Final Report to World Health Organization
Commission on the Social Determinants of Healthfrom Measurement and Evidence Knowledge Network:
Michael P. Kelly (Co-chair)
Josiane Bonnefoy (Co-chair)
Lead authors of final report:
Michael P. Kelly, Antony Morgan, Josiane Bonnefoy,
Jennifer Butt, Vivian Bergman
Abstract
This report begins by identifying six problems which make developing the evidence base on the social determinants of health potentially difficult. These are: lack of precision in specifying causal pathways; merging the causes of health improvement with the causes of health inequities; lack of clarity about health gradients and health gaps; inadequacies in the descriptions of the axes of social differentiation in populations; the impact of context on interpreting evidence and on the concepts used to gather evidence; and the problems of getting knowledge into action. In order to overcome these difficulties a number of principles are described which help move the measurement of the social determinants forward. These relate to defining equity as a value; taking an evidence based approach; being methodologically diverse; differentiating between health differences, health gaps and health gradients; clarifying the causal pathways; taking both a structural and a dynamic approach to
understanding social systems; and explicating potential bias. The report proceeds by describing in detail what the evidence based approach entails including reference to equity proofing. The implications of methodological diversity are also explored . A framework for developing, implementing, monitoring and evaluating policy is outlined. At the centre of the framework is the policy-making process which is described beginning with a consideration of the challenges of policies relating to the social determinants. These include the multi-causal nature of the social determinants themselves, the fact that social determinants operate over the whole of the life
course which is a considerably longer time frame than most political initiatives, the need to work intersectorally, and the removal of the nation state as the major locus of policy-making in many parts of the world. The ways to make the case for policies are described and appropriate entry points and communications strategies are identified. The next four elements of the framework are outlined in turn: (a) evidence generation, (b) evidence synthesis and guidance development, (c) implementation and evaluation, and (d) learning from practice. Finally the report describes the principal ways in which policies relating to the social determinants may be monitored.
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