• By Dartington SRU
  • Posted on Tuesday 26th July, 2011

Health policy: bringing social context in

In yesterday’s story (26th July 2011), a team of researchers from the University of California, Los Angeles (UCLA), described how social determinants get “into the body,” and argued that health inequality could be reduced by improving the social environments in which people live and work. What are the implications for policy?According to the UCLA team, effective interventions are likely to have three characteristics. First, they will be comprehensive and integrated, crossing traditional service sector boundaries. Second, they should target the early years and be sustained across developmental transitions. Finally, population-based interventions aimed at “shifting the curve” for an entire group or community have the potential to save more lives than individually focused biomedical interventions.This is a far cry from what exists. Instead, we are confronted with “a confusing landscape of fragmented programs.” These loosely coordinated systems aren’t enough to overcome the negative effects of social contexts – especially disadvantaged social contexts that include insecure employment, limited social safety nets, and reduced income support for families of young children.Reasons for policy failureChildren are often relatively invisible on the policy horizon, the authors charge. Because children’s programs are relatively cheap, they can appear less significant than programs for adults. Furthermore, the fragmentation of services makes it difficult for any one agency to support the necessary investments. Money invested in one sector (early years, for example) will likely result in benefits for another (such as less need for special education): the sector that made the original investment is not the one that reaps the financial rewards. Similarly, data systems tend to give a partial picture of the child. Finally, cultural beliefs complicate the picture: in individualist societies, child well-being is regarded as the responsibility of the family, not the state. Overall, the result is an emphasis on “second-chance programs for children that fail rather than a community-wide strategy focused on investing in all children for success.”Direct and indirect approachesThere are two ways to tackle the negative consequences of social context. Social determinants can be addressed directly through policies to eliminate poverty, inequality and discrimination, or indirectly through strategies designed to disrupt the pathways between social risks and poor health outcomes, say the authors. Direct approaches tend to appeal to countries with a strong social democratic tradition, and indirect approaches to more individualist countries.The two different approaches have deep ideological roots. Social democratic countries tend to talk about “health inequities,” differences in health that are fundamentally unfair in moral and ethical terms. By contrast, individualist countries such as the US and Canada tend to talk about ethically value-free “health disparities,” which are then explained as the result of a health service that is not performing effectively. “Rather than addressing social determinants directly, indirect approaches are framed as performance-enhancing quality improvements that encourage cost-effective, evidence-based interventions to improve the performance of health and social care systems,” the authors say.In reality, most nations use a combination of direct and indirect approaches, with different degrees of emphasis and framing to fit the policy context of the day. Even so, the UCLA team is adamant that “mounting an effective response to the health threats posed by social determinants will take nothing short of a transformation of our existing child health systems.“Incremental change strategies that rely on the addition of ‘special programs’ to an essentially dysfunctional infrastructure with its misaligned financial incentives, inadequate (or non-existent) communication and coordination tools and administrative inefficiencies will not result in the health gains that we seek, and could even result in greater fragmentation and management challenges.”Seven strategies for radical changeTo kick off the radical changes needed, they suggest seven strategies to start the transformation of children’s health and health systems.1. Raise public awareness about the social determinants of health. Policy makers need access to comprehensive information about social risks that are prevalent in their communities and the relationship between these risks and health. This might take the form of community surveys or efforts to map school readiness.2. Promote children’s developmental health as the foundation for lifelong well-being. In the view of the UCLA team, “Adult health policy discussions that omit to mention childhood are at best incomplete and at worst ineffective.”3. Promote place-based initiatives that link services and sectors to address needs that cross health, education and welfare sectors. The UK Sure Start program is cited as a good example of effective work across sectors. 4. Align incentives. When incentives aren’t aligned, the consequences can be severe and unexpected. For example, one initiative to manage the health of inner-city children with asthma provided nurses to visit children’s homes, and inspections for mold and pests. It was a massive success: hospital re-admission rates fell by 80% and care costs plummeted. But because the hospital’s revenue depended on bed occupancy, its financial integrity was threatened.5. Create a common accountability framework. In other words, don’t have health professionals worrying only about health outcomes, or teachers focused only on educational achievement, but instead help them to see how what they do contributes to various aspect of child well-being. England’s Every Child Matters framework is cited as a good example of this approach. 6. Promote positive social determinants of health as well as preventing and treating illness. For example, encourage parents to read regularly to their children and to take an interest in their academic progress.7. Create new parent-professional partnerships. Government alone cannot transform the health of children. Web-based social networking and local measurement of well-being offer two means of empowering parents to take action on behalf of children and families in communities.ReferenceHalfon, Neal, Kandyce Larson, and Shirley Russ. 2010. “Why social determinants?” Healthcare Quarterly 14 (Special issue, October): 9-20.

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