OPINION AND ANALYSIS OPINIÓN Y ANÁLISIS
Integrating social determinants of health in the universal health coverage monitoring framework
La integración de los determinantes sociales de la salud en el marco de la vigilancia de la cobertura universal de salud
Jeanette VegaI; Patricia FrenzII
IRockefeller Foundation, New York, New York, United States of America
IIEscuela de Salud Pública, Facultad de Medicina, Universidad de Chile, Santiago, Chile. Address for correspondence: email@example.com
Underpinning the global commitment to universal health coverage (UHC) is the fundamental role of health for well-being and sustainable development. UHC is proposed as an umbrella health goal in the post-2015 sustainable development agenda because it implies universal and equitable effective delivery of comprehensive health services by a strong health system, aligned with multiple sectors around the shared goal of better health. In this paper, we argue that social determinants of health (SDH) are central to both the equitable pursuit of healthy lives and the provision of health services for all and, therefore, should be expressly incorporated into the framework for monitoring UHC. This can be done by: (a) disaggregating UHC indicators by different measures of socioeconomic position to reflect the social gradient and the complexity of social stratification; and (b) connecting health indicators, both outcomes and coverage, with SDH and policies within and outside of the health sector. Not locating UHC in the context of action on SDH increases the risk of going down a narrow route that limits the right to health to coverage of services and financial protection.
Key words: social policy; equity in health; health systems, trends; guidelines as topic; Americas.
El respaldo al compromiso mundial con la cobertura universal de salud representa la principal función de la salud en favor del bienestar y el desarrollo sostenible. La cobertura universal de salud se propone como una meta general de salud en el programa de desarrollo sostenible para después del 2015, pues conlleva una prestación eficaz, universal y equitativa de servicios de salud integrales por medio de un sistema de salud fuerte, en consonancia con múltiples sectores en torno a la meta compartida de una mejor salud. En el presente artículo, se sostiene que los determinantes sociales de la salud son centrales en la búsqueda equitativa de vidas saludables y también en la prestación de servicios de salud para todos y, por consiguiente, estos determinantes se deben incorporar explícitamente en el marco de la vigilancia de la cobertura universal de salud. Esto puede llevarse a cabo: a) desglosando los indicadores de la cobertura universal en función de las diferentes mediciones de la situación socioeconómica a fin de que reflejen el gradiente social y la complejidad de la estratificación social; y b) vinculando los indicadores de salud, tanto de resultados como de cobertura, con los determinantes sociales de la salud y con las políticas dentro y fuera del sector sanitario que influyen sobre la salud. Si no se sitúa la cobertura universal en el contexto de la acción sobre los determinantes sociales de la salud, aumenta el riesgo de interpretar el derecho a la salud como un derecho circunscrito a la cobertura de servicios y la protección económica.
Palabras clave: política social; equidad en salud; sistemas de salud, tendencias; guías como asunto, Américas.
Impressive momentum is building across the globe calling for accelerated action on universal health coverage (UHC) so that every person in the world will be able to obtain needed health services without incurring financial hardship (1, 2). The core tenets of universality, comprehensiveness, and affordability put the focus on the equitable distribution of health care, and ultimately, health. Underpinning the interest in UHC is the fundamental role of health for well-being, which is acknowledged as "a precondition for, an outcome and an indicator of all three dimensions of sustainable development" (3). Specifically regarding UHC, the 2012 United Nations General Assembly resolution on The Future We Want affirmed that "Universal Health Coverage is a key instrument to enhancing health, social cohesion, and sustainable human and economic development" (3).
Consequently, UHC is being proposed as a unifying central health goal in the post-2015 Millennium Development Goal (MDG) framework that puts rights and equity at the forefront and is relevant for all countries, rich and poor (4, 5). Yet, some thought leaders argue that UHC, while a noble goal and a necessary condition for development, is not enough. The concern is that embracing UHC as a global priority might lead to forgetting about action on social determinants of health (SDH), thus severely limiting the potential for reducing health inequities (6-8).
This paper addresses this concern and advocates for incorporating SDH indicators in the monitoring framework for UHC, which is being developed jointly by the World Health Organization (WHO) and the World Bank (WB) with an initial proposal currently in consultation (9). Including UHC as a global development goal necessitates clarity in the definition of the concept and a common approach to measurement. The starting point is in understanding the notion of UHC and its relationship with healthy lives and the overall goal of sustainable development.
Beginning with the 2010 World Health Report, WHO defined UHC as a situation where "all people can access the health services they need without incurring financial hardship" (1). In subsequent reports, some aspects of the definition were more precisely delineated, but three interrelated dimensions of UHC were consistently emphasized: (a) coverage for the whole population; (b) for a comprehensive set of services, encompassing prevention, promotion, treatment, rehabilitation, and palliative care, of sufficient quality to be effective; and (c) financial protection from direct payment (free or affordable services) (9, 10).
Health in the sustainable development agenda
Defining what the health goal should be in the post-2015 global agenda requires examining the role of different sectors in the overarching goal of sustainable well-being for all people. Sustainable development includes several economic, social, cultural, and environmental dimensions. Health is one of these dimensions. Health contributes to sustainable development because a healthy population means increased labor productivity and higher returns to households from labor market participation, which leads to improved country competitiveness, and in turn, more inclusive and sustainable growth (11, 12). Undeniably, health is an extremely sensitive tracer of sustainable development since human health outcomes are the embodiment of the integrated impacts of social, economic, and physical life conditions (13). Yet, the direct actions of the health sector contribute only a small share to social well-being, as compared to the policies of other sectors, for example a country´s economic policy.
Even when looking at the production of health itself-the goal of healthy lives at all stages-the health sector´s contribution does not exceed 25% (14). Thus, in order to achieve health goals, the health sector must work with other sectors, as a catalyst and partner for action on SDH, the conditions in which people are born, grow, live, work, and age, as well as the inequities in power, money, resources, and networks that give rise to them (11). Nevertheless, UHC is an irreplaceable contribution of the health sector and important in itself as a right. Still, even in regards to providing UHC, the SDH influence access and effective coverage, and so, other sectors should be involved. As many authors have highlighted, several obstacles related to social circumstances may occur in the complex, multi-stage process leading to effective coverage by which individuals recognize the need for health care, find available and acceptable services, make contact, and ultimately receive an appropriate intervention (15-17). At each step of the process of effective coverage, some groups are left behind, particularly those who are most disadvantaged (18). Consequently, achieving UHC is set within a broader policy context of redressing the structural inequities that define the social hierarchy and determine differential health needs, resources, and capabilities for navigating the health system (19). Therefore, we argue that SDH are central to both the pursuit of healthy lives and the provision of health services for all, and should be expressly incorporated into the framework of UHC.
Why should UHC be the umbrella goal for health post-2015?
Advocates convincingly argue that UHC is the only proposal with a vision of universal rights and equity that encompasses the whole health system (4, 5). As an umbrella health goal in the post-2015 global agenda, UHC recognizes the intrinsic contribution of the health sector to sustainable development through the equitable provision of quality, affordable health services to address population health needs, thus contributing to healthy lives and overall well-being (4). Sustaining this commitment to universal coverage requires that countries implement strong health systems (20). This means investing in all the building blocks of health system development: delivery of effective, safe, quality personal and non-personal health services, with appropriate medical products, vaccines, and other technologies; adequate and fair health financing; a well-performing and motivated health workforce; health information systems, leadership, and governance (21). Since UHC is unequivocally located in the context of action on SDH, it requires a health system that envisions health as a social production, capable of engaging with other sectors in integrated multisectoral interventions. Accordingly, UHC embraces this integrated systems perspective, sustained by a responsive, adequately-resourced and well-governed health system, providing comprehensive, affordable services and catalyzing pro-health policies in other sectors (6).
The recently published WHO/WB proposal for monitoring UHC (Box 1) affirms that multisectoral influences on health are important, but specifically does not address how to link monitoring of UHC progress with monitoring of social determinants of health and sustainable development (9). This task is left to others. As it stands, not including these important linkages to health outcomes (healthy living) or wider determinants of well-being as a vital part of UHC monitoring, suggests that UHC is viewed as a sub-goal, rather than an umbrella goal. Yet, not locating UHC in the context of action on SDH increases the risk of going down a narrow route to realizing the right to health as limited to coverage of services and financial protection. It cannot be forgotten that social protection, employment, and early care, among other SDH, are crucial to ensuring health lives and overall well-being, as well as the equitable distribution of health services.
In order to incorporate the monitoring of SDH within a UHC monitoring framework, Marmot (6) has proposed two steps:
The first is to disaggregate all of the UHC measurements by socioeconomic position, such as income, education, sex, geographic area, and other relevant health equity measures. Doing so would bring to light how unfair the distributions of health status and health care are for different social groups across the social gradient.
The second is to monitor the distribution of key SDH indicators, recommending four indicators that measure important aspects of development over the life course: (a) early child development at age 5; (b) the proportion of youth not employed, in school, or in training; (c) adults in poverty; and, (d) social isolation and poverty among the elderly.
The WHO equity monitoring for UHC group has recently proposed to include SDH and equity-based monitoring targets within the framework for measuring progress towards UHC in two ways (22): (a) by stratifying the core set of health outcome and health coverage measurements by relevant markers of equity and socioeconomic position, starting with income quintiles and urban-rural differences; and (b) by including indicators from other sectors to monitor the equitable distribution of key SDH with direct impact on health. Both of these aspects are important for population health and will help influence other sectors and contribute to increased multisector actions. The WHO equity group´s proposal encompasses Marmot´s general indications to set out specific recommendations for incorporating equity and SDH in UHC monitoring (Table 1).
Importance of multiple stratifiers and a gradient approach
In introducing an equity lens in the monitoring of advances towards UHC, two considerations are important. First, inequality due to socioeconomic position, caused by social stratification, is a multidimensional concept. Thus, monitoring only one dimension of social inequality does not accurately represent the full extent of social stratification within a given context. For example, income-related inequality, the most frequently used measure of socioeconomic position inequality, shows varying correlations with education-related, gender-related, and urban/rural-related inequalities across health indicators. (23, 24).
Second, inequality is about more than simply focusing on the situation of the poorest or most vulnerable groups. Hence, centering an "equity" measure exclusively on the poorest income quintile or the lowest 40% of the population (as is currently proposed as a health target by WHO/WB) (9) does not take into account the differential situation or progression in the other 60% of the population. Focalization ignores the pattern of inequality across the social gradient, whose visualization provides fundamental information for designing interventions to increase health or service coverage and to reduce inequalities. Simple five-point graphs of the differences in outcomes or coverage by income or wealth quintiles can reveal the shape of the distribution, with three general inequality patterns referred to as "marginal exclusion" or a "bottom" pattern, a "linear" or "queuing" pattern, or a "top" or "mass deprivation" pattern (25, 26).
The top inequality pattern, common in lowcoverage countries, shows that the richest quintile is way ahead of the rest, reflecting a situation of mass deprivation (A in Figure 1). In this case universal strategies to reach all four lower quintiles are most cost-effective. Often as coverage increases, the pattern is linear with stepwise increments by quintile, requiring differential efforts across the gradient (B in Figure 1). As higher levels of coverage are reached for most of the population, a bottom inequality pattern of marginal exclusion often emerges, where the poor lag behind other groups (C in Figure 1). In this case, a targeted approach focusing on the poor is the most cost-effective approach to implement (26).
We believe that UHC should be the umbrella health goal in the post-2015 sustainable development agenda. This assumes universal and equitable effective delivery of comprehensive health services by a strong health system, as well as policies and services addressing the wider SDH, aligning multiple sectors around the shared goal of better health. The monitoring framework for measuring progress towards UHC, proposed by WHO and the WB discussion groups, is critical work that will shape the concept, scope, targets, and metrics of this goal. Importantly, it introduces an equity lens. However, we argue that the scope of this equity lens must be magnified to mirror the social gradient and the complexity of social stratification by expanding the disaggregation of measures by different measures of socioeconomic position. In addition, the framework must be completed by connecting health indicators, both outcomes and coverage, with SDH and policies that impact on health, both within and outside of the health sector.
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Manuscript received on 18 December 2013.
Revised version accepted for publication on 31 December 2013.