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Print version ISSN 0042-9686
Bull World Health Organ vol.89 n.10 Genebra Oct. 2011
Kumanan Rasanathan*; Rüdiger Krech
Department of Ethics, Equity, Trade and Human Rights, World Health Organization, Geneva 1211, Switzerland
Noncommunicable diseases cannot be effectively addressed without action on social determinants of health. Without addressing social inequalities and the conditions in which people are born, grow, live, work and age, along with the reasons that health systems work better for some population groups than for others that is, adopting a social determinants approach prospects for reversing the noncommunicable diseases epidemics are poor.1
This year's United Nations General Assembly High-Level Meeting on Prevention and Control of Noncommunicable Diseases (in New York) and the World Conference on Social Determinants of Health (in Rio de Janeiro) provide a unique opportunity for progress. There may never be a better global platform for countries, civil society and international organizations to commit to a coherent social determinants approach to tackling noncommunicable diseases and other global priorities at local, national and global levels. In this context, we explain why a social determinants approach is essential for combating noncommunicable diseases, discuss what such an approach entails, and identify priority actions for the global community.
Tackling noncommunicable diseases by addressing social determinants of health
Eighty per cent of noncommunicable diseases could be prevented through primary prevention through modifying behaviours such as reducing tobacco consumption and fat, alcohol and salt intake, preventing obesity, and promoting physical activity, and improving environmental conditions such as air quality and urban planning.2 Furthermore, early interventions and treatment to minimize the impact of noncommunicable diseases are available. Yet cardiovascular diseases, mental illness, cancer, respiratory illness, and diabetes now dominate the disease burden in middle- and high-income countries, and are projected to do so in low-income countries by 2030.3 Knowledge of how to prevent and treat noncommunicable diseases has not been translated into effective action. For example, only 5% of the world's population is protected by the full range of evidence-based strategies for tobacco control, despite endorsement of these strategies in the Framework Convention on Tobacco Control.4 Even in countries where progress has been made, unequal uptake of interventions lead to noncommunicable diseases being a major cause of health inequities and social inequalities.
However, the health sector cannot, by itself, prevent noncommunicable diseases. The strategy of identifying risks (such as smoking or obesity) and expecting individuals to change their behaviour to minimize their exposure has proved inadequate. Genuine choice and an ability to modify risks depend on living conditions and access to resources. Furthermore, noncommunicable diseases arise from exposures throughout the life course, starting in utero.
Prevention of noncommunicable diseases requires collaboration between different sectors (including finance, trade, agriculture, housing, education, community planning, transport and environment) to address the conditions that give rise to noncommunicable diseases, and to implement policies that support people to minimize their exposure to risks. For example, effective tobacco control includes the use of fiscal policies to reduce tobacco consumption, allied with labour and environmental laws to reduce exposure to smoke and regulation of marketing practices. None of these activities are the primary domain of the health sector.
Treatment is also important, because large numbers of people have noncommunicable diseases, and because whole populations have been exposed to risks that make noncommunicable diseases likely. A social determinants approach is also relevant to ensure that effective interventions are available to all. The common scenario of some often wealthier populations having better access and receiving higher quality care contributes to significant inequities in outcomes for people with noncommunicable diseases. Health systems are themselves an important social determinant, with unequal health services performance a challenge for all countries, rich or poor. There is no contradiction in improving treatment effectiveness using a social determinants approach.
Implementing a social determinants approach
An approach that focuses solely on treatment or attempts to emulate recent HIV and tuberculosis programmes, is one that ignores important lessons and risks failing to tackle noncommunicable diseases. Impressive advances in HIV and tuberculosis treatment have to be weighed against poor progress in reducing incidence and the need for a renewed focus on prevention.
The celebrated example of using community participation and working with industry to reduce salt and fat intake and redirect agriculture in North Karelia, Finland, shows how coherent policies to address social determinants can provide an effective means of reducing noncommunicable diseases.5 Despite this example, too little has been done globally to consider how policies for food production and distribution can be better coordinated to serve health and development goals. The Finnish experience shows the potential for governments to work with the agricultural sector and food industry to prioritize nutritious and environmentallysustainable food, including regulatory action when necessary. Other countries, such as New Zealand, have adopted a social determinants approach with some success in reducing both prevalence of noncommunicable diseases and inequities by implementing policies across all of society.6
As low- and middle-income countries increasingly grapple with noncommunicable diseases as a major development threat, where should the emphasis be? For example, what is more important for India to provide access to statins for middle-class urban populations or to reduce indoor air pollution through replacing inefficient stoves in rural areas? Equitable provision of both statins and clean stoves are required, but a social determinants approach would highlight the latter's potentially greater returns for noncommunicable disease prevalence and health and social equity.7
Implementing a social determinants approach requires building governance with the capacity to address these issues, including the use of comparative health impact assessment methodologies to inform broader policy decisions and prioritization. Understanding the importance of action across society to ensure health and health equity was strongly promoted in the 1986 Ottawa Charter's call for healthy public policy, itself building on the 1978 Alma Ata Declaration. A social determinants approach extends this by placing health and health equity as central societal goals, of relevance to all sectors. Better health contributes to increased wellbeing, education, social cohesion, environmental protection, increased productivity and economic development.8 A virtuous circle is possible whereby improvements in health and its determinants feedback into each other, providing mutual benefits.9
Realizing this vision requires concerted efforts to change the way governments operate and policies are made, transcending silos to implement coordinated policies that improve health and reduce inequities. Risks for health and benefits of action occur at all levels local, national and global therefore implementation is required at all levels. For example, local transport and housing policies are needed; national fiscal, environmental, education and social policies; and global financial, trade and agricultural policies (I Kickbusch, personal communication). It is difficult to interest non-health sectors in achieving targets expressed in terms of disease, such as mortality from noncommunicable diseases. Instead, the aim needs to be to implement policies that serve broader societal goals, such as improving wellbeing and development, which also contribute to tackling noncommunicable diseases.
Implementing a social determinants approach also provides the opportunity to transcend the divide between communicable and non-communicable diseases. Separate global health initiatives or funding mechanisms for vertical noncommunicable disease-specific programmes are unlikely to work. There is now increased understanding of the links between communicable and noncommunicable diseases. Smoking, harmful use of alcohol, indoor air pollution and diabetes are major drivers of the tuberculosis epidemic,10 and long-term use of antiretroviral therapy increases the risk for some noncommunicable diseases.11 Increased prevalence of both communicable and noncommunicable diseases in disadvantaged populations is caused by the same social conditions. By shifting the focus to act on these conditions, a social determinants approach offers a more effective and equitable path for progress.
Priorities for action
The World Conference and High-Level Meeting can stimulate global commitment and action at a time when health and social budgets are at risk. Three potential priorities are of key relevance to noncommunicable diseases. First, improved monitoring is required of social determinants, linked to outcomes for noncommunicable diseases and the performance of health services. Social determinants need to be routinely monitored and factored into policy-making in order to evaluate the impact of policies and change course when necessary. The global community can agree on a monitoring framework for social determinants, aligned with key risks for noncommunicable diseases, and assist countries in implementation.
Second, commitment towards a global agenda for noncommunicable diseases is only a partial solution. As the 2015 deadline draws near, coordinated global action, keeping equity foremost, is needed on the unfinished Millennium Development Goals agenda, climate change, social protection and noncommunicable diseases. This requires a social determinants approach at global level, with aligned strategies, implementation and monitoring. The global community can ensure that commitments on noncommunicable diseases and social determinants support this endeavour.
Third, the UN system can show how intersectoral collaboration and policy coherence towards equity is possible, by aligning its agencies' efforts to support countries in addressing multiple priorities through a social determinants approach. UN agencies and bilateral cooperation partners should also ensure that they enable national policy makers to implement a social determinants approach in tackling noncommunicable diseases, taking into account the impact of international agreements.
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(Submitted: 3 August 2011 Accepted: 6 September 2011)