1.1 Background......2
1.2 Rationale......3
1.5 Summary......5
References......7
1
World Health Organization (WHO)
2
Special Programme for Research and Training in Tropical Diseases (TDR)
* Corresponding author: sivasankarakurupa@who.int
2 SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: from concept to practice
Differential exposure
(social and physical environment)
Differential vulnerability
(population group)
Differential consequences
(individual)
to change; and what has been tried and what were the many a public health programme. This is particularly
lessons learned. true when programmes address social determinants
of health conditions and how health is distributed in a
As part of the WHO-led PPHC-KN, a research node population. Programmes will inevitably have to deal
was created and charged with substantiating, through with fundamental structures of societies, including who
empirical case study research, how specific public health controls power and resources. One can appear to do all
programmes have addressed issues related to the social the right things and still not get the right results. It may be
determinants of health and equity. This effort involved tempting to do a two-by-two matrix.
13 institutions and more than 40 researchers. The current
volume is a compilation and synthesis of these 13 case
studies. The case studies examine the implementation
challenges of addressing the social determinants of health,
especially in low- and middle-income settings.
1.2 Rationale
To have meaning in public health, ideas and concepts need
to be translated into concrete action, and interventions
need to be implemented at the scale of populations. The
transition from the drawing board, the experiment, or
the pilot project into the real-life situation has challenged
4 SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: from concept to practice
The matrix indicates that if we have the right interventions programmes addressing the social determinants of health
and implement them in the right way, we get the right and health inequities. Mean scores were computed and
results. While this is hard to dispute, when it comes to the the 14 highest-ranking projects were then selected to
real world, there may be no such thing as 100% right or examine the implementation challenges faced by them
wrong; instead, there may be a range of nuances and grey in addressing the social determinants of health in public
zones. There is a lot of learning to be done from examples health programmes. Thirteen studies were completed
where both the interventions and the implementation and are included in this volume.
were right. However, these cases are rare, and there may
be much more learning from cases where interventions The studies used a variety of standard methods in
and their implementation were almost right and where case study research (Yin, 2003), including interviews
the results were almost there than from cases of complete with key informants involved at the policy level and in
perfection or failure. implementing the respective programmes, document
review of official and unofficial statistics, project
A critical phase in most programmes is that of going to documents and reports, and the published literature.
scale – moving from the experiment or pilot project to Review and clearance for research involving human
the full-scale intervention required to have an impact at subjects was obtained from the Research Ethics Review
the population level. Another critical phase is when the Committee (ERC) of WHO, and from national or
programme is to be sustained, for example, to be funded institutional review boards of the participating research
and institutionalized for the long term and to operate institutions.
without the day-to-day involvement of those who
conceived the project and worked in it. This transition
process may also offer many insights and opportunities
for learning.
1.4 Case study themes
The primary objective of undertaking these case studies
Most research on the social determinants of health and was to review their implementation processes and to
equity has focused on possible causal relationships. The set draw lessons that can be learned by others embarking
of case studies presented here focused on programmatic on the difficult path to correct inequities in health by
issues concerning the organization of public health addressing the social determinants. The objective was
programmes and the process of implementation. In thus not to evaluate the performance and outcomes of
particular, the case studies document the challenges faced these programmes, but to understand how they addressed
and how they were dealt with in practical local situations. the challenges to implementation. Therefore, the case
studies focused on the following five types of processes of
implementation, and the learning and challenges thereof
– going to scale, managing policy change, managing
1.3 Process and methods intersectoral processes, adjusting design and ensuring
sustainability.
In order to commission case studies on a wide range of
public health programmes and a representative set of
countries, a call for letters of interest was issued jointly Going to scale
by the WHO Department of Ethics, Equity, Trade
and Human Rights in collaboration with the Special Many successful programmes are often conceived by
Programme of Research, Development and Research visionaries, and carried forward by dedicated personnel,
Training in Human Reproduction (HRP), the Special who understand the ideas, purposes and ideologies
Programme for Research and Training in Tropical behind the programmes. However, while moving from
Diseases (TDR), and the Alliance for Health Policy and small-scale pilot programmes to large interventions
Systems Research (AHPSR). The call attracted 70 letters covering and benefiting a whole population, these
of interest from all WHO Regions. All letters of interest programmes often face considerable challenges. The case
were peer reviewed and scored on a set of pre-established studies documented the learning from such projects on
selection criteria. Evaluation of the proposals included the processes of moving from a small to a large scale, the
criteria such as the quality of the proposal, feasibility and challenges encountered on the way, how they overcame
potential to contribute new knowledge on implementing the challenges, and what were the barriers and facilitators.
Introduction and methods of work 5
commitment is necessary for multisectoral policy knowledge and skills; it also requires health objectives
development, implementation and monitoring, and to be translated into the interests of and institutionalized
effective scaling up. within government sectors as well as community
organizations. Having a visionary and energetic
champion, if not a must, will greatly facilitate the process.
Chapter 5. China
Dedicated delivery centre for migrants in
Minhang District, Shanghai Chapter 8. Kenya
Lessons learned from the China case study suggest that The Millennium Villages Project to improve
a values-based project requires particular considerations health and eliminate extreme poverty in rural
to go to scale. Policy change requires innovative
African communities
thinking, questioning of conventional wisdom, and This case study reviews early experience with a
diligently taking on both higher authorities and health multisectoral development project, the Millennium
professionals. In the practical implementation, priority- Villages Project (MVP), in rural African communities.
setting, technical approaches, values and staff, and The MVP tests the key recommendations of the UN
institutional development had to be considered and Millennium Project and demonstrates in practice at the
addressed simultaneously. The case demonstrates that village level how to achieve the Millennium Development
inequity in pregnancy outcomes between migrants and Goals (MDGs). It demonstrates that integrated
residents is avoidable, and that at least some among the interventions that simultaneously target the availability,
public, authorities and within the health-care profession acceptability and accessibility dimensions are feasible and
find them unfair. can lead to high-impact programmes at the village level
but there are important contextual constraints as well.
Chapter 6. Indonesia
Reviving health posts as an entry point for
Chapter 9. Nigeria
community development: Gerbangmas Immunization programme in Anambra State
movement in Lumajang district, Indonesia
Despite continued attempts, routine immunization
The Gerbangmas movement in Lumajang district, coverage in some areas of Nigeria has remained very
Indonesia is an innovation within a decentralized health low. Local ownership of the programme is the key to
system. The policy change of the Gerbangmas initiative sustainability of the programme; involvement at the
was an incremental process that took approximately political level is necessary but not sufficient. Local-level
five years. The Gerbangmas movement has encouraged administrative integration is indispensable. This study
multiple sectors to set programmes for community explores the roles of stakeholders in the development
empowerment and to bring these together through and implementation of the Reaching Every Ward (REW)
a common indicator framework controlled by the policy for delivering immunization services in Nigeria,
community. The study suggests that for conducting and the factors influencing their roles in keeping and not
community empowerment to address the social keeping the focus of the REW.
determinants of health, it is of importance to use a non-
sectoral mechanism that can accommodate multisectoral
interests. Chapter 10. Pakistan
Multipartner national project to reduce
malnutrition among rural girls in Pakistan –
Chapter 7. Iran Tawana
Child malnutrition: engaging health and other
sectors Malnutrition figures for children below the age of 5 years
have been stagnant in Pakistan over the past several years.
Intersectoral collaboration becomes difficult when The Tawana project, initiated by the Federal Ministry
resources are limited. Highest-level government of Women and Development, following a pilot project
commitment is a must when going to scale. Establishing undertaken by the Aga Khan University, was a national
effective intersectoral action needs more than building project launched in 29 districts. It focused on empowering
organizational capacity through upgrading staff local women by giving them the opportunity to plan and
Introduction and methods of work 7
manage a feeding programme, and demonstrates how of monitoring and research in such programmes as
malnutrition could be reduced. Enrolment and retention well as the influence of shifting donor interests and
of girls in government primary schools increased approaches.
through a concerted approach. However, the project
also demonstrated that showing results and impact is
not sufficient to maintain political and administrative Chapter 14. Vanuatu
support. Pacific Action for Health Project: addressing the
social determinants of alcohol use and abuse
with adolescents
Chapter 11. Peru
Local Health Administration Committees (CLAS) Young people in the Republic of Vanuatu are
increasingly being faced with rapid urbanization, lack
Local Health Administration Communities (CLAS) of education, consumption of unhealthy foods, limited
in Peru are non-profit civil associations that enter into job opportunities, and the widespread availability and
agreements with the government and receive public accessibility of inexpensive cigarettes and alcohol. This
funds to administer PHC services, applying private sector case study covers an integrated health promotion and
law for contracting and purchasing. It is an example of a community development programme, the Pacific Action
strategy that effectively addresses the social determinants for Health Project (PAHP), set up to address the social
of health. These refer to social, cultural and economic determinants for noncommunicable diseases in the
barriers at the local level which keep people from capital of Vanuatu, Port Vila.
effectively utilizing health-care services. This case study
describes the political and professional opportunities as
well as threats that such programmes face in the long run. Chapter 15. From concept to practice –
synthesis of findings
Chapter 12. South Africa The synthesis process involved analysing the five key
Intervention with Microfinance for AIDS and aspects of the programmes that have been covered by
Gender Equity (IMAGE) the case studies: going to scale, managing policy change,
managing intersectoral processes, adjusting design and
The Intervention with Microfinance for AIDS and ensuring sustainability. It looked closely at the common
Gender Equity (IMAGE) was an attempt to design, lessons learned under each of these five aspects of the
implement and evaluate a cross-sectoral intervention programme. Among the key messages emerging from the
that aimed to improve health outcomes by targeting synthesis are: the importance of evidence and baseline;
their social determinants in rural South Africa. The that in the long haul, the battle for equity takes place in
intervention combined an established microfinance the public space through intelligent use of the evidence
programme with gender and HIV/AIDS training, and and partners; and finally, that scale-up should consider
activities to support community mobilization. The case three phases – providing proof of principle; testing the
study highlights key lessons from the experiences of scalability of the programme with particular focus on
developing an intersectoral collaboration, expanding the drivers of expansion and how to transfer the values
the scale of intervention delivery following a trial, and torch; and roll-out with systematic monitoring, repeated
exploring models for long-term sustainable delivery. evaluation and timely adjustments to the programme.
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