What can be done?

The improvements in healthcare in the more developed parts of the world have taken generations to achieve, even though disparities do still exist by social strata. The Commission’s report suggests that, to remedy the situation, we need to bring in an inter-sectorial approach to i) improve daily living conditions, ii) get governments to commit to health equity by examining issues of access and resources and iii) build systems to monitor equity and promote training and activities to build awareness for all stakeholders and the public.

These are no easy tasks. A comprehensive approach to early childhood initiatives for child survival and education requires commitment at the highest level. The Commission not only suggests this as a necessity, but also advocates the inclusion of packages to promote physical, social and cognitive development. Barriers for children, particularly girls, to obtaining primary school education and to staying in school need to be identified and addressed. Particularly in urban areas, environments need to be developed keeping in mind affordable housing, provision of water and sanitation, electricity and paved roads as a minimum for all social classes. Beyond the basics, promotion of healthy behaviours requires attention to transport, access to healthy food, and control of unhealthy foods and alcohol. In rural areas, addressing policies that lead to exclusion, resulting in landlessness and displacement, requires investment in rural infrastructure and policies that support migrants. In both urban and rural settings, safe and secure employment with good working conditions can help alleviate poverty, reduce social inequities and exposure to hazards, enhancing healthy living. These needs are the bedrock of a healthy society and if we continue to permit the widening of the social equity gap, we will be moving backwards rather than to a better future.

Policies and schemes are needed to provide a basic standard of living below which no person should have to fall due to circumstances beyond their control. These should not be considered support systems that promote a parasitic culture, but can be mechanisms to reduce poverty and promote the economic development of societies. Healthcare systems need to be developed, that are based on principles of equity and aimed at the prevention of disease and the promotion of health. This requires quality primary healthcare services, which ensure universal access without limitations imposed by the ability to pay. These may seem to be unachievable goals in a short time frame, but a healthy workforce leads to increased productivity, and this needs to be emphasised to governments, to promote buy-in from policymakers.

The second major issue is the unequal distribution of access and resources. Again, this requires support from the highest level of government and coherent action to ensure public finance for equity by developing a framework of action to address the social determinants of health. The state must provide basic services essential to health, such as water and sanitation, and work towards redressing gender biases and increasing universal coverage of health and social programmes.

All the evidence generated so far tells us that health-related initiatives are unlikely to be sustainable unless social and societal issues are addressed. However, these need evidence for action and it is clear that countries lacking basic data on morbidity and mortality by socioeconomic indicators cannot move forward in the provision of health-related interventions. Take the example of a country that does not have basic systems to register births and deaths-this country will not be able to have any estimates for child survival or any form of developmental outcomes. Unfortunately, most health research funding is focused on biomedical research and data related to health at the national scale come from economic research, which tends to ignore the social determinants of health.

Policies are determined by three key features: evidence, political will and institutional capacity. Stakeholders and policy makers need to understand what affects population health and what determines the gradient of equitable access.

What has been done?

Does all this seem impossible? From around the world, there are dozens of examples showing that targeted action does work. Brazil’s national programme of food and nutrition assures all citizens of permanent access to sufficient amounts of basic quality foods without compromising other basic needs. Implemented in alignment with the family health programme, it was possible for Brazil to promote exclusive breast feeding until six months of age, and regulate media advertisements for children’s food. SEWA in India is a trade union of poor self-employed women. They needed childcare which would allow them to work while keeping their children safe. Working with the government, they have established 100 childcare centres looking after children 0-6 years old. Teachers hold regular meetings with mothers to discuss the child’s development, nutrition and education. This has resulted in improved physical growth and in all children starting primary school and the majority carrying on to high school (5). Another example is that for equivalent work, women generally earn less than men which has important consequences for poverty levels, such as among children of single mothers. In Quebec, trade unions have committed themselves to "the equal pay for work of equal value" struggle (1). These are important actions to tackle unjust situations and demonstrate that committed integrated actions do work.

Is a change possible in India?

Recently, researchers at Oxford created the Multidimensional Poverty Index (MPI), which complements the traditional focus on income to reflect the fact that the lives of people living in poverty are affected by more than just their income. This index, which reports acute poverty in 104 developing countries, shows that India ranks below Bangladesh, and that India has 845 million MPI poor people, more than 26 sub-Saharan African nations put together. This is not surprising, given that one in five households does not have a single person with primary school education, one in four households has had a child die, two in five households have malnourished children or adults, one in eight has no access to clean drinking water and one in two has no access to its own sanitation facility (6). In this context, what trickle-down effect can we claim for our globalising and growing economy?

As described in the Commission’s extensive review, without remedying social determinants there can be no chance of sustainably improving healthcare. Action is needed now and from multiple players — the WHO, other multilateral agencies, national and local governments, civil society, the private sector, and research institutions studying economics, health and development. The National Rural and Urban Health Missions are evidence of commitment, but words need to be supported by deeds. Transparency and action are needed across various fields, not just in health.

Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative. There are two possibilities – the first being that we do not change and things stay the way they are. The second is that we try to change things and make opportunities for health and development in a universal social support framework giving everyone equal access and care and that way we could go far. As stated in the report, "it is the right thing to do, and now is the right time to do it".