingfrank debate on the connections between health and the broader policy environment. Papers are all peer-reviewed.

Background:Tis paper was prepared for the launch of the Commission on Social Determinants of Health (CSDH) by its secretariat based atWHO in Geneva. It was discussed by the Commissioners and then revised considering their input. It was written by Alec Irwinand Elena Scali.

Acknowledgments:Te authors want to thank Dr Jeannette Vega and Dr Orielle Solar and the 18 commissioners that participated in the launch of

the Commission on Social Determinants of Health for the valuable comments and peer review in the preparation of the dierentdras of this paper.

Suggested Citation:Irwin A, Scali E. Action on the Social Determinants of Health: learning from previous experiences. Social Determinants of HealthDiscussion Paper 1 (Debates).

WHO Library Cataloguing-in- Publication Data

Action on the social determinants of health: learning from previous experiences.

(Discussion Paper Series on Social Determinants of Health, 1)

1.Socioeconomic factors. 2.Health care rationing. 3.Health services accessibility. 4.Patient advocacy. I.World Health Organization.

ISBN 978 92 4 150087 6 (NLM classication: WA 525)

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Printed by the WHO Document Production Services, Geneva, Switzerland

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Action on the social determinants of health: le arning from previous experiences

ExEcutivE Summary 2

1. introduction 4

2. HiStorical ovErviEw 5

2.1 Roots of a social approach to health 52.2 Te 1950s: emphasis on technology and disease-specic campaigns 5

2.3 Te 1960s and early 70s: the rise of community-based approaches 6

2.4 Te crystallization of a movement: Alma-Ata and primary health care 8

2.5 In the wake of Alma-Ata: Good health at low cost 9

2.6 Te rise of selective primary health care 12

2.7 Te political-economic context of the 1980s: neoliberalism 14

2.8 Te 1990s and beyond: contested paradigms and shiing power relations 16

2.8.1 Debates on development and globalization 16

2.8.2 Mixed signals from WHO 17

2.8.3 SDH approaches at country level 18

2.9 Te 2000s: growing momentum and new opportunities 25

3. taKinG it to tHE nExt lEvEl: tHE commiSSion on Social

dEtErminantS oF HEaltH 27

3.1 Aims of the CSDH 27

3.2 Key issues for the CSDH 27

3.2.1 Te scope of change: dening entry points 27

3.2.2 Anticipating potential resistance to CSDH messages and preparing strategically 30

3.2.3 Identifying allies and political opportunities 34

3.2.4 Evidence, political processes and the CSDH story line 37

4. concluSion 39

liSt oF abbrEviationS 41

rEFErEncES 42

Contents

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T

oday an unprecedented opportunity exists to improve health in some of the worlds poorest andmost vulnerable communities by tackling the root causes of disease and health inequalities. Te

most powerful of these causes are the social conditions in which people live and work, referredto as the social determinants of health (SDH). Te Millennium Development Goals (MDGs)

shape the current global development agenda. Te MDGs recognize the interdependence of health andsocial conditions and present an opportunity to promote health policies that tackle the social roots ofunfair and avoidable human suering.

Te Commission on Social Determinants of Health (CSDH) is poised for leadership in this process.o reach its objectives, however, the CSDH must learn from the history of previous attempts to spuraction on SDH. Tis paper pursues three questions: (1) Why didnt previous eorts to promote healthpolicies on social determinants succeed? (2) Why do we think the CSDH can do better? (3) What canthe Commission learn from previous experiences negative and positive that can increase its chancesfor success?

Strongly armed in the 1948 WHO Constitution, the social dimensions of health were eclipsed duringthe subsequent public health era dominated by technology-based vertical programmes. Te socialdeterminants of health and the need for intersectoral action to address them re-emerged strongly inthe Health for All movement under the leadership of Halfdan Mahler. Intersectoral action on SDHwas central to the model of comprehensive primary health care proposed to drive the Health for Allagenda following the 1978 Alma-Ata conference. During this period, some low-income countriesmade important strides in improving population health statistics through approaches involving actionon key social determinants. Rapidly, however, a scaled-back version of primary health care, selectiveprimary health care, gained inuence. Selective primary health care focused on a small number of cost-eective interventions and downplayed the social dimension. Te most important example of selectiveprimary health care was the GOBI strategy (growth monitoring, oral rehydration, breastfeeding andimmunization) promoted by UNICEF in its child survival revolution. Te contrast in approaches

between comprehensive and selective PHC raises strategic questions for the CSDH.

Like other aspects of comprehensive primary health care, action on determinants was weakened bythe neoliberal economic and political consensus dominant in the 1980s and beyond, with its focus onprivatization, deregulation, shrinking states and freeing markets. Under the prolonged ascendancy ofvariants of neoliberalism, state-led action to improve health by addressing underlying social inequitiesappeared unfeasible in many contexts. Te 1990s saw an increasing inuence of the World Bank inglobal health policy, with mixed messages from WHO. During this period, however, important scienticadvances emerged in the understanding of SDH, and in the late 1990s several countries, particularly inEurope, began to design and implement innovative health policies to improve health and reduce healthinequalities through action on SDH. Tese policies targeted dierent entry points. Te more ambitiousaimed to alter patterns of inequality in society through far-reaching redistributive mechanisms. Less

radical, palliative programmes sought to protect disadvantaged populations against specic forms ofexposure and vulnerability linked to their lower socioeconomic status.

Executive summary

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Action on the social determinants of health: le arning from previous experiences

Te 2000s have seen a pendulum swing in global health politics. Health stands higher than ever onthe international development agenda, and stakeholders increasingly acknowledge the inadequacy of

health strategies that fail to address the social roots of illness and well-being. Momentum for action onthe social dimensions of health is building. Te Millennium Development Goals were adopted by 189countries at the United Nations Millennium Summit in 2000. Tey set ambitious targets in poverty andhunger reduction; education; womens empowerment; child health; maternal health; control of epidemicdiseases; environmental protection; and the development of a fair global trading system, to be reached by2015. Te MDGs have created a favourable climate for multisectoral action and underscored connectionsbetween health and social factors. An increasing number of countries are implementing SDH policies,but there is an urgent need to expand this momentum to developing countries where the eects ofSDH are most damaging for human welfare. Tis is the context in which the CSDH will begin its work.

Based on the historical survey, four key issue areas are highlighted, in which the members of the CSDHmust take strategic decisions early in their process.

1 Te rst concerns the scope of change the Commission will seek to promote and appropriate policyentry points. Here the CSDH will face its own version of the choice between comprehensive andselective primary health care that confronted public health leaders in the 1980s. Te CSDH willneed evaluation criteria for identifying appropriate policy entry points for dierent countries/jurisdictions.

2 Potential resistance to CSDH messages can be anticipated from several constituencies, which theCommission should seek to engage proactively. Te Commission will want to identify a set ofpotential quick wins for itself and for national political leaders taking up an SDH agenda. Commissioners will want to develop a strategy for dialogue with the international financialinstitutions, in particular the World Bank.

3 Te CSDH will also benet from exceptional political opportunities. It will eectively position itselfwithin the global and national processes connected to the MDGs. Alliances with both the businesscommunity and civil society are possible, but competing interests will need to be managed. Teopportunity and limits of economic arguments for SDH policies remain to be claried, and sucharguments raise deeper ethical questions.

4 In addition to robust evidence, the Commission needs a compelling, collectively owned story lineabout the social determinants of health, in which the evidence can be embedded and communicated.What story does the CSDH want to tell about social conditions and human well-being?

With answer to these questions in place, the Commission will lead a global eort to protect vulnerablefamilies and secure the health of future generations by tackling disease and suering at their roots.

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D

oday health stands higher than ever onthe international development agenda,

and health inequalities between andwithin countries have emerged as a

central concern for the global community1,2,3,4.An unprecedented opportunity exists to improvehealth in some of the worlds poorest andmost vulnerable communities if approachesare chosen that tackle the real causes of healthproblems. Te most powerful of these causes arethe social conditions in which people live andwork, referred to as the social determinants ofhealth (SDH). Social determinants reect peoplesdierent positions in the social ladder of status,

power and resources. Evidence shows that most ofthe global burden of disease and the bulk of healthinequalities are caused by social determinants5,6.

he Millennium Development Goals (MDGs)recognize this interdependence between healthand social conditions. Te MDG framework showsthat without signicant gains in poverty reduction,food security, education, womens empowermentand improved living conditions in slums, manycountries will not attain health targets7,8. Andwithout progress in health, other MDG objectiveswill also remain beyond reach. oday, an

international development agenda shaped by theMDGs provides a crucial opportunity to promotehealth policies that tackle the social roots of unfairand avoidable human suering.

he Commission on Social Determinants ofHealth (CSDH) is poised for leadership in thisprocess. o reach its objectives, however, theCSDH must learn from history. In the 1970s and80s, the global Health for All strategy emphasizedthe need to address social determinants, yet

these recommendations were rarely translatedinto eective policies. Strong messages on SDH

emerged again in the mid-1990s, but once morepolicy implementation made little headway in thedeveloping countries where needs are greatest.Understanding the reasons for these frustrationsis fundamental to planning an eective strategyfor the CSDH.

As an input to the strategy process, this paper seeksto shed light on three related questions:

1 Why didnt previous eorts to promote healthpolicies on social determinants succeed?

2 Why do we think the CSDH can do better?3

What can the Commission learn from previousexperiences negative and positive that canincrease its chances for success?

he first part of this study reviews previousmajor eorts to address social determinants withattention to these eorts political contexts. Tesecond part identifies a series of key strategicissues based on the historical record and outlinesfactors that should enable the CSDH to catalyseeective action.

An issue of vocabulary requires preliminary

clarification. One of the Commissions mainmessages is that policies and interventions wellbeyond the traditional health sector should beunderstood as part of a robust health policy.Health policy is not equal to health carepolicy. In the following pages, terms such asSDH policies and SDH approaches are usedas a time-saving shorthand. Tese terms refer tohealth policies that address the social determinantsof health.

1 Introduction

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Action on the social determinants of health: le arning from previous experiences

2.1 Roots o a social approachto health

Te recognition that social and environmentalfactors decisively influence peoples health isancient. he sanitary campaigns of the 19thcentury and much of the work of the foundingfathers of modern public health reflectedawareness of the powerful relationship betweenpeoples social position, their living conditionsand their health outcomes. Recent epidemiologicalresearch has conrmed the centrality of social andenvironmental factors in the major populationhealth improvements registered in industrialized

countries beginning in the early 19th century.McKeowns analyses revealed that most of thesubstantial modern reduction in mortality frominfectious diseases such as tuberculosis took placeprior to the development of effective medicaltherapies. Instead, the main driving forces behindmortality reduction were changes in food suppliesand living conditions10.

Te Constitution of the World Health Organization,draed in 1946, shows that the Organizationsfounders intended for WHO to address the socialroots of health problems, as well as the challenges

of delivering eective curative medical care. TeConstitution famously denes health as a state ofcomplete physical, mental and socialwell-being

(emphasis added), identifying the Organizationsgoal as the attainment by all peoples of the highest

possible level of this state11. Te Organizationscore functions include working with MemberStates and appropriate specialized agencies topromote the improvement of nutrition, housing,sanitation, recreation, economic or workingconditions and other aspects of environmentalhygiene, as required to achieve health progress.WHOs Constitution thus foresees a supportiveintegration of biomedical/technological andsocial approaches to health, though this unity hasoen come unravelled during the Organizationssubsequent history12.

2.2 The 1950s: emphasison technology and disease-specifc campaigns

Te WHO Constitution provided space for a socialmodel of health linked to broad human rightscommitments. However, the post-World War IIcontext of Cold War politics and decolonizationhampered the implementation of this visionand favoured an approach based more on healthtechnologies delivered through campaigns bearing

a militaristic imprint13. Several historicalfactors promoted this pattern. One was theseries of major drug research breakthroughs thatproduced an array of new antibiotics, vaccinesand other medicines in this period, inspiringhealth professionals and the general public withthe sense that technology held the answer to theworlds health problems. Tis boom also propelledthe rise of the modern pharmaceutical industry,destined to become not only a source of scienticbenets but also a political force whose lobbyingpower would increasingly inuence national and

international health policy. Another key change inthe political context was the temporary withdrawalof the Soviet Union and other communist countries

2 Historical overview

Do we not always nd the

diseases of the populace traceable

to defects in society?9

Rudolf Virchow (1821-1902)

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from the United Nations and UN agencies in1949. Following the Soviet pullout, UN agencies,including WHO, came more strongly under theinuence of the United States. Despite the key USrole in shaping the WHO Constitution, US ocialswere at that time reluctant to emphasize a socialmodel of health whose ideological overtones wereunwelcome in the Cold War setting.

During this period and subsequently, health caremodels in the developing world were inuencedby the dynamics of colonialism. Te health systemsestablished in areas of Africa and Asia colonizedby European powers catered almost exclusivelyto colonizing elites and focused on high-technology curative care in a handful of urban

hospitals. Tere was little concern for broaderpublic health and few services for people livingin slums or rural areas. Many former coloniesgained independence in the 1950s and 60s andestablished their own national health systems.Unfortunately these were oen patterned on themodels that had existed under colonial rule. Onpaper, post-independence health strategies oenacknowledged the need to extend services to ruraland disadvantaged populations, but in practicethe bulk of government and international donorfunding for health continued to ow to urban-

based curative care. During this period, somenewly independent low-income countries spentover half their national health budgets maintainingone or two gleaming disease palaces high-techhospitals stocked with the latest equipment, staedby western-trained doctors and catering to thehealth needs of the urban elite14.

International public health during this period wascharacterized by the proliferation of verticalprogrammes narrowly focused, technology-driven campaigns targeting specific diseasessuch as malaria, smallpox, B and yaws. Such

programmes were seen as highly efficient andin some cases offered the advantage of easilymeasurable targets (number of vaccinationsdelivered, etc.). Yet by their nature they tended toignore the social context and its role in producingwell-being or disease. Like hospital-centredhealth care, they tended to leave the most serioushealth challenges of the bulk of the population(particularly the rural poor) unaddressed. Tevertical campaigns begun in this period generateda few notable successes, most famously theeradication of smallpox. However, the limitations

of this approach were revealed by failures likethe WHO-UNICEF campaign for the globalelimination of malaria. Te malaria campaign,

begun in the mid-1950s, relied once again ontechnology in this case the wide spraying ofthe insecticide DD to kill mosquito vectors. Temassive programme proved to be a costly failure15.

2.3 The 1960s and early 70s:the rise o community-basedapproaches

By the mid-1960s, it was clear in many parts ofthe world that the dominant medical and publichealth models were not meeting the most urgentneeds of poor and disadvantaged populations(the majority of people in developing countries).Out of necessity, local communities and health

care workers searched for alternatives to verticaldisease campaigns and the emphasis on urban-based curative care. A renewed concern withthe social, economic and political dimensions ofhealth emerged.

During the 1960s and early 70s, health workersand community organizers in a number ofcountries joined forces to pioneer what becameknown as community-based health programmes(CBHP)14. Such initiatives emphasized grassrootsparticipation and community empowerment

in health decision-making and often situatedtheir eorts within a human rights frameworkthat related health to broader economic, social,political and environmental demands. heimportance of high-end medical technologywas downplayed, and reliance on highly trainedmedical professionals was minimized. Instead,it was thought that locally recruited communityhealth workers could, with limited training, assisttheir neighbours in confronting the majorityof common health problems. Health educationand disease prevention were at the heart of thesestrategies.

Chinas rural health workers (guratively referredto as barefoot doctors) were the most famousexample. Tese were a diverse array of villagehealth workers who lived in the communitiesthey served, stressed rural rather than urbanhealth care, preventive rather than curativeservices, and combined western and traditionalmedicines16. Community-based initiatives alsoourished in Bangladesh, Costa Rica, Guatemala,India, Mexico, Nicaragua, the Philippines, SouthAfrica and other countries. In some instances,

such initiatives engaged directly not only withsocial and environmental determinants of health,but with underlying issues of political-economic

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Action on the social determinants of health: le arning from previous experiences

structures and power relations. In some parts ofLatin America, Brazilian educator Paulo Freiresawareness-raising methods were adapted to healtheducation and promotion. In the Philippines,some groups practiced community-basedstructural analysis through which communitymembers traced the social and political roots oftheir health problems. Tese methodologies forempowerment became tools in helping groupsof disadvantaged people conduct a communitydiagnosis of their health problems, analyze themultiplicity of causes and plan strategic remedialactions in innovative ways14. In Central America,South Africa and the Philippines, loose alliancesof community-based health programmes graduallygrew into social movements linking health, social

justice and human rights agendas. Werner andSanders argue that in several cases (the overthrowof the Somoza dictatorship in Nicaragua, resistanceto the South African apartheid regime and theweakening and eventual toppling of FerdinandMarcos authoritarian government in thePhilippines), community-based health movementshelped lay the groundwork for political changeand the eventual reversal of despotic regimes14.Reciprocally, Cueto argues, anti-imperialistmovements in many developing countries and aweakening of US prestige as a result of setbacks

in Viet Nam helped create favourable conditionsfor the global uptake of these alternative healthmodels during the late 1960s16.

What had begun as independent, local ornational CBHP experiments acquired a growinginternational prole and a cumulative authorityin the early 1970s. Some NGOs and internationalmissionary organizations, in particular theChristian Medical Commission, played animportant role in promoting community-based models on the ground and disseminatinginformation on their success17. By the early 1970s,

awareness was growing that technologicallydriven approaches to health care had failed tosignicantly improve population health in manydeveloping countries, while results were beingobtained in some very poor settings throughcommunity-based programs. Some leadingscholars, international public health planners anddevelopment experts began to advocate broadadoption of an approach to health informed bythe practices and priorities of CBHP. Tis includedleaders at WHO. In 1975, WHOs KennethNewell, Director of the Organizations Division of

Strengthening Health Services, published Healthby the People, which presented success stories froma series of community-based health initiatives

in Africa, Asia and Latin America. he bookadvocated a robust engagement with the socialdimensions of health, arguing that:

We have studies demonstrating

that many of the causes of

common health problems derive

from parts of society itself and that

a strict health sectoral approach is

ineffective, other actions outside

the eld of health perhaps having

greater health effects than strictlyhealth interventions18.

Newell (1975)

In the same year, WHO and UNICEF published ajoint report examiningAlternative approaches tomeeting basic health needs in developing countries.he report underscored the shortcomingsof vertical disease programmes that relied ontechnological fixes and ignored community

ownership. It emphasized that social factors such aspoverty, inadequate housing and lack of educationwere the real roots underlying the proximal causesof morbidity in developing countries19.

his emerging model of health work found apowerful champion in Halfdan Mahler, a Danishphysician and public health veteran who becameDirector-General of WHO in 1973. Mahler was acharismatic leader with deep moral convictions,for whom social justice was a holy word20. He wasangered at global inequities in health and at theavoidable suering undergone by millions of poor

and marginalized people. Having participated invertical disease campaigns in Latin America andAsia, Mahler was convinced that such approacheswere incapable of resolving the most importanthealth problems, and that an excessive focus onadvanced curative technologies was distortingmany developing countries health systems.Hand in hand with the expansion of basic healthcare services to disadvantaged communities,action to address non-medical determinantswas necessary to overcome health inequalitiesand achieve Health for All by the year 2000,

as Mahler proposed at the 1976 World HealthAssembly. Health for all, he argued, impliesthe removal of the obstacles to health that is to

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say, the elimination of malnutrition, ignorance,contaminated drinking water and unhygienichousing quite as much as it does the solution ofpurely medical problems21.

2.4 The crystallization o amovement: Alma-Ata andprimary health care

his new agenda took centre stage at theInternational Conference on Primary Health Care,sponsored by WHO and UNICEF at Alma-Ata,Kazakhstan, in September 1978. 3,000 delegatesfrom 134 governments and 67 internationalorganizations participated in the Alma-Ata

conference, destined to become a milestone inmodern public health. Te conference declarationembraced Mahlers goal of Health for All bythe Year 2000, with primary health care (PHC)as the means. he adoption of the HFA/PHCstrategy marked a forceful re-emergence of socialdeterminants as a major public health concern.he PHC model as articulated at Alma-Ataexplicitly stated the need for a comprehensivehealth strategy that not only provided healthservices but also addressed the underlying social,economic and political causes of poor health

(original emphasis)

14

.

Many elements of the PHC approach were shapedby the Chinese barefoot doctors model andother community-based health experiencesaccumulated over the previous decade. heAlma-Ata declaration presented PHC in a doublelight. On the one hand, as the fundamental levelof care within a health system recongured toemphasize the basic health needs of the majority,PHC was the rst level of contact of individuals,the family and community with the national healthsystem22. But PHC was also aphilosophyof health

work as part of the overall social and economicdevelopment of the community22. Cueto identiesthree salient principles of the PHC philosophy.Te rst was appropriate technology: i.e., thecommitment to shi health resources from urbanhospitals to meeting the basic needs of rural anddisadvantaged populations. he second was acritique of medical elitism, implying reducedreliance on highly specialized doctors and nursesand greater mobilization of community membersto take responsibilities in health work. Te thirdcore component of PHC was an explicit linkage

between health and social development. Healthwork was perceived not as an isolated and short-lived intervention but as part of a process of

improvement of living conditions16. Logically,PHC included among its pillars intersectoralaction to address social and environmental healthdeterminants. Te Alma-Ata declaration speciedthat PHC involves, in addition to the healthsector, all related sectors and aspects of nationaland community development, in particularagriculture, animal husbandry, food, industry,education, housing, public works, communication,and other sectors; and demands the coordinatedeorts of all these sectors.

Under Mahlers leadership, WHO reconguredits organizational prole and a signicant part ofits programming around Health for All throughPHC. Accordingly, health work under the

HFA banner regularly incorporated, at least onpaper, intersectoral action to address social andenvironmental determinants. During the 1980s,as the drive towards HFA unfolded, the conceptof intersectoral action for health (IAH) took onincreasing prominence, and a special unit wascreated within WHO to address this theme. In1986, WHO and the Rockefeller Foundation co-sponsored a major consultation on IAH at thelatters Bellagio conference facility23, and technicaldiscussions on IAH were held at the 39th WorldHealth Assembly. Te WHA discussions included

working groups on health inequalities; agriculture,food and nutrition; education, culture, informationand lifestyles; and the environment, includingwater and sanitation, habitat and industry24.

From the mid-1980s, SDH were also givenprominence in the emerging health promotionmovement. Te First International Conference onHealth Promotion cosponsored by the CanadianPublic Health Association, Canadas Health andWelfare department and WHO was held inOttawa in November 1986. Te conference adoptedthe Ottawa Charter on Health Promotion, which

identied eight key determinants (prerequisites)of health: peace, shelter, education, food, income,a stable eco-system, sustainable resources, socialjustice, and equity. It was understood that thisbroad range of fundamental enabling factors couldnot be addressed by the health sector alone, butwould require coordinated action among dierentgovernment departments, as well as amongnongovernmental and voluntary organizations,the private sector and the media25. FollowingOttawa, a series of international health promotionconferences developed the messages contained

in the charter and sought to build a sustainedmovement26.

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Action on the social determinants of health: le arning from previous experiences

2.5 In the wake o Alma-Ata:Good health at low cost

he years following the Alma-Ata conferencewere not generally favourable for health progressamong poor and marginalized communities,for reasons to be examined shortly. However,a number of developing countries emerged asmodels of good practice during this period. Teywere able to improve their health indicators andstrengthen equity, through programmes in whichintersectoral action on health determinants playedan important role.

Good health at low cost (GHLC) was the titleof a conference sponsored by the RockefellerFoundation in April-May 1985. Te publishedproceedings became an important reference indebates about how to foster sustainable healthimprovements in the developing world27. heconference closely examined the cases of threecountries (China, Costa Rica and Sri Lanka) andone Indian state (Kerala) that had succeededin obtaining unusually good health results (asmeasured by life expectancy and child mortalitygures), despite low GDP and modest per capitahealth expenditures, relative to high-incomecountries.

Costa Rica

In 1988 the Pan-American Health Organization characterized Costa Rica as a developing non-industrial nation with health indicators comparable to

those registered a ew years ago by some advanced industrial nations28. Between 1970 and 1983, the country cut general mortality by 40 percent, and

inant mortality was reduced by 70 percent29.

Commitment to nationwide coverage in health care and key basic social services contributed crucially to this pattern. A 1971 law guaranteed medical

care and hospitalization coverage under social security or the entire population. Regardless o salary level, all workers became afliated with social

security benefts provided through the Caja Costarricense del Seguro Social (Costa Rican Social Security Fund, or CCSS), unded through state resources

and compulsory contributions rom workers. The CCSS was one o a range o policy instruments based on principles o national solidarity and coverage

or the very poor. The CCSS drove several broad public health interventions: immunization campaigns were intensifed against diseases such as measles

and diphtheria; the provision o potable water and sewage disposal were expanded, especially in rural areas. The two-thirds decline in inant mortality

in the 1970s appears to have been due to Costa Ricas multi-pronged strategy simultaneously tackling a range o medical, inrastructural and social

actors30.

The Rural Health Program (RHP), launched in 1973, and the urban Community Health Program o 1976 delivered robust, multiaceted primary health care.

Taken together, these programs expanded access to medical services to approximately 60 percent o the population both urban and rural by 1980 30.

At the outset o the CCSS, less than 20 percent o the rural population had access to minimal health services 31. The RHP identifed areas o greatest

need and trained community health workers to visit homes in their respective areas in order to improve health practices, sanitation and vaccination

o children. At its core was a primary health care approach which provided a broad range o services to individuals (e.g., vaccination, nutrition,

amily planning, and dental care); environmental health activities (e.g., potable drinking water, improvement o rural housing, excreta elimination); and

complementary supporting services (e.g., health education, data collection and promoting community organization)29. The RHP signifcantly expanded

services so that by the end o the 1970s, health services covered more than 60 percent o the rural population while all health indicators improved

signifcantly nationwide29,31. The urban Community Health Program, patterned ater the RHP, aimed to improve the living conditions o slum dwellers.

Within three years o its creation in 1976, the program reached 57 percent o the urban population. By the end o the decade, this initiative has

succeeded in expanding vaccination to 85-90 percent o urban population, eces disposal in urban areas had increased rom 60 to 96 percent and 100

percent o the urban population had access to potable water 29.

Analysts o the countrys success have underscored Costa Ricas strong policy link between health and education. Knowledge about health is regarded

as an essential part o education at all levels, and the education system has consciously been used as a venue through which to promote good health.

The ree and compulsory grammar school system, operational since 1869, was expanded to include ree middle school and a strengthening o the

university system in 1949. Due to the expansion o childrens school during the 1940s and 1950s, the proportion o women who completed primary

school increased rom 17 percent in 1960 to 65 percent in 1980. This trend appears to have been a driver o the substantial decline in inant mortality

during the 1970s30.

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Sri Lanka

Sir Lanka achieved strong improvements in health indicators ollowing independence in 1948, despite the countrys ailure to generate sustained

economic growth32. An expansive primary health care system provided ree to the entire population contributed signifcantly to population health gains33.

At the same time, pro-equity strategies across several social sectors played a major role in improving health outcomes32.

In agriculture, sel-sufciency in rice production and other essential ood stus was a priority or the newly independent nation. The agricultural

strategy o succeeding governments diversifed peasant agriculture with high-yielding crops, increased overall production and boosted the incomes

o armers. By the early 1980s, this program had reduced regional and class disparities, providing relie or some o the poorest groups, such as the

rice-growing peasantry, as part o a national eort to meet basic needs across the whole population. Over several decades, a ood rationing scheme

ensured the supply o rice and several other essential ood items at subsidized or stable prices to all households through a network o cooperatives. As

a result, between 1956 and 1963, the average caloric intake o the population as a whole increased by 40 percent 32. Simultaneous eorts to increase

and improve the rural housing stock led to better structure, design and quality o rural housing34. Meanwhile, the health and well-being o workers,

particularly women and youth, were addressed through a series o labour laws in the 1950s. These included provisions to limit the work week to 45

hours and to provide annual compulsory vacation and sick leave with pay. The extension o an aordable public transportation network o rail and road

services increased the rural populations access to basic health care services. In 1978, 70 percent o births in Sri Lanka took place to hospitals, clinics

and maternity homes32.

Universal ree education has been provided since independence through a network o primary, secondary and tertiary educational institutions. By 1980,

health education and physical activity were included in the school curriculum. From 1945 onward, all students were provided with a ree mid-day meal.

A large expansion in emale education in the 1950s and 1960s virtually eradicated literacy dierences between males and emales and led to a wide

acceptance o amily planning and a decline in the birth rate rom the early 1960s 32.

Analysts ound that this whole range o intersectoral actions was acilitated by the countrys political system and culture o civil society participation.

The competitive political environment in Sri Lanka enabled the poor rural majority to secure a considerable degree o redistribution and social welare

benefts. Women became active in the political process even beore national independence, orcing the political elite to respond to their concerns.

The high priority accorded to maternal and child health in the 1930s and 1940s was a result. The popularity o political leaders, particularly in the twodecades prior to independence, was based upon their capacity to secure a wide range o state services or the electorate, among which health and

education assumed a high priority. A large and active non-governmental sector pressed political, economic and health concerns eectively. Groups

including village-level rural development societies and womens associations were active in initiating public health campaigns, such as the anti-TB

campaign34.

Te GHLC cases are still frequently cited whenanalysts wish to give examples of health progressin developing countries, and in particular to showhow policy in non-health sectors can improvehealth status. he question of which factorscontributed most to these jurisdictions successhas continued to concern analysts along with thecorollary problem of why it has been so dicult forother countries at similar income levels to replicatetheir achievements. A generation later, the issuesraised in Good health at low costremain relevant,and it is well worth looking in greater depth at

some of the strategies pursued by GHLC countrieswhich contributed to their status as good practicemodels. In what follows, we look at two GHLCjurisdictions and a third country, Cuba, whichwas not included in the study, but had pursuedsimilar public health policies. Our particular aimis to see how these countries used intersectoralpolicies addressing health determinants as keytools for improving population health indicatorsand in particular meeting the needs of vulnerablepopulation groups.

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While the GHLC jurisdictions and countrieslike Cuba exhibited a range of dierent politicalframeworks and public health strategies, Goodhealth at low cost argued that it was possible todiscern elements of a common pattern amongdeveloping countries that had made exceptionalhealth progress.

In the area of IAH, the most crucial areas appearedto be: (1) guaranteeing an adequate food intakefor all, including the most socially vulnerablegroups, and (2) womens education. Te theme ofwomens education/literacy as a health determinantsubsequently provided the rationale for healthpromotion campaigns in several developingcountries40.

Ironically, by the time Good health at low costwaspublished, several of the jurisdictions studied including Costa Rica and Sri Lanka were

being aected by global economic and politicalchanges that would threaten the population healthachievements praised in the volume (see below).Subsequent decades revealed the vulnerability toexternal shocks and domestic political vicissitudesof some of the policies that had enabled thesecountries to become models for improvingpopulation health and health equity.

he message of GHLC was both encouragingand deeply challenging for health policy makersin developing countries41. On the one hand, the

study conrmed that impressive health gains werepossible in countries with relatively low GDPper capita. But on the other hand, the enabling

Cuba

Post-revolutionary Cuba constituted an important example o good health at low cost that did not make it onto the agenda o the 1985 conerence.

Cubas population health profle more closely resembles wealthy countries like the US and Canada than most other Latin American countries 35. WhileCuba had likely attained one o the most avourable mortality levels in the developing world by the end o the 1950s, urther signifcant declines in

mortality took place ollowing the socialist revolution o 1959. The revolution brought medical and public-health resources within the reach o ormerly

marginalized sectors o society. By redirecting national wealth towards the ulflment o basic needs, the standard o living or the more disadvantaged

social groups was improved despite the countrys altering economic perormance in the 1960s and 1970s. Rural-urban dierences in health and its

social determinants were reduced as the state invested more national resources in rural areas36. In 1959 the countrys inant mortality rate was 60/1000

live births and lie expectancy was 65.1 years. By the mid-1980s Cuba had attained an inant mortality rate o 15/1000 and emale lie expectancy o

76 years37.

The principles o universality, equitable access and governmental control guided post-revolutionary Cuban health policies, which ocussed on achieving

social equity through ree provision o needed services, including medical care, diagnostic tests and vaccines or 13 preventable diseases. Cubas

public health policy prioritizes health promotion and disease prevention activities, decentralization, intersectoral action and community participation;

it eatures a local primary care approach which exists within an organized system o consultation and reerral or more specialized care. At local level,

physicians and nurses live within the community they serve and provide not only clinical diagnosis and treatment, but also community education aboutgeneral health issues and non-medical health determinants35.

Cuba has made progress in addressing the social determinants o health, applying the same basic principles o universality, equitable access and

government control. Education has been a national priority. The government launched massive literacy campaigns shortly ater the revolution,

nationalizing all private schools and making education ree and universal. Subsequently, programmes to ensure that every adult obtained at least a

sixth grade education were put in place36. Cubas literacy rate is 96.7 percent, remarkable considering that beore the revolution, one quarter o Cubans

were illiterate and another tenth were semiliterate35. The post-revolutionary period also saw campaigns to improve standards o hygiene and sanitation

in urban areas by increasing access to potable water through expansion o the network o aqueducts35,36. From early on, discussion o post-revolutionary

Cubas health and social policies bore an ideological and polemical stamp. Critics o the Cuban system pointed to restrictions on individual rights and

a generalized economic stagnation under the socialist regime. Deenders argued that Cubas commitment to social equity and universal primary health

care enabled the country to limit the health damage associated with prolonged economic embargo 38.

Five shared social and politicalfactors making good health at lowcost possible39

p Historical commitment to healthas a social goal

p Social welfare orientation todevelopment

p Community participation indecision-making processesrelative to health

p Universal coverage of health

services for all social groups(equity)

p Intersectoral linkages for health.

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social and political conditions that appeared tohave made GHLC countries success possible wereprecisely, as the above list suggests, conditions thatthe majority of developing countries did not andperhaps could not full. Many of these countrieslacked a historical commitment to health as asocial goal; a tradition of democratic communityparticipation; and equity in health servicescoverage (or even the serious political will tostrive for it). Few countries development policiescould realistically be described as oriented towardsbroadly shared social welfare.

Tus, of the ve social and political factors foundby Roseneld to be common to GHLC countriesand to explain their success, the one seemingly

most easily within reach for developing countrypolicymakers was the last: intersectoral linkagesfor action on health determinants. Accordingly,a formal commitment to IAH became part ofmany countries ocial health policy frameworksin the 1980s. However, the track record ofactual results from national implementation ofIAH was feeble. Indeed, despite the high proleaccorded to intersectoral action in the Alma-AtaDeclaration, WHA technical discussions, the healthpromotion movement and Good health at low cost,IAH to address social and environmental health

determinants generally proved, in practice, to bethe weakest component of the strategies associatedwith Health for All42.

Why? In part, precisely because many countriesattempted to implement IAH in isolation fromthe other relevant social and political factorspointed out in the above list. Tese contributingfactors are to an important degree interdependentand mutually reinforcing. Tus, the chances ofsuccess in IAH vary with the strength of the otherpillars: broad commitment to health as a collectivesocial and political goal; the craing of economic

development policies to promote social welfare;community empowerment and participation; andequity in health services coverage. Where theseobjectives were not seriously pursued, IAH alsofaltered.

Later analysts identied further reasons why IAHfailed to take o in many countries in the wakeof Alma-Ata and GHLC. One problem concernedevidence and measurement. Decision-makers inother sectors complained that health experts wereoen unable to provide quantitative evidence on

the specic health impacts attributable to activitiesin non-health sectors such as housing, transport,education, food policy or industrial policy42. At

a deeper level, beyond the inability to furnishdata in specic cases, profound methodologicaluncertainty persisted about how to measuresocial conditions and processes and accuratelyevaluate their health eects. Te problem wascomplicated both by the inherent complexityof such processes and by the frequent time-lagbetween the introduction of social policies andthe observation of eects in population health.Measurement experts reached no clear resolutionon the methodological challenges of evaluationand attribution in social contexts where bydenition the conditions of controlled clinicaltrials could not be approximated.

During the 1980s, IAH also ran up against

government structures and budgeting processespoorly adapted to intersectoral approaches. Onereview identied the following diculties:

Vertical boundaries between sections ingovernment

Integrated programmes often seen asthreatening to sector-specic budgets, tothe direct access of sectors to donors, andto sectors functional autonomy

Weak position of health and environmentsectors within many governments

Few economic incentives to support

intersectorality and integrated initiatives Government priorities oen dened bypolitical expediency, rather than rationalanalysis43.

Uncertainties about evidence and intra-governmental dynamics were only part of theproblem, however. Wider trends in the globalhealth and development policy environmentcontributed to derailing efforts to implementintersectoral health policies. A decisive factor wasthe rapid shi on the part of many donor agencies,international health authorities and countries from

the ambitious Alma-Ata vision of primary healthcare, which had included intersectoral action onSDH as a core focus, to a narrower model ofselective primary health care.

2.6 The rise o selectiveprimary health care

From early on, both the potential costs and thepolitical implications of a full-blown versionof PHC were alarming to some constituencies.

Selective PHC was rapidly proposed in the wakeof the Alma-Ata conference as a more pragmatic,nancially palatable and politically unthreatening

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alternative14,44. Rather than trying to strengthenall aspects of health systems simultaneously orto transform social and political power relations(a possibly laudable but necessarily long-termobjective), advocates of selective PHC maintainedthat, at least in the short term, efforts shouldconcentrate on a small number of cost-eectiveinterventions aimed to attack a countrys orregions major sources of mortality and morbidity.Selective PHC in eect eliminated the social andpolitical dimensions of the original PHC vision.Te theorists of selective PHC presented it as aninterim strategy to be implemented urgentlywhile countries worked to marshal the moreconsiderable resources and political commitmentneeded for comprehensive PHC44. In many

settings, however, the interim model eectivelysuppressed comprehensive PHC as a long-termobjective.

Selective PHC focused particularly on maternalhealth and child health, seen as areas where a fewsimple interventions could dramatically reduceillness and premature death. Te most famousexample of selective PHC was the strategy forreduction of child mortality known as GOBI short for growth monitoring, oral rehydrationtherapy, breastfeeding and immunization. By

concentrating on wide implementation of theseinterventions in developing countries, proponentsargued, rapid progress could be made in reducingchild mortality, without waiting for the completionof necessarily lengthy processes of health systemsstrengthening (or a fortiori for structural socialchange). Te four GOBI interventions appearedeasy to monitor and evaluate. Moreover, they weremeasurable and had clear targets. It was foreseenthat this model would appeal to potential funders,as well as to political leaders eager for quickresults, since indicators of success and accountscould be produced more rapidly than with the

sorts of complex social processes associated withcomprehensive PHC16.

he GOBI strategy became the centrepieceof the child survival revolution promotedby UNICEF in the 1980s45. Under its earlierExecutive Director Henry Labouisse, UNICEFhad cosponsored the Alma-Ata conference andsupported much of the early groundwork forthe original PHC strategy. he arrival of JimGrant at the head of the agency in 1979 (the yearafter Alma-Ata) signalled a fundamental shift

in UNICEFs philosophy. Like Halfdan Mahler,Grant was a charismatic leader. But where Mahler

was convinced international organizations hada mission of moral leadership for social justice,Grant believed international agencies had to dotheir best with nite resources and short-livedpolitical opportunities, working within existingpolitical constraints, rather than succumbing toutopian visions. Tis meant renouncing ambitionsof broad social transformation to concentrate onnarrow but feasible interventions16. Tis tightlyfocused, pragmatic approach was embodied inthe GOBI strategy.

GOBI proved effective in many settings incutting child mortality. However, it constituteda dramatic retreat from the original Alma-Atavision, particularly regarding intersectoral action

on social and environmental health determinants.Additional components with a more multisectoralcharacter (family planning, female educationand food supplementation) were added later,on paper, to the original GOBI interventions,but these additional ideas were ignored in manyplaces. Indeed, in actual practice the GOBIstrategy was even narrower than the acronymimplied, since many countries restricted theirchild survival campaigns to oral rehydrationtherapy and immunization14. he narrowselection of interventions targeted primarily at

women of childbearing age and children under 5was designed to improve health statistics, but itabandoned Alma-Atas focus on social equity andhealth systems development38.

he fate of the Health for All effort and theimplications of the shi from comprehensive toselective PHC have generated a substantial andoen polemical literature14,46,47,48,49. For critics ofselective PHC, including recently Magnussen etal.: the selective approach ignores the broadercontext of development and the values that areimbued in the equitable development of countries.

It does not address health as more than the absenceof disease; as a state of well-being, includingdignity; and as embodying the ability to be afunctioning member of society. In conjunctionwith the lack of a development context, theselective model does not acknowledge the role ofsocial equity and social justice for the recipientsof technologically driven medical interventions38.Cueto summarizes that, for its critics, SPHC wasa narrowly technocentric strategy that turnedaway from the underlying social determinantsof health, ignored the development context and

its political complexities, and resembled verticalprogrammes16.

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On the other hand, defenders of the selectiveapproach object that comprehensive PHC and theAlma-Ata vision as a whole, while draped in morallanguage to which no one can object, were from thestart technically vague and nancially unrealistic,hence impossible to implement. he multiplemeanings of the term primary health careundermined its power. As Cueto observes: In itsmore radical version, PHC was adjunct to a socialrevolution. For some this was negative and Mahlerwas to be blamed for transforming WHO from atechnical into a politicized organization. Othersbelieved Mahler was nave to expect changesfrom the conservative bureaucracies of developingcountries, and that he far overestimated thecapacity of a small number of enlightened experts

and bottom-up community health projects toeect lasting social change. Meanwhile the deeppolitical marginalization and impotence of therural poor were not suciently understood byPHC advocates. Likewise, defenders of the Alma-Ata vision tended to romanticize and idealizecommunities in the abstract, with too littleattention to their actual functioning16.

Tese debates have implications that reach farbeyond the specic historical context of the 1980sto raise questions of relevance today including

for the Commission on Social Determinantsof Health. Arguably, both the great strengthand the fatal weakness of comprehensivePHC stemmed from the fact that it was muchmore than a model for delivering health careservices. PHC and Health for All as presentedat Alma-Ata constituted a far reaching projectof social transformation, guided by an ideal ofthe empowerment of disadvantaged people andcommunities, under a model of developmentin the spirit of social justice22. With such valuesat stake, it is hardly surprising that impassioneddebates on the meaning and legacy of Health for

All continue today. A question with which theCSDH must grapple is a version of the problemembodied in the emblematic gures of Mahlerand Grant. Whether to focus on highly chargedconcepts like social justice or less strong (but alsoless threatening) ones like equity or eciency.Te choice is not only about language but impliesdifferent levels of engagement with politicalprocesses and quite dierent proposals for action.

Te emergence of selective PHC as an alternativeto the Alma-Ata vision in the early 1980s was not

accidental. Rather, it was the logical reection ofa broader shi in political power relations and

economic doctrines occurring at global level. Tisshi had signicant consequences for health, and inparticular for the capacity of governments to crahealth policies addressing social determinants. ofully understand the failures of intersectoral actionon SDH (and the Alma-Ata strategy as a whole),we must situate the PHC vs. SPHC problemwithin this broader context.

2.7 The political-economiccontext o the 1980s:neoliberalism

Te 1980s saw the rise to dominance of the economicand political model known as neoliberalism (for

its emphasis on liberalizing or freeing markets)or the Washington consensus (since its mainproponents the US government, the WorldBank and the International Monetary Fund arebased in Washington, DC). Te historical originsand evolution of the neoliberal model have beendiscussed in detail elsewhere50,51. Te core of theneoliberal vision was (and is) the conviction thatmarkets freed from government interference arethe best and most ecient allocators of resourcesin production and distribution and thus the mosteective mechanisms for promoting the common

good, including health

50

. Government involvementin the economy and in social processes should beminimized, since state-led processes are inherentlywasteful, cumbersome and averse to innovation.Te welfare state, in the neoliberal view, interfereswith the normal functioning of the market andthus inevitably wastes resources and deliversunsatisfactory results50. Logically, an overarchinggoal of policy must be to reduce the role of thestate in key areas (including health) where itspresence leads to ineciencies. Instead, maximumfreedom must be accorded to market actors whosepursuit of their own interests will most rapidly

generate economic growth and create wealth the key preconditions for improved well-beingfor all. Better than any form of state-managedredistribution, market processes themselves canbe trusted to distribute the benets of economicgrowth through all levels of society. A key postulateof the neoliberal economic orthodoxy of the 1980sand 90s was that, since economic growth was thekey to rapid development and ultimately to a betterlife for all, countries should rapidly and rigorouslyimplement policies to stimulate growth, with littleconcern for the social consequences in the near

term. While growth-enhancing policies such ascuts to government social spending might involve

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questionable, especially in Asian countries55. Tefaith in the inherently benecial eects of marketdynamics which underlay reform proposals wasmisplaced in developing countries with relativelyweak regulatory and administrative capacities.

In reality the current state

must have even more strengths

and abilities than its archaic

predecessors, if it is going

to capitalize on the virtuous

efciencies of the marketplacewithout suffering the latters side

effects, including negative impacts

on equity56.

Te same assumptions shaping HSR processeswere writ large in the macroeconomic structuraladjustment programmes (SAPs) implemented bymany countries in Africa, Asia and Latin Americaunder the guidance of the IFIs. SAPs typicallyincluded the following components: liberalization

of trade policies (through elimination of tarisand other restrictions on imports); privatization ofpublic services and state enterprises; devaluationof the national currency; and a shift fromproduction of food and commodities for domesticconsumption to production of goods for export14,51.

o understand the implications of neoliberaleconomic models for eorts to address SDH, itis important to recall the impact of structuraladjustment packages on many countries socialsector spending. A central principle of SAPs wassharp reduction in government expenditures,

in many cases meaning drastic cuts in socialsector budgets. Tese cuts aected areas of keyimportance as determinants of health, includingeducation, nutrition programmes, water andsanitation, transport, housing and various formsof social protection and safety nets, in addition todirect spending in the health sector. With sharplyfalling public sector budgets, not only could newinvestment not be seriously envisaged to addresssocial and environmental factors influencinghealth, but already existing supports wereshorn away. Food subsidies, for example, were

slashed in many countries, while price controlson staple goods were lied. In addition, manySAPs demanded large and abrupt cuts in public

sector payrolls. Te sudden layos propelled hugenumbers of people into unemployment, with nosafety nets and little chance of finding formalwork in the private sector in many cases. Tenegative health eects for individuals, familiesand whole communities have been documented.In some countries, particularly in southern Africa,the resulting social destabilization and insecuritycontributed to hunger, the propagation of armedconict and the rapid spread of HIV/AIDS withthe poor, women and other socially disadvantagedgroups bearing the brunt of the damage57.

As a result of SAPs and the global economicmalaise, social sector spending in many countriesplummeted during the 1980s, with negative eects

on the health status of vulnerable communities.In the poorest 37 countries in the world, publicspending on education dropped by 25% in the1980s, while public spending on health fell 50%58.Since SAPs were implemented at the cost of greathuman suering, one would assume that their trackrecord in delivering enhanced economic growth,their ocial raison dtre, must be impressive.Unfortunately this is not the case. Many of thelow-income countries that implemented SAPs,particularly in Africa, saw little if any improvementin their GDP growth rate or other core economic

indicators following adjustment. Tus the short-term pain the programmes brought was muchworse than the international nancial institutionshad predicted, while the promised long-termgain failed to materialize in many cases14,51.

2.8 The 1990s and beyond:contested paradigms andshiting power relations

2.8.1 Debates on development andglobalization

Neoliberal economic prescriptions continued tobe widely applied through the 1990s. However,as the decade advanced, these models were calledincreasingly into question, in developing countriesand by a growing number of international agenciesand constituencies in the global north. hesuccesses and failures of the economic orthodoxyembodied in SAPs were intensely debated;indictments of the IFIs multiplied through thedecade59,60,61. Fuel was added to the critiques as

countries of the former Soviet bloc began toregister the social and health eects of economicshock therapy programmes designed to move

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these societies rapidly from planned economiesto the market system62,63. A series of local andregional economic crises in the course of thedecade underscored the volatility of the neweconomic order and the vulnerability of poor andmarginalized people to the economic uctuationsthat global actors seemed unable or unwillingto prevent. Te resultant critiques fed a growingmovement of social and political protest thatsurged into international headlines when tens ofthousands of demonstrators disrupted the meetingof the World rade Organization in Seattle, USA,in 1999, opening a period in which massive streetprotests accompanied most major meetings ofinternational nancial and trade bodies, as wellas fora like the G-8.

Te concept of globalization was central to thesecontestations. Protesters and critics denouncedthe perceived threat of a global economic orderdominated by transnational corporations andvolati le flows of hot money, whose ficklemovements could have devastating effects onnational economies and the well-being of poorand vulnerable communities. Other commentatorsemphasized the benets of progressive economicand technological integration and argued that thedynamism of the liberalized global economy was

the key to liing hundreds of millions of peopleout of poverty, hunger and despair. Rival visionsof what globalization is or should be clashed in themedia, scholarly publications, international foraand policymakers debates64,65,66.

Te international institutions which were primeobjects of many of the debates were themselvesundergoing changes. Shaken by an unprecedentedwave of intellectual criticism and popular anger, theBretton Woods institutions and entities such as theG-8 began to rethink their respective missions orat the very least to alter their rhetoric. o grapple

more eectively with the debt problems plaguingnumerous developing countries, the World Bankand IMF launched the Heavily Indebted PoorCountries (HIPC) initiative in 1996, and followedit with an enhanced HIPC programme. heHIPC programmes oered carefully structuredforms of debt relief to more than 40 of the poorestcountries (the majority in Africa), the gains fromwhich could be largely invested in core socialexpenditures such as health and education. ofurther galvanize poverty reduction efforts,the World Bank and IMF introduced Poverty

Reduction Strategy Papers (PRSPs) in December1999 as a new approach to the challenge ofreducing poverty in low-income countries, based

on country-owned poverty reduction strategiesthat would serve as a framework for developmentassistance67. he value of the PRSP modelcontinues to be debated. Te evidence available sofar suggests, however, that PRSPs tend to neglectkey issues related to health68, while a WHO reportin 2002 found no evidence that the PRSP processwas leading to signicantly increased spendingcommitments in health and education69. A 2003review of 23 highly-indebted poor countriesinterim PRSPs (iPRSPs) concluded that muchremains to be done to integrate appropriate healthpolicies in poverty reduction strategies70. A lackof country-specic data on the distribution ofdisease, the composition of the burden of disease,the prevailing health system constraints and the

impact of health services were found in mostof the iPRSPs reviewed. Moreover, only a smallgroup of iPRSPs documented eorts to explicitlyinclude the interests of the poor in the design ofhealth policy; in fact, the majority did not takean explicitly pro-poor approach. Te attentiongiven to making the distribution of public healthexpenditures more responsive to the needs of thepoor was even more limited.

2.8.2 Mixed signals rom WHO

Te late 1980s and early 1990s witnessed a waningof WHOs authority, with de facto leadership inglobal health seen to shi from WHO to the WorldBank. In part this was a result of the Banks vastlygreater nancial resources; by 1990, Bank lendingin the population and health sector had surpassedWHOs total budget71. In part the shi also reectedthe Banks elaboration of a comprehensive healthpolicy framework that increasingly set the terms ofinternational debate, even for its opponents. Whileopen to criticism in many respects, the Bankshealth policy model as presented in the 1993World Development Report Investing in Health

showed intellectual strength and was coherentwith regnant economic and political orthodoxy72.

Despite the erosion of WHOs inuence duringthis period, however, the Organizations activitiespresent a complex picture; important andforward-looking work was undertaken by manygroups within or connected with WHO. Someefforts gave an important place to social andenvironmental determinants. For example, incertain regions, most clearly Europe, action toaddress health equity challenges and the social

underpinnings of health continued as part ofan unbroken commitment to the Health for Allideal. A dedicated WHO Equity Initiative (1995-

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98) based at Geneva Headquarters claried theunderstanding of health equity as primarily relatedto peoples positions within social hierarchies, andthus to gradients of social, economic and politicalpower73,74. Despite intellectual products of highquality, the momentum of the initiative was brokenby personality conicts and political struggles. Teinitiative was suspended in 1998.

From 1994 to 1997, WHO sponsored the askForce on Health in Development, chaired byBrandford aitt and including other prominentpolicy-makers as well as public health leaders. Teask Force reviewed global development policiesand their health implications, highlighting theeect of social conditions on health and arguing

that health impact among vulnerable populationsshould be a central criterion in shaping policychoices for economic development. Among a rangeof other documents, the ask Force on Health inDevelopment produced a WHO Position Paper forthe 1995 World Summit for Social Development inCopenhagen. Te paper interrogated the trendstowards privatization and market economies thatcharacterized the globalization of the economicsystem. It argued that eorts to promote economicgrowth should be accompanied by more equitableaccess to the benets of development, as inequities

have severe health consequences. And it stressedthat health issues could be most effectivelyaddressed through intersectoral collaborationto tackle factors such as poverty, unemployment,gender discrimination and social exclusion75.Unfortunately, the ask Forces practical impactwas not proportional to the moral strength of itsarguments. Te group proposed a valuable set ofbroad recommendations, but was not providedwith mechanisms for implementation and follow-up. Tere was no systematic eort to recruit pilotor partner countries to apply the ask Forcesadvice in national policymaking and to measure

outcomes. Within WHO itself, no structures hadbeen foreseen to operationalize the ask Forcesndings, and these lessons had little measurableinuence on the Organizations country-level workand policy dialogue with Member States.

A major WHO effort in the mid-1990s wasthe attempt to reinterpret and reinvigorate theHealth For All strategy under the banner ofHealthFor All in the 21st Century76. Te revitalizationof HFA included a renewed effort to promoteintersectoral action as a key component of

public health strategies. Tus, ten years aer thelandmark 1986 WHA technical consultationson intersectoral action for health, a new WHO

initiative on IAH was launched. Te initiativeproduced a set of substantial scholarly papers andreviews of IAH experience at national and globallevels and culminated in a major internationalconference in Halifax, Nova Scotia, in 1997. Teexistence of the IAH initiative attested both tocontinued recognition of the importance of thesocial and environmental determinants of healthand the ongoing diculties countries experiencedin addressing them77.

Te arrival of Gro Harlem Brundtland as Director-General in 1998 brought significant changesin WHOs institutional agenda. Brundtlandspriorities included a new initiative on malaria (RollBack Malaria), a global campaign against tobacco

and a rethinking of health systems. Brundtlandis credited with having restored much of WHOstarnished credibility in international developmentdebates. However, this renewal came at a price, andthe sacrices aected areas of importance for theOrganizations capacity to promote action on SDH.For example, the ambitions ofHealth for All in the21stCentury were sharply scaled back. In the areaof health and development, Brundtlands signaturewas the Commission on Macroeconomics andHealth (CMH), chaired by Jeffrey Sachs. heCMHs basic argument was not novel. But by

putting numbers on the idea that ill-health amongthe poor costs the global economy vast sumsof money, the CMH captured the attention ofpolicy-makers. Quantifying in dollar terms thepotential economic payo of health improvementsin low and middle income countries, the CMHhelped secure fresh prominence for health asa development issue. Because it embraced thelanguage of cost-eectiveness and looked at healthin terms of returns on investment, the CMH mayhave been perceived as more realistic, pragmaticand in touch with the real world than earlier WHOinitiatives such as the ask Force on Health in

Development, which had discussed ethical valuesand invoked the courage to care78.

2.8.3 SDH approaches at countrylevel

Several countries made notable strides in the eortto address social dimensions of health through the1990s and early 2000s.

he direct roots of contemporary efforts toidentify and address socially-determined health

inequalities reach back to the Canadian LalondeReport79 (1974) and the Black Report in theUnited Kingdom80 (1980). Te Black study had

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Action on the social determinants of health: le arning from previous experiences

little immediate policy impact in the UK, thengoverned by Prime Minister Margaret TatchersConservative Party, whose leadership dismissedBlacks recommendations as utopian. However,the document generated strong interest in portionsof the scientic community. It inspired a numberof comparable national enquiries into healthinequalities in countries such as the Netherlands,Spain and Sweden. Public health specialists andpolitical leaders in several countries began toexplore policy options to address the troublingpatterns the studies revealed though actionremained vulnerable to political power shifts(e.g., in Spain). Meanwhile the pervasive eectsof social gradients on health were progressivelyclarified, in particular by data emerging from

the Whitehall studies of comparative healthoutcomes among British civil servants, led by SirMichael Marmot81,82. In Canada during the early90s, a remarkable interdisciplinary research eortsponsored by the Canadian Institute for AdvancedResearch (CIAR) brought together experts frompublic health and other natural and social scienceelds to explore together the determinants of thehealth of populations. Te objective was not onlyto bolster scientic knowledge, but to identifyeective policy options in answer to the question:What can be done to improve a democratic

nations health status? Te groups key ndingsand recommendations, published in 1994 as Whyare some people healthy and others not?, inuenceddebates in Canada and beyond83.

Te specic vocabulary of social determinants ofhealth came into increasingly wide use beginningin the mid-1990s. arlov (1996) was one of the rstto employ the term systematically. arlov identiedfour categories of health determinants: genetic andbiological factors; medical care; individual health-related behaviours; and the social characteristicswithin which living takes place. Among these

categories, he argued, the social characteristicspredominate6. A series of important publicationsgeneralized the use of this vocabulary84.Researchers explored the questions of how socialconditions and processes might translate intoindividual experiences of disease, as well as thecontentious issue of whether social and economicinequality per se could be seen as comprisinghealth status for all members of a society, suchthat at any given level of national income moreegalitarian societies could be expected to exhibitbetter health than less egalitarian ones across the

full range of socioeconomic positions85,86

. hegrowing sense that emerging evidence on SDH had

potentially far-reaching implications for publicpolicy led to eorts to translate relevant scienticndings into language accessible to policy-makersand the general public87.

Te most rapid advances were made in a numberof Western European countries, where in the late1990s and early 2000s momentum gathered forsystematic policy action to tackle health inequalitiesand address SDH88. In some cases, notably Sweden,the result has been a dramatic reorientation ofpublic health towards a social approach. In the UK,the arrival in power in 1997 of a Labour governmentresponsive to health equity concerns sparked awave of fresh research and policy innovation thatput the country at the forefront of eorts to tackle

SDH and reduce health inequalities. Outside ofEurope, Australia, Canada and New Zealand havebeen leaders in research and policy action on thesocial dimensions of health, though tensions havesurfaced between an SDH approach and strategiesrooted in more market-based and individualizedmodels of health and health care89,90. Meanwhile,successful eorts to address SDH through publicpolicy have not been limited to high-incomecountries. In the 1990s, a number of developingcountries have also begun to implement promisingpolicies and interventions to tackle the social roots

of ill health. o provide a sense of the range ofapproaches being implemented; of obstacles andproposed solutions; and of the momentum that hasbegun to build around social determinants, we willnext explore developments in a number of countriessince the 1990s.

o survey and compare national SDH programmesand policies requires a typology that can enablethem to be grouped coherently, so that theirsimilarities and dierences emerge. Te followingframework has been developed for that purpose.Building on Diderichsen, Evans and Whitehead

(2001)91, Mackenbach et al (2002)92 and others,this framework classies SDH policies accordingto their entry points: i.e., the stage of the socialproduction of disease/well-being at which theyseek to intervene. o visualize the relationshipsamong these strategies, it is useful to adopt theimage of a social production chain of linkedmechanisms that lead from underlying socialstratification to an inequitable distribution ofhealth outcomes, and then back from poorhealth to peoples socioeconomic position andopportunities.

Te rst entry point concerns programmes that

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seek to alter the socioeconomic hierarchy itselfvia redistributive measures. he second andthird reect more modest intermediate strategiesthat aim to shield disadvantaged groups againstthe negative health consequences of their social

position, for example by improving workingconditions or reducing smoking rates amonglow-income groups. Te fourth points to targetedmedical care delivery strategies that seek to repairthe damage social forces inflict on vulnerablepeoples health once that damage is already done,and to prevent the eects of illness from loweringpeoples socioeconomic status even further. Acategorization of policies and interventionsaccording to these four entry points should also be

crossed with a classication according to whetherprogrammes aim for universal coverage or insteadtarget specic groups within the population.

Based on the typology just sketched, several

national programmes which took shape in thelate 1990s are particularly illustrative. Amongmany cases that merit discussion, we have chosenfour for the purposes of present analysis. Tey havebeen selected: (1) to illustrate the range of entrypoints identied above; (2) because lessons maybe drawn not only from the actual content of thepolicies, but from the political processes throughwhich they arose. Te existence and accessibility ofample documentation on this political background

There are four key points along this chain where policies can intervene:

p By trying to decrease social stratication itself, i.e., to reduce inequalitiesin power, prestige, income and wealth linked to different socioeconomicpositions92;

p By trying to decrease the specic exposure to health-damaging factors sufferedby people in disadvantaged positions;

p By seeking to lessen the vulnerability of disadvantaged people to the health-damaging conditions they face;

p By intervening through healthcare to reduce the unequal consequences of ill-health and prevent further socioeconomic degradation among disadvantagedpeople who become ill.

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Action on the social determinants of health: le arning from previous experiences

A comprehensive national public health strategy: Sweden

In the late 1990s, Sweden launched a new and innovative public health strategy based on a social determinants model. Tellingly, the strategy does

not defne its objectives in terms o morbidity or mortality fgures. Rather, national health objectives are set by targeting the social and environmentaldeterminants o disease. The overall goal o the strategy is the creation o societal conditions that ensure good health, on equal terms, or the entire

population93. Equity in health is thus a central and explicit aim o Swedens public health policy. The strategy aims to alter the pattern o social

stratifcation that produces health inequities, while at the same time working at the intermediate level to address actors o specifc exposures and

vulnerability among disadvantaged groups.

The policy is based on 11 objectives reecting the most important determinants o health:

1 Participation and inuence in society2 Economic and social security3 Secure and avourable conditions during childhood and adolescence4 Healthier working lie5 Healthy and sae environments and products6 Health and medical care that more actively promotes good health

7 Eective protection against communicable diseases8 Sae sexuality and good reproductive health9 Increased physical activity0 Good eating habits and sae ood

Reduced use o tobacco and alcohol, a society ree rom illicit drugs and a reduction in the harmul eects o excessive gambling

The frst six objectives relate to structural actors while the remaining fve are about liestyle choices which an individual can inuence, but where

the social environment plays an important part. Responsibility or meeting these objectives is divided among various sectors and dierent levels in

society, including municipalities, county councils and voluntary organizations, in addition to national government90. The program includes strategies to

reduce housing segregation and social isolation, to increase participation in healthy leisure activities, to channel extra resources to needy schools, and

to reduce unemployment and eliminate employment discrimination against immigrants. In essence, this approach seeks to strengthen conditions that

improve health in society that will in turn improve the health o individuals, particularly among the most vulnerable groups.

The strategy builds both on a Swedish cultural tradition o solidarity and on a governmental model o evidence-based decision-making 94. Sweden hasa longstanding interest in the vital statistics o its population. Since the 18th century the government has kept records o births, deaths and causes o

mortality. This has aorded Sweden a strong statistical evidence base with which to pinpoint trends and causal patterns in health.

The new public health policy came to ruition through a consultative political process in which representatives o all Swedens major political parties

and o civil society were engaged. Demand or action on the social causes o health outcomes was expressed by researchers, politicians, county

councils, municipalities and health care providers, who called or guidelines and national objectives. Support also came rom trade unions and non-

governmental organizations. The availability o reliable data to show the existence and patterns o health disparities was a major actor in galvanizing

pressure or action.

A member o the secretariat supporting development o the policy reported that, in the policy design process, surveys were sent to dierent government

sectors to explore how their sectoral activities inuenced public health; taking a social determinants perspective - as opposed to a disease perspective

- it became relatively easy or non-health sectors to think through the health consequences o their activities. In this way other sectors were closely

involved in the policy design process rom early on. Through the preparation, circulation and iteration o green papers, they were able to give

their eedback to the commission. Participation rom civil society groups was also encouraged. Civil society organizations received green papers or

comment, and many provided substantive input94.

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Coordinating national and local policy to tackle health inequalities: United Kingdom

The recommendations o the 1980 Black Report had little impact in Britain during the years o Conservative government (1979-1997). Over this period

the social health divide documented by Black