doctors for health equity - World Medical Association

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doctors for health equity - World Medical Association
UCLINSTITUTEOFHEALTHEQUITY
DOCTORSFORHEALTHEQUITY
THEROLEOFTHEWORLDMEDICALASSOCIATION,NATIONALMEDICALASSOCIATIONS
ANDDOCTORSINADDRESSINGTHESOCIALDETERMINANTSOFHEALTHANDHEALTH
EQUITY
REPORTRATIONALE
Acrosstheworld,people’shealthisshapedbytheconditionsinwhichtheyareborn,grow,live,work
andage–andtheinequitiesinpower,moneyandresourcesthatgiverisetotheseconditions[1].
These‘socialdeterminantsofhealth’influencethelengthandqualityofpeoples’lives,andcreate
clear inequalities in health outcomes between countries as well as within countries. Most of the
systematicdifferencesinhealthandlifeexpectancybetweenpopulationsacrosstheworldariseasa
resultofdifferencesintheconditionsinwhichpeopleareborn,grow,liveworkandage.Theselevels
ofhealthinequalityareunnecessaryandavoidableandreducingthemisamatterofsocialjustice.
Healthisprofoundlyshapedbyfactorsoutsidethehealthcaresectorandreducinghealthinequality
requirestheinvolvementofsectorsoutsidehealthcareisessential.Buttherearealsosignificantand
importantactionsthathealthprofessionalscantaketohelpimprovetheconditionsinwhichpeople
live.
Thisreportexploresevidenceandcasestudiestohighlightthewaysinwhichdoctors,nationalmedical
associations(NMAs)andtheWorldMedicalAssociation(WMA)canactonthesocialdeterminantsof
healthandimprovehealthequity.Theseactionsrangefromhighleveladvocacyandadvice,shaping
policiesatlocal,national,regionalandinternationallevel,partneringandcollaboratingwithsectors
outsidehealthandthroughdoctor’sindividualinteractionswithpatientsduringclinicalencounters.
ThereportexplicitlysetsoutastrategyforWMAandNMAsandprovidespracticalapproachesfor
medicalprofessionalsandtheirassociationstoincorporatethesocialdeterminantsofhealthintheir
everydaypracticeandbroadersocietalroles.
Effectivechangerequiresasystemwide,multilevelapproach.Thecontext,organisationandstructure
ofcountriesandhealthbodieswillempowerorlimitwhatcanbedoneindifferentsettings.Actions
bymedicalprofessionalsandmedicalassociationsareconstrainedbynationalandglobaleconomic
factors,andpoliticalwill.
ThisreporttakesthesameviewastheWHOEuropeanReviewofSocialDeterminantsofHealth:do
something,domore,dobetter.
Ifcountrieshaveverylittleinplaceintermsofpoliciesonsocialdeterminantsofhealth,thecapacity
ofhealthprofessionalsandassociationstoaffectsystematicchangeislimited,buteffectiveactioncan
stillbetaken–dosomething
Wheretherearesomeexistingpolicies,thisreviewshowshowdoctorscanworktowardsoradvocate
formoreimprovementstoreducewideandpersistenthealthinequities–domore.
In countries that have a track record of acting on the social determinants of health and acting to
improve health equity, there is still much scope to do better on these inequities and doctors can
influence,andinsomecasesleadthis–dobetter.
Followingtheintroduction,thereportisstructuredtofollowtheareasforaction:
1. EducationandTraining
2. Buildingtheevidence:monitoringandevaluation
3. Theclinicalsetting:workingwithindividualsandcommunities
2
4. Healthsystemroles:asemployers,managersandcommissioners
5. partnerships:withinthehealthsectorandbeyond
6. Advocatingforchange:forthepatient,communityandhealthsystem
3
TABLEOFCONTENTS
INTRODUCTION..............................................................................................................................6
GLOBALHEALTHINEQUITIES.................................................................................................................6
REGIONALDIFFERENCES...............................................................................................................................6
WITHINCOUNTRYINEQUITIES.......................................................................................................................6
THESOCIALDETERMINANTSOFHEALTH...................................................................................................9
LIFECOURSEINASOCIALDETERMINANTSAPPROACH.......................................................................................11
WIDERSOCIETY........................................................................................................................................11
MACRO-LEVELCONTEXT.............................................................................................................................12
SYSTEMS.................................................................................................................................................12
SOCIALDETERMINANTSOFHEALTHANDTHEWMA................................................................................13
CURRENTGUIDELINESFORHEALTHPROFESSIONALSONTHESOCIALDETERMINANTSOFHEALTH.........................14
1.UNDERSTANDINGTHEISSUEANDWHATTODOABOUTIT:EDUCATIONANDTRAINING..........16
INCORPORATINGTHESOCIALDETERMINANTSOFHEALTHINTOTHEEDUCATIONCURRICULUM..........................16
CRITERIAFORADMISSION..........................................................................................................................16
COMPETENCIES........................................................................................................................................18
CHANNELS...............................................................................................................................................21
CAREERPATHWAYS...................................................................................................................................22
2.BUILDINGTHEEVIDENCE:MONITORINGANDEVALUATION.....................................................25
NATIONALLEVEL..............................................................................................................................26
LOCALLEVEL....................................................................................................................................26
USINGTECHNOLOGY..........................................................................................................................28
3. THECLINICALSETTING:WORKINGWITHINDIVIDUALSANDCOMMUNITIES..........................31
CONSULTATIONS..............................................................................................................................31
CONSULTATIONTIMES...............................................................................................................................31
CONSULTATIONFORMAT...........................................................................................................................32
INTERVENTIONS................................................................................................................................33
SOCIALHISTORY.......................................................................................................................................33
WORKINGWITHPATIENTS..........................................................................................................................35
CAREPLANNING.......................................................................................................................................35
SOCIALPRESCRIBING.................................................................................................................................36
DOCTORSANDTHECOMMUNITY..........................................................................................................38
WORKINGWITHINDIGENOUSCOMMUNITIESTOIMPROVEHEALTHOUTCOMES...................................................38
SYSTEMSWHICHSUPPORTDOCTORSTOTAKEACTIONONSDH..................................................................41
4.ASANEMPLOYER,MANAGERANDCOMMISSIONER................................................................44
THEHEALTHCAREWORKFORCEANDTHESOCIALDETERMINANTSOFHEALTH..................................................44
ASEMPLOYERS.........................................................................................................................................44
ASMANAGERS.........................................................................................................................................46
ASCOMMISSIONERS..................................................................................................................................47
4
5.WORKINGINPARTNERSHIP:WITHINTHEHEALTHSECTORANDBEYOND.................................51
PARTNERSHIPSOUTSIDETHEHEALTHSECTOR..........................................................................................51
WORKINGWITHCOMMUNITIES..................................................................................................................53
COMMUNITYLEADERS/FAITHLEADERS.........................................................................................................54
PARTNERSHIPSWITHCHARITYSECTOR..........................................................................................................55
NATIONALPARTNERSHIPS..........................................................................................................................56
INTERNATIONALPARTNERSHIPS...................................................................................................................58
6.ASADVOCATES.........................................................................................................................60
ADVOCATINGFORINDIVIDUALSANDCOMMUNITIES.................................................................................60
ADVOCATINGFORTHEWORKINGCONDITIONSOFDOCTORS,ANDOTHERHEALTHSTAFF...................................61
MEDICALPROFESSIONASADVOCATES..................................................................................................62
WMAASADVOCATES...............................................................................................................................62
MEDICALASSOCIATIONSASADVOCATES........................................................................................................62
DOCTORSASADVOCATESFORPOLICYCHANGE...............................................................................................63
STUDENTSASADVOCATES..........................................................................................................................63
CONCLUSION................................................................................................................................66
REFERENCES....................................................................................................................................67
5
INTRODUCTION
GLOBALHEALTHINEQUITIES
Thereisaglobaltrendofincreasedlifeexpectancy.Between1990and2013globallifeexpectancy
increasedbysevenyearsfrom64to71years.In2013lifeexpectancywas68yearsformenand73
yearsforwomen(worldhealthstatistics).Thesegainswereseenacrosscountriesindifferentincome
groups, and are largest in low-income countries. [2] Despite these overall improvements, large
differencesinlifeexpectancyandhealthoutcomescanstillbeseenwithinandbetweencountries.
The gaps in health are not only about poor health in the poorest countries and good health for
everyoneelse.Thereareclear,persistentandsystematicdifferencesinhealthbetweensocialgroups
inallcountries,low-middle-andhighincome.Nomatterwhereintheworld,theloweranindividual’s
socio-economicpositionthehighertheriskofpoorhealthandgreaterthelikelihoodofpremature
death. To illustrate this we have looked at life expectancy or mortality rates, between and within
countries.
REGIONALDIFFERENCES
In2013,theregionoftheAmericashadthehighestlifeexpectancyat77,theEuropeanRegion,and
Western Pacific Region followed with a life expectancy of 76, followed by Eastern Mediterranean
RegionandSouth-EastAsiaRegion68.Africahasanaveragelifeexpectancyof58withmanycountries
withinAfricahavinglifeexpectanciesinthe50s.[2]
WITHINCOUNTRYINEQUITIES
Forallcountriesforwhichdataexistthereisagradientinhealthaccordingtosocioeconomicstatus
(SES):healthoutcomesworsenwithgreaterlevelsofsocialdisadvantageasmeasuredby,forexample,
income, education, social position and employment. [3] Fig. 3 illustrates this by comparing the
gradientinself-reportedhealthbyincomeinLatviaandSweden.
6
FIGURE1:PERCENTAGEREPORTINGTHEIRHEALTHASBEING“GOOD”OR“VERYGOOD”BY
HOUSEHOLDINCOMEQUINTILE,LATVIAANDSWEDEN,2011
Source: Emese Mayhew, Jonathan Bradshaw, University of York, United Kingdom, personal
communication,2012(fromEuropeanReview).
ForEnglandasawhole,theaveragelifeexpectancyatbirthin2011-13was79.4formalesand83.1
forfemales.Thisaverage,however,canhidevastdifferencesinlifeexpectancybetweenindividuals,
as shown in figures 2 and 3. When neighbourhood deprivation is looked at the median level of
inequalityacrossalllocalauthoritiesinEnglandwas7.9yearsformalesand5.9yearsforfemales.The
gapbetweenneighbourhoodsisevenlargerwhenhealthylifeexpectancy(thenumberofyearsan
individualcanexpecttospendinverygoodorgoodgeneralhealth)isexamined.In2011-13healthy
lifeexpectancyformalesinBlackpool,themostdeprivedareabasedonthe2015classification,was
54.9whileitwas71.4inWokingham(classifiedastheleastdeprived)–a16.5yeardifference.For
femalestherespectivefigureswere58.3and69.9–an11.6yeardifference.InEngland,peoplefrom
more deprived areas do not only die sooner, but they spend longer of their shorter lives with
disabilities.[4]
7
FIGURE2:MALELIFEEXPECTANCYANDDISABILITYFREELIFEEXPECTANCY(DFLE)ATBIRTH
IN1999-2003AND2009-13BYNEIGHBOURHOODDEPRIVATION
FIGURE3:FEMALELIFEEXPECTANCYANDDISABILITYFREELIFEEXPECTANCY(DFLE)ATBIRTH
IN1999-2003AND2009-13BYNEIGHBOURHOODDEPRIVATION
Source:MarmotIndicators2015[4]
8
Lifeexpectancybysocioeconomicstatusisnotregularlymeasuredforallcountries;however,dataon
thesocialgradientinunder-fivemortalitycanbefound.Inlowandmiddle-incomecountriesaclear
gradientcanbeseeninunder-fivemortality,asshowninthefigure3below.
FIGURE 3: UNDER FIVE MORTALITY BY WEALTH QUINTILE IN UGANDA, INDIA,
TURKMENISTAN,BANGLADESHANDPERUATVARIOUSDATES
Source:DHS[5]
THESOCIALDETERMINANTSOFHEALTH
Healthinequalitiesarecausedbyindividuals’exposuretohealthdamaging(andhealth-promoting)
conditionsthataccumulatethroughouttheirlife.Theseconditionsareinfluencedbythecontextin
which those individuals live, including the macro level context (global, socioeconomic and political
context);widersociety(cohesionandresilienceincommunities,atthelocalandnationallevel)and
thesystemsandinstitutionsthatinteractwithindividualsandsocietysuchasthehealthcaresystem,
educationandjudicialsystem.[6]Exposuretothesehealth-damaging(andhealth-promoting)effects
aredeterminedbyanindividual’ssocialpositionssuchastheireducation,occupation,income,and
influencedbyothercharacteristicssuchasgenderandethnicity.Forexample,inNewYorkCity,USA
therateofprematuredeath(under70)is50%higheramongblackmenthanamongwhitemen.[7]
Figure4belowoutlinesthebroadmechanismsthatimpactonindividual’shealth.
9
FIGURE 4: CONCEPTUAL FRAMEWORK FOR THE SOCIAL DETERMINANTS OF HEALTH, BASED
ONTHEHEALTHDIVIDE
Source:WHOEuropeanReviewofSocialDeterminantsofHealth[8]
The WHO Commission on the social determinants of health highlighted the following key areas to
tacklingtheSDH:
•
•
•
•
earlychilddevelopment;
education;
workandlivingconditions;and
thestructuralcausesoftheselivingandworkingconditions.
ThethreeprinciplesofactionhighlightedtotackletheSDHwere:
•
improvetheconditionsofdailylife;
10
•
•
tackletheinequitabledistributionofpowerand
expandtheknowledgebasethroughmeasurementandevaluation.
Twin high priorities for societies generally and in particular health professionals, health systems,
governmentsandcivicsocietyshouldbetoimproveaveragehealthofthepopulationandtoreduce
healthinequities.Todothiseffectivelyitisessentialtobringthehealthofless-advantagedpeople
closertowardsthelevelofthemost-advantagedbytacklingtherootcausesofinequalities.Thesocial
determinants of health approach looks beyond provision of health care to a wide range of social,
economic, political and cultural factors that influence people’s exposure to health-damaging or
health-promotingconditionsateachstageofanindividual’slife.[3]ByapplyingtheSDHapproach,
healthcarecouldbedeliveredinawaythatmoreeffectivelytacklesinequalitiesinhealth.
Whiletheroleofhealthprofessionalsandhealthsystemshastraditionallybeenseenasinfluencing
individualsandthehealthcaresystem,agrowingbodyofevidencesuggeststhathealthprofessionals,
andthehealthcaresystemhavetheleversandinfluencetoimprovehealthforthewholepopulation.
ThisreportdrawsontheconceptualmodelsintheCommissionontheSocialDeterminantsofHealth
[3]andtheReviewofSocialDeterminantsandtheHealthDivideintheWHOEuropeanRegion,[8]as
outlinedinfigure4above.
LIFECOURSEINASOCIALDETERMINANTSAPPROACH
Thelifecourseperspectivelooksatpeople’slivesandthestructuralcontextinwhichtheyliveover
thecourseoftheirlife.[9]Theseeventscanhavepositiveornegativeeffectsonanindividual’shealth
andwellbeing.Theseeffectsaccumulatethroughoutanindividual’slife,beginningatgestationand
early years’ development, through educational experiences, reproductive ages and relationship
building, to the labour market and income generation during normal working ages, and into later
years. Many of these advantages and disadvantages are transmitted across generations from
grandparentsandparentstochildren–‘intergenerationaltransmission’ofinequalities.Thelife-course
perspectiveshouldbeusedtounderstandthecontextofpatients’livesandemergesasaneffective
waytoplanpartnershipsandactiononsocialdeterminantsofhealthateverystageoflife.
WIDERSOCIETY
Atthesocietallevel,actionsthatgeneratesocietalcohesionandmutualresponsibilitywillhavethe
greatestimpactonhealthequity.Thisincludesinfluencingsocietalnormsandfiscalpoliciessuchas
socialprotection,toensureitisdistributedaccordingtoneed.Evensmallimprovementsinlegislated
socialrightsandsocialspendingareassociatedwithimprovedhealth.[8]
Culturalandsocietalnormscanaffecthealthbyinfluencingtrustandcooperationinsociety,thelevels
oftrustandsupportinsociety,or‘socialcapital’isassociatedwithhealthinequalitiesasitisassociated
withtotalmortalityandmortalityrelatedtocoronaryheartdisease.[10]Thelowerpeopleareonthe
socioeconomic gradient, the more likely they are to live in areas of deprivation and have reduced
access to social capital. Many vulnerable groups face exclusion and discrimination in society for
exampleEurope’sRomafacepowerfulsocial,economic,politicalandculturalexclusionaryprocesses,
including prejudice and discrimination, which adversely affects their human rights and selfdetermination.[11]Theinfluenceofwidersocietypointsfortheneedforjointactionateverylevelas
11
well as the need to advocate for vulnerable groups who face exclusion. The large effect of wider
societyonanindividualpatient’shealth,pointstotheneedforthehealthsystemtoworkcloselywith
communities,organisationsandcharitiesthatcaninfluencethis.
MACRO-LEVELCONTEXT
Global and national forces such as global economics, the nature of trade, aid, international
agreements and environmental policies all play an integral role in individuals’ exposure to health
damaging (and health-promoting) conditions. They affect individuals’ and communities’
vulnerabilities(andresilience).Factorsaffectinghealthandhealthinequalityareoftentheverysame
factorsdeterminingforexampleenvironmentalquality.Thepoorestarethemostlikelytoexperience
harmfrompoorenvironmentalconditionsandthustobenefitfrominterventionsthatcreateahealthy
environmentandmoreequitablehealthcaresystem.Thereisaneedtointegratehealthwithother
social and environmental policies. Health inequality should be integrated with other societal and
environmentalpolicies.Thispointstotheneedfordoctorsandmedicalassociationstobeawareof
thismacro-levelcontextandtobeempoweredtoadvocateonbehalfofcommunitiesandindividuals
whosehealthisnegativelyaffectedbythis.Forexample,thenegativehealtheffectsofclimatechange
onindividualsinpoorercountries.[12]
SYSTEMS
Thehealthsystemandhealthprofessionalsdealwithmanyhealthoutcomeswhicharetheresultof
actions in other sectors including national governments; multinational organisations; foundations;
civilsocietyandnongovernmentalorganisations;academicinstitutionsandcorporations.Coherence
ofactionisneededacrossthesesectorstoeffectivelytacklethesocialdeterminantsofhealthand
reducethedistributionsofhealthinequities.ThishasledsomecountriessuchasFinlandtoadopta
HealthinallPoliciesApproach(HiAP),[13]whichissupportedbytheWHO.[14]Thisstrategyshould
includeastrongfocusonhealthequity,andmanyhavesuggestedthatHealthEquityinAllPolicies
shouldbeadopted.[15]
Thesesystemsthemselvesshouldbedesignedandgovernedtoreducethesocialgradientinhealth
inequalitybyfollowingtheprincipleofproportionateuniversalism.Ofteneffortstoimprovehealth
equityfocusonlyonthemostexcluded,whohavetheworsthealth;however,thismeansonlyasmall
proportionofthosesufferingunfairhealthinequitieswillbenefit.Theclearsocialgradientinhealth
in countries across the world, for a range of health outcomes, show that health inequities affect
everyonetosomedegree,exceptthoseattheverytop.Soeffortstoimprovehealthequityneedto
focusonliftingandflatteningthegradient.Thisrequireseffortproportionatetoneedacrossthewhole
socialclassgradient.Effortneedstobeuniversal,forthewholepopulation,butproportionatetoneed.
For doctors and health systems, this suggests that health services should be designed around the
conceptofproportionateuniversalism.
12
SOCIALDETERMINANTSOFHEALTHANDTHEWMA
Despitethefactthathealthprofessionalsarewitnessestoinequalitiesandseetheoutcomesona
dailybasis,theirpotentialimpactandthatofthehealthcaresystem,toreducehealthinequalities
throughactiononthesocialdeterminantsofhealth,isoftenunder-developed.TheWorldMedical
Association(WMA)isanindependentconfederationof111nationalmedicalassociationsalloverthe
world.Astheonlyorganisationrepresentingthevoiceofthemedicalprofessionglobally,itplaysa
keyroleinsettingstandardsandadvocatingfordoctors,medicalstudentsandforahealthysocietyin
general. At the World Health Assembly in May 2009 the WMA, on behalf of the World Health
ProfessionsAlliance(WHPA)presentedastatementwelcomingtheWHOCommissionontheSocial
DeterminantsofHealthreportforitsholisticapproachtohealthcarebutcalledintoquestionthelack
of emphasis on the role of health professionals in tackling health inequalities. [16] At the WMA
GeneralAssemblyinDelhi,2009,theWMAformallyrecognisedtheimportanceofSDH[17]andmade
thefollowingrecommendations:
•
•
•
•
•
Recognisetheimportanceofhealthinequalityandtheneedtoinfluencenationalpolicyand
actionforitspreventionandreduction
Identifythesocialandculturalriskfactorstowhichpatientsandfamiliesareexposedandto
planclinicalactivities(diagnosticandtreatment)tocountertheirconsequences.
Advocatefortheabolishmentoffinancialbarrierstoobtainingneededmedicalcare.
Advocateforequalaccessforalltohealthcareservicesirrespectiveofgeographic,social,age,
gender,religious,ethnicandeconomicdifferencesorsexualorientation.
Requiretheinclusionofhealthinequalitystudies(includingthescope,severity,causes,health,
economicandsocialimplications)aswellastheprovisionofculturalcompetencetools,atall
levels of academic medical training, including further training for those already in clinical
practice.
This commitment was reinforced at the 2011 WMA General Assembly. [18] The role of doctors as
informedparticipantsinthedebateandadvocatesforactionwerestated.TheWMAdefineditsrole:
•
•
•
•
•
Understandwhattheemergingevidenceshowsandwhatworks,indifferentcircumstances.
To help doctors to lobby more effectively within their countries and across international
borders,andensurethatmedicalknowledgeandskillsareshared.
Gather data of examples that are working, and help to engage doctors and other health
professionalsintryingnewandinnovativesolutions.
Workwithnationalassociationstoeducateandinformtheirmembersandputpressureon
nationalgovernmentstotaketheappropriatestepstotrytominimisetheserootcausesof
prematureillhealth.
TheWMAshouldgatherexamplesofgoodpracticefromitsmembersandpromotefurther
workinthisarea.
At the WMA Council meeting in 2015 it was agreed to formally adopt a declaration on the social
determinants of health. The Declaration of Oslo was given general support by General Medical
AssemblyinMoscowin2015[19].Thisreportaimstousethebestevidencetodevelopthisagenda
and support the 2015 declaration. A number of NMAs around the world are enthusiastic about
13
workingonSDHandthisreportprovidesevidenceandexamplesofwhatdoctorscandotoeffectively
tacklingtheSDH.
CURRENT GUIDELINES FOR HEALTH PROFESSIONALS ON THE SOCIAL DETERMINANTS OF
HEALTH
WhiletheprimaryfocusforaddressingthesocialdeterminantsofhealthbytheWMAhasbeenon
fosteringandsupportingnationalpolicychangesbygovernmentpoliciesandsociety,thereisgrowing
recognitionoftheneedtoalsotargetthe“livedexperienceofinequalities"p967)[20]inhealthcare
settings.[21]
Forexample,achildwithasthmathatislivinginadamphomerequiresremedialactiononthecauses
of the poor health - the damp home. Doctors may advocate for that patient and request that the
appropriatehousingisfoundorimprovementstothehomemade.Adoctorcouldalsoadvocatewith
housingprovidersandcommissioners,aboutthelikelihoodthatdamphousingwillleadtomorecases
of asthma in the community, draining healthcare resources, impacting on the child’s education,
wellbeingandactivitylevels.
However,clearguidanceonhowdoctorscaninfluenceandimprovethesocialdeterminantshasbeen
minimal.AforthcomingreviewofrecommendationsinternationallyfordoctorstotackletheSDH[22]
demonstrated that only 13% of all recommendations were ‘downstream’, or actions that could be
takenatthelocallevel,andmanyprovidedlimitedpracticalguidanceforadoptingpractices.Ofthese
only14werepublishedbynationalmedicalassociationsandcolleges,mostlyindevelopedcountries,
namelyAustralia,CanadaandtheUK.Guidanceonwhathealthprofessionalscandoinresourcepoor
settingshasbeenlacking.
This report builds on the Institute of Health Equity’s Working for Health Equity report [23] which
included commitments to action from a number health professional bodies in England.
Recommendationsfocusedonsixcoreareas:
•
•
•
•
•
•
Workforceeducationandtraining
Workingwithindividualsandcommunities
HealthServiceorganisations-asmanagers,employersandcommissioners
Workinginpartnership
Workforceasadvocates
Thehealthsystem-challengesandopportunities
Twenty-onehealthprofessionalorganisationsintheUKparticipatedinthereportincludingmidwives,
paramedics, dieticians, physiotherapists and speech and language therapists. Each organisation
providedstatementsaboutactionsthathealthprofessionalscouldtakeintheirpractitionerrole,and
providedaseriesofcommitmentsforfuturework.Sincethen,numerouspositiveactionshavebeen
takenbyarangeofprofessionals.ForexampletheRoyalCollegeofPhysiciansofLondonpublished
thereporttheFutureHospitalCommission,[24]advocatingforaholistic,patient-centredapproach
tocare,withspecificattentiongiventosomeofthemostmarginalisedpatientgroups.Throughthe
Future Hospital Programme, they are supporting more joined-up ways of working across the local
health and social care economy, including doctors working out in the community. They are also
developingane-learningmoduleontheroleofphysiciansintacklinghealthinequality,whichthey
14
aimtohaveaccreditedforcontinuousprofessionaldevelopment(CPD)(REF-toolwhenonline).The
Royal College of GPs produced the Social Inclusion Commissioning Guide with the University of
Birmingham.[25] They are reviewing clinical cases in the MRCGP exam (the examination to ensure
corecompetenciestobeamemberoftheRCGPandrecognisedasreadyforindependentpractice)
fromatacklinghealthinequalitiesperspective.Theyhavepublishedaclinicalhandbookonworking
withvulnerablepatientsforthoseundergoingGPtraining.
Healthprofessionalsandmedicalassociationsarealreadyinvolvedinarangeofinspiringandpositive
actions.Thisreportaimstohighlightwhatishappeninginternationally,andsetoutastrategyforthe
WMA,NMAsandmedicalprofessionalstobetterincorporatethesocialdeterminantsofhealthinto
theirwork.Thesestrategiesarecategorisedaccordingtothefollowingsections.
1.
2.
3.
4.
EducationandTraining
Buildingtheevidence:monitoringandevaluation
Theclinicalsetting:workingwithindividualsandcommunities
Health system roles: as employers, managers and commissioners partnerships: Within the
healthsectorandbeyond
5. Advocatingforchange:forthepatient,communityandhealthsystem
15
1. UNDERSTANDING THE ISSUE AND WHAT TO DO ABOUT IT: EDUCATION AND
TRAINING
In many countries the education of health professionals does not include a focus on the social
determinants of health – the real drivers of poor health and inequity. Whilst professionals are
comfortablewithinterventionsaroundindividuallevelfactorsthataffecthealth,traininginbroader
communityandsociallevelsaregenerallylacking,leadingtoprofessionalsfeelinglesscomfortable
withthislevelofintervention.[26]Thishasledsomenationalmedicalassociations(NMAs)tocallfor
this to be included in the curriculum for health professionals. For example, the Australian MA
encourages medical colleges and professional societies to increase their members’ awareness of
health inequities in general, and of potential bias in medical treatment decisions. [27] This report
showswaysofbolsteringeducationaroundtheseissues,toimproveunderstandingamonghealth
professionalsandtoleadtogreaterembeddingofappropriatepracticesandadvocacyroles.
INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO THE EDUCATION
CURRICULUM
Oneofthepurposesoftheeducationofdoctors,atbothundergraduateandpostgraduatetraining,
shouldbetoenhancetheperformanceofhealthsystemstomeettheneedsofpeopleandpopulations
in an efficient and equitable manner. In order for medical professionals to improve the social
determinantsofhealth,andachievesuccessinreducinghealthinequalities,therighteducationand
training is essential. The Commission on the Education of Health Professionals categorised the
challengestohealthprofessionaleducationaccordingtothefourCs [28,29].Thesecategoriesare
usefultoexplorehowthesocialdeterminantsofhealthcanbebetterintegratedintotheeducation
ofdoctors.
•
•
•
•
Criteriaforadmission:Professionalstudentsaredisproportionatelyadmittedfromthehigher
socialclassesanddominantethnicgroups.Effortsshouldincludeupstreamcriteriasuchas
socialequityinadmissionsandscholarshipsfordisadvantagedstudents
Competencies: Students should be trained on competencies that tackle the social
determinantsofhealthsuchascommunication,partnershipandadvocacyskills.
Channels:Effortsshouldbemadetomobilisealllearningchannelstotheirfullpotentiale.g.
lectures, small student learning groups, team-based education, early patient or population
exposure, different worksite training bases, longitudinal relationship with patients and
communities,andIT.
Career pathways: While not every professional graduate needs to be a social reformer,
artificialbarriersshouldnotbeconstructedtoblockthesocialagencyofprofessionals.“Health
professionsshouldbeexposedtothehumanities,ethics,socialsciences,andnotionsofsocial
justicetoperformasprofessionalsandtojoininpublicreasoningasinformedcitizens.”p.1946
[28]
CRITERIAFORADMISSION
Asdiscussed,accesstothemedicalprofessionbyminoritiesandpeoplefromlowersocio-economic
groupsisagrowingconcerninmanycountries.Forexample,intheUK,only6.3%ofmedicalstudents
16
studyingin2013grewupinthemostdeprivedareasoftheUK,[30]and20%ofsecondaryschools
provide 80% of applicants to medicine. [31] Individuals from lower socioeconomic groups are less
likelytoapplyandhaveloweracceptanceratesduetoanumberofdisincentivessuchasthecostof
training.[32]Only4%ofU.S.doctorsareblack,comparedwith13%ofthepopulation,andthenumber
ofblackmedicalschoolgraduateshasnotincreasednoticeablyinthepastdecade.[33]
Improvingaccesstothemedicalprofessioncanimpactonsocialdeterminantsofhealthbyincreasing
employmentopportunitiesforpeoplefromlowersocioeconomicgroups,asdescribedinsection4.
Thereisalsoevidencethatpeoplefrommoredeprivedareasaremorelikelytoworkindeprivedareas
[34]anditcreatesamoreculturallycompetentworkforcecapableoftreatingadiversesociety[35].
TheAustralianMAencouragesthoseinvolvedinmedicaleducationtodevelopandimplementpolicies
thatsupporttheentryandcompletionofmedicalstudiesbystudentsfromdisadvantagedgroups.
[27]IntheUK,theMedicalSchoolsCouncil(representingundergraduatemedicalschoolsintheUK)
producedanumberofguidelinestowidenparticipationandaccesstomedicaleducationforpeople
fromlowersocioeconomicgroups,[31]withaseriesoften-yeartargetstomonitorprogress.These
recommendationsinclude:
theexpansionofoutreachactivity;
theprovisionofmoreworkexperienceforstudentsfromdisadvantagedbackgroundsinthe
healthsystemand;
theuseofmore‘contextualised’admissionprocesses.
•
•
•
Anumberofuniversitiesareworkingtowardsimplementingthis,suchastheUniversityofGlasgow,
asoutlinedbelow.
CASESTUDY:WIDENINGOPPORTUNITIESFORALLTOSTUDYMEDICINEUNIVERSITYOF
GLASGOW[36]
TheUniversityofGlasgowhasseenasubstantialincreaseintheaveragenumberofentrantstoits
MedicalSchoolfromthe40%mostdeprivedareasfromanannualaverageof10.6studentsin200911to19.6studentsbetween2012and2014.Thiswasachievedthroughanumberofactivities:
•
•
•
•
•
•
•
•
ReachProgramme:anationalprojecttoraiseawarenessofandencourage,supportand
preparesecondaryschoolstudentswishingtopursueprofessionaldegrees.
applyingcontextualinformationinconsideringapplicantsandadoptingrelatedflexibility,
which allows many candidates to progress to interview, who would otherwise not have
reachedthisstage,
applyingabroaddefinitionofworkexperiencetoallowforallapplicantstobeconsidered,
irrespectiveofabilitytoobtaindirectexperienceinthehealthsector,
considering applicants flexibly under ‘extenuating circumstances’ and accepts students
fromthisprocessonanannualbasis,
involving a significant number of student ambassadors in recruitment and admissions
activitytorepresentthediversitywithinthestudentbody,
not issuing interviewers with application forms, to minimise preconception from the
process,
forgingcloseworkingrelationshipsintheUniversityandexternally,
implementing a Certificate of Higher Education (Pre-med, Pre-dent) for government
sponsoredinternationalstudents,tofurtherincreasetheopportunityforstudentdiversity.
17
Giventheshortagesofhealthcareprofessionalsinlowerandmiddleincomecountries(LMICs),as
discussedinSection4,manyLMICcountriesaredevelopingeducationprogrammestotrainhealth
professionals. For example the Rwandan Ministry of Health has developed Human Resources for
Health,along-termstrategyandimplementationplantoincreasethequantityofhealthprofessionals
inthecountry,aswellasthequalityanddiversityoftheirtraining.[37]Zambiahasdevelopedaoneyearcommunityhealthworkercourseforindividualsandlocalcommunitieswiththehopethatmany
willprogresstohigherpositionsinthehealthprofessionsuchasnurses(seecasestudyinsection4).
Cuba has developed an innovative medical school for individuals from LMIC countries, discussed
below.
CASESTUDY:CUBA:ESCUELALATINOAMERICANADEMEDICINA(ELAM)(LATIN
AMERICANSCHOOLOFMEDICINE)[38]
ELAMwasestablishedin1999,toprovidemedicaleducationtoindividualsfromLMICs,andin2013
it was the largest medical school in the world, enrolling approximately 19,550 students on full
scholarships from 110 countries. It is officially recognised by the Educational Commission for
Foreign Medical Graduates (ECFMG) and the World Health Organization. While initially only
studentsfromLatinAmericaandtheCaribbeancouldenrol,itisnowopentocandidatesfromlow
incomeormedicallyunderservedareasinAfrica,AsiaandtheUnitedStatesi.
Preference is given to applicants who are from lower socio-economic groups and/or people of
colourwhoshowthemostcommitmenttoworkingintheirdisadvantagedcommunities-80%of
graduatesendupworkinginpoorruralcommunities.
The full scholarship includes medical education in general medicine, all doctors interested in
specialising must first serve two years working in primary care, and graduating doctors are not
driventospecialisebysalaryincentives.[39]Thescholarshipalsoincludesfulltuition,dormitory
housing,threemealsperdayatthecampuscafeteria,textbooksinSpanishforallcourses,school
uniform,basictoiletries,beddingandasmallmonthlystipend.
Today,CubasendsmoredoctorstoassistindevelopingcountriesthantheentireG8combined,
accordingtoRobertHuish,aninternationaldevelopmentprofessoratDalhousieUniversitywhohas
studiedELAMforeightyears.[40]
COMPETENCIES
‘Competencies’referstothedevelopmentofpracticalskills.Fortheeducationofhealthprofessionals
toaddresshealthinequality,itneedstogobeyondatheoreticalunderstandingofthenatureofthe
social determinants of health, to include non-medical practical competencies that can reduce
inequalitythroughactiononthesocialdeterminants.Theseskillscouldincludetakingsocialhistories,
communicating in an advocacy role, working in effective partnerships, and commissioning services
equitably.Thesectiononworkingwithindividualsandcommunitiesgoesintomoredetailabouthow
toharnesstheseskillstoreduceinequalities.TheRoyalCollegeofPhysiciansofLondonhavestated
thattrainingonthesocialdeterminantsofhealthneedstobeembeddedasaverticalthreadatevery
18
stageoftheeducationcurriculumandtraining.[23]Examplesofhowthiscanbedoneareoutlined
below.
UNDERGRADUATEANDPOSTGRADUATE
Education on the social determinants of health should be a mandatory core element of all
undergraduate courses. [23] This should include identifying the inequitable impacts of social
determinantsonhealthoutcomesseeninpatients,understandinginequalitiesinpopulationhealth,
reflecting on the impact at individual, family and community levels. The curriculum should include
evidenceonwhatworksinpracticeandprovidespecificstepsthatcanbetaken.TheRoyalCollegeof
Physicians (London) suggests that strong and active role models are needed in training, not only
medicalpractitionersbutfromothersectorssuchassocialworkers;thirdsectorworkersandchildcare
specialists.[41]Maryon-Davis(2011)suggeststhatrotationsincommunity-basedspecialties,suchas
general practice, community paediatrics and public health should be considered and that shared
learning programmes and placements between clinical specialities and public health could be
productive.[42]TheRoyalCollegeofPhysiciansrecommendedthatanelementofprimarycareand
/orpublichealthshouldbeincludedinthefoundationtrainingofalljuniordoctorstoallowthemto
workmoredirectlywithhealthinequalitiesissues.
AcommunityhealthcentreservingaLatinoimmigrantpopulation,PuentesdeSalud,Philadelphia,
USA, introduced a service-learning course, called the Health Scholars Program (HSP). It includes
didacticinstruction,serviceexperiencesandopportunitiesforcriticalreflection.TheHSPcurriculum
alsoincludesalongitudinalprojectwherestudentsdevelop,implement,andevaluateanintervention
to address a community-defined need. Medical students who had completed the course stated a
perceptionoflearningmoreaboutthistopicintheHSPthanintheirformalmedicaltrainingandoften
along-termdesiretoservevulnerablecommunitiesasaresult.[43]O’Brienandcolleaguespointto
the need to develop and monitor community level outcomes. Medical schools should develop a
coherent strategy to teach the social determinants of health, exploring both didactic teaching
elements,andotherchannelssuchascommunityservices,althoughthisshouldincorporatetheneed
todefineandmonitorcommunityleveloutcomes.Anumberofcasestudiesofuniversitiesthathave
incorporatedthesocialdeterminantsofhealthintotheireducationareincludedbelow.
CASESTUDY:UCLMEDICALSCHOOLSOCIALDETERMINANTSOFHEALTHMODULE[44]
TheSocialDeterminantsofHealthModuleinUCLaimstoeducateundergraduatemedicalstudents
aboutthesocialdeterminantsofhealthandtrainthemtointegrateandapplythisknowledgeto
every clinical problem and each individual patient they encounter during their studies and
throughouttheirmedicalcareers.Thisisincorporatedthroughouttheirundergraduateeducation
asdescribedbelow:
Year1:focusontheoryandevidenceregardingtheeffectsofthesocialdeterminantsofoneveryday
medicalpractice,andvariationincausationandoutcomesofillhealth-locallyandglobally.Linked
tocommunityandGPplacementsandcommunityvisitors.
Year2:Focus on doctor-patient communication, health promotion, and individual experience of
health and healthcare. Linked to community visitors, disability workshops and community/GP
placements.
19
Year4:Focusonaccessandequityinhealthcare;diseaseprevention,screeninghealthpromotion
and-populationandindividualperspectives–especiallyvulnerablepeople.
Year5:Focusonpublichealthdimensionsofhorizontalmodules(communicablediseases,drugs
and alcohol, and mental health); health systems case studies - local, national and global and
transnationalthreatstohealth.IntroducingtheElectivesGlobalhealthportfolio.
Year6:CompletionofGlobalHealthandElectivesPortfolio
This is achieved through a combination of lectures, workshops, GP placements and community
visitorsandassessedthroughexamquestions,reflectivereportsandaspartofanonlineportfolio.
CASESTUDIES:UNIVERSITIESINCORPORATINGTHESOCIALDETERMINANTSOFHEALTH
INMEDICALTRAINING:
LeedsSchoolofMedicine;intheUKhaveincorporatedthesocialdeterminantsofhealthandhealth
inequalitiesintotheirteaching.[45]Thisincludes:
•
•
•
•
Emphasisestheimportanceofcommunicatingeffectivelyandworkinginpartnershipwith
patients,carersandtheirfamilymembers.
Patients and carers are involved in the teaching of students through the Patient Carer
CommunitybasedattheUniversity
Firstandsecondyearmedicalstudentsarrangeacommunityvisittoavoluntarygroupto
allowthemtothinkmoreholisticallyandlearnoftheimportanceofthevoluntarysectoras
potentialpartnersinhealthcaredelivery.
Apodcastforstudentsonpovertyandthesocialdeterminantsofhealth
Centre on Social Disparities in Health at the University of California, San Francisco, School of
Medicine(UCSF)[46]
•
•
SecondyearstudentsarerequiredtotakethecourseDeterminantsofHealth.
Studentshaveanimmersionexperiencewithacommunityserviceorganisationandreflect
onhowtheirpersonalassumptionsaboutmarginalisedracialandsocioeconomicgroups
mightshapetheirpracticeofmedicine.
UniversityofPennsylvaniaPerelmanSchoolofMedicine[46]
•
•
Trainee physicians work in multidisciplinary research teams which include economists,
sociologists,anthropologists,nurses,businessfaculty,andphysicianswhoworktogetherin
thelocalcommunitytounderstandthesocialdeterminantsofhealth
Pilot projects are hosted on an ongoing basis to help patients maintain health after a
hospitalisation by connecting them with community resources. For example, medical
studentsusedapeer-mentoringmodeltohelpblackmenmanagetheirdiabetesleadingto
substantialimprovementinthemen’sdiabetescare.
UniversityofNewMexicoHealthSciencesCentreandNewMexicoStatehavedevelopedtheHealth
ExtensionRuralOffices(HEROs)program,[46]which
20
•
•
•
Has12healthextensionagentstoidentifypriorityareasinspecificcommunities(suchas
schoolretention,foodinsecurityandlocaleconomicdevelopment),andlinktheneedswith
universityresourcesineducation,clinicalcareandresearch.
Establishedapipelineprogrammeformedicalstudentstotribalareas
Healthextensionagentstrainedcommunityhealthworkerswhicharenowinone-thirdof
NewMexicocounties,andHEROsplanstotrainmore.
Culturally Competent in Medical Education (C2ME) project includes 11 medical schools in the
EuropeanUnion.TheC2MEprojecthasdefinedasetofknowledgeandskills(e.g.,basicknowledge
ofethnicandsocialdeterminantsofhealth;skillstoteachinanon-judgmentalway;andskillsto
engage,motivate,andencourageparticipationofallstudents)thatallteachersneedinorderto
incorporateculturalcompetencetopicsintotheirteaching[47]
CONTINUALPROFESSIONALDEVELOPMENT
ContinualProfessionalDevelopment(CPD)shouldbe“flexible,practicebasedandworkbased”.(p.56
[23]).Itshouldbefree,universallyavailableandhaveincentivesforprofessionalstotakepart.The
provisionshouldbeabroadassessmentofsocialandeconomicconditionsthataffecthealth,andon
strategiesandsuccessfulpracticeswithintheprofessiontoreduceinequalities.Typicalopportunities
includecertificatedmodulesinpublichealth,anMScinpublichealth-relatedsubjects,work-based
learningnetworksandstructuredseminars,workshopsandconferences.Medicalassociationsoften
provideCPDforpublichealthprofessionalsandthereisroomforthemtodevelopCPDonHIandSDH.
E-LEARNINGONTHESOCIALDETERMINANTSOFHEALTH:ROYALCOLLEGEOF
PHYSICIANS,ANDTHEROYALCOLLEGEOFMIDWIVES,UK:(REFWHENAVAILABLE)
The Institute of Health Equity is working with both the RCP and the RCM to develop an online
learning tool on the social determinants of health that will be CPD certified. This course will
interactive and include key information and skills that will help physicians to tackle the social
determinantsofhealthintheireverydayworklife.
CHANNELS
Channelsaredefinedinthisreportasallofthelearningchannelsthatcanbeusedtoeffectivelyteach
health professionals about the social determinants of health in an equitable way and to reach
populationsandgroupswhodonothavephysicalorfinancialaccesstomajoreducationcentres.This
canincludedifferentworksitetrainingbases,longitudinalrelationshipwithpatientsandcommunities,
reflective learning and online courses. Experiential training is important and placements with
communitygroups,charitiesandsocialcarenetworksallowstudentstoseehowavarietyofsocial
situationsaffectthehealthofthepeoplelivingwithinthem,enablingstudentstodevelopasenseof
socialresponsibility.[48][49]TheUniversityofHongKongispilotinga‘servicelearning’programme
inpartnershipwithlocalNGOswithtargetingpopulationsthataresociallydisadvantaged.Students
will work on site in both medical-related and non-medical work. [50] Using the SDH approach can
21
informhowthesechannelscanbeutilizedtoeffectivelytacklehealthinequality.Twosuchexamples
areoutlinedbelow.
CASESTUDY:KATHMANDUMEDICALCOLLEGE,NEPAL:COMMUNITYDIAGNOSIS
PROGRAMME[51]
TheCommunitydiagnosisprogramme(CDP)isacommunityorientedapproachtotheeducationof
doctors,nursesanddentists.Secondyearmedicalstudentsvisitanearbycommunitywithanumber
ofobjectives,includingtheidentificationofthevarioussocio-cultural,economicandenvironmental
factorsthatunderliethehealthproblemsinthecommunityandtofindsolutionstothem.Areview
oftheprogrammeinGunduVillage,Bhaktapur,Nepal,demonstratesthatstudentsbenefitfrom
theintegratedtraininginclinicalskillsandpublichealthinreal-lifesituations,aswellasgaininga
deeperunderstandingoftheproblemsfacingcommunities.Thecommunityalsobenefitedwithan
increased awareness of health-related matters and evidence of behavioural changes towards
healthierlifestyles.
CASESTUDY:WHOE-BOOK[52]
WHO eBook on integrating a Social Determinants of Health Approach into Health Workforce
EducationandTraining;theeBookwillprovideaframeworkthatarticulatesanddemonstratesthe
relevance of the social determinants of health approach to transformative health workforce
educationandtraining.
Itaimstodrawtogetherthebestglobalresourcesonsocialdeterminantsofhealthillustrateswith
casesstudiesdrawnfromaroundtheworldandisdesignedtobeusedonmultipleplatforms
CAREERPATHWAYS
Theeducationofmedicalprofessionalsneedstogobeyondtheacquisitionofknowledgeandskillsto
include the development of professional attributes such as behaviour, identity and values. This
professionalismshouldpromotequality,teamwork,haveastrongfoundationinethicsandbecentred
on the interests of patients and populations. [28] A rights based approach to health has been
promotedasameansofeducatingprofessionalsonequitablepoliciesandprogrammes.[53]
MedicalstudentsoftenenterthemedicalprofessionwithapassiontotackletheSDHandmobiliseto
tackle health inequality, such as the International Federation Of Medical Students Associations
(IFMSA)‘whitecoatdieins’aroundtheUSAtoprotesthealthinequalityofBlackpeopleintheUnited
States[54].Moregenerally,IFMSAhavedevelopedaGlobalHealthEquityInitiative,seethecasestudy
below.Thisinterestisnotdrivenordevelopedbytheircorecurriculum,butbynon-taughtactivities.
Students should be given the opportunity to develop this interest and necessary skills within their
professional training and NMAs should work with student groups that are mobilised to tackle the
socialdeterminantsofhealth.Someoftheseinitiativesareoutlinedbelow.
THEINTERNATIONALFEDERATIONOFMEDICALSTUDENTSASSOCIATIONS(IFMSA)
GLOBALHEALTHEQUITYINITIATIVE[55]
22
TheIFMSAGlobalHealthEquityInitiativewasestablishedtoprovide:
•InstitutionalvoiceforglobalhealthequitywithinIFMSA
•Accessibleinformation,capacity-buildingtools,andtechnicalguidanceonglobalhealthequityfor
IFMSAmembers
•ADynamicforumforexchangeanddialogue
•AKeyplatformforadvocacyandcampaignforglobalhealthequitywithintheFederationandto
thelargerglobalhealtharena
AUSTRALIANMEDICALSTUDENTSASSOCIATIONCAMPAIGNTOINFLUENCEAUSTRALIAN
MEDICALSCHOOLS:[56]
The Australian Medical Students Association campaigned for medical schools to adopt medical
curriculathatwereadaptedtolocalcontexts,andequipallstudentswiththeskillstodealwith
healthinequities.Thiswouldrequiregraduatestodemonstrate:
•
•
•
•
Asocialaccountabilitytothelocalandglobalcommunitiestheyserve;
Asoundknowledgeofthesocialdeterminantsofgoodhealthandofhealthinequities;
The ability to place individual patient care within the context of globally integrated
systems;
Skillsforpatientandglobalhealthadvocacysuchas:leadership,policyanalysisandsocial
changetheory.
23
WHATTHEWMACANDO
The WMA has no direct influence on the education of medical professionals at any level
(undergraduate, postgraduate). However, as the only organisation representing the voice of the
medical profession globally it has a large influence on gathering consensus of best practice in the
medicalprofession.
•
•
•
•
•
issueadeclarationontheneedformandatorycoreelementsofSDHineducation
promotethatdeclarationinternationallyandtoitsmembership
workwithstudentgroupsandeducationalbodiestoissueastatementoncoreknowledgeand
skillsthatshouldbetaughtaroundthesocialdeterminantsofhealth,
learnfromlowandmiddle-incomecountries,andfromstudentsandjuniordoctorswhohave
ahugewealthofexperienceaboutwhatneedstobedone.
develope-learningmaterials,thiswillbepartofablendedlearningapproachthatinvolves
meetingsandworkshopsandwillbedevelopedovertime.WearealsodevelopingaMOOC
to bring the online discussion to wider audience, conduct workshops (potentially regional
clusters)forallNMAstosendcandidates.
WHATNMASCANDO
NMAs’powertoinfluencetheundergraduateandpostgraduatecurriculumisalsolimited,butthey
couldstillinfluenceeducationatanumberoflevels.Forexample,theycould:
•
•
•
ReviewtheexistingarrangementsthatmedicalschoolshaveontheSDHandworknationally
toinfluencethecurriculaby:
o pressingthoseregulatingmedicaleducationtoincludesocialdeterminantsasacore
elementofthecurriculum
o liaisingwithandencouragingmedicalschoolstoembedagreaterunderstandingof
theSDHandskillstrainingthroughoutundergraduateandpostgraduatetraining
o ensurethateducationprovidersarecompetentandcapableineducatingontheSDH
o advocating that specific skills training to work with individuals and communities is
incorporatedintoeducation,includingculturalsensitivitytraining
Work with student groups and young professionals to empower them to advocate for the
teachingofthesocialdeterminantsofhealthtobeincludedattheiruniversities
Produce training materials for professional development, and encourage members to
participateintraining.
WHATDOCTORSCANDO
•
•
•
•
Educatethemselvesandcolleaguesonwhatthesocialdeterminantsofhealthare,andthe
necessaryskillstotacklethem
PromoteandadvocatefortheSDHapproachbeincludedineducationtraining
AsmanagersandteachersensurethatSDHisarequiredcomponentofprogression,including
specificskillssuchasculturalcompetencies;takingsocialhistories;motivationalinterviewing
HealthProfession:AdvocateforagreaterfocusontheSDHinpracticeandeducationforall
healthprofessionals
24
2.BUILDINGTHEEVIDENCE:MONITORINGANDEVALUATION
“To Make People Count, We First Need To Be Able To Count People.” — Dr Lee Jong-Wook,
FormerDirector-GeneralWHO[57]
Healthinequalitymonitoringistheprocessoftrackingthehealthofapopulationaccordingtokey
socioeconomicvariablesandisanimportanttooltoprovideinformationforpolicies,programmesand
practicestoreducehealthinequality.Whileevidenceshowsthesocialdeterminantsofhealthtohave
ahugeinfluenceonthehealthofpopulations,inmanysettingsstandarddatacollectionoftenfailsto
take the social determinants into account. By failing to capture this information, an accurate
understandingoftheimpactofkeyhealthdeterminantsovertimeisnotpossible,norisaninformed
appraisaloflikelyimpactofpoliciesandprogrammesonthesocialdeterminantspossible.Thisalso
meansthathealthprofessionalswillnotbeabletoaccuratelyservetheircommunitiesbasedontheir
needs.
Thereisalsoaneedtoevaluateinterventionstolearnandsharebestpracticeatthelocal,national
andinternationallevel.Thiswillhelptobuildmomentumforchange.HealthprofessionalsandNMAs
could be key players in achieving this by advocating for national monitoring systems. At a recent
symposiumontheroleofhealthprofessionalsintacklinghealthinequality[58],theimportanceof
datacollectionwasraisedbymanyprofessionalsasavitalcomponenttounderstandwhatworksin
differentcontexts.ItisthereforeakeyaspectofwhattheWMA,NMAanddoctorscandotodevelop
theagendaonthesocialdeterminantsofhealth.Bestpracticeinformation-sharingonhowtotackle
the social determinants of health should be encouraged and centralised at the national and
internationallevel,andshouldbeakeycomponentoftheWMA,NMAsandofindividualdoctors.Data
collectionshoulddirectlyinformplanningattheindividual,communityandnationallevel.Strategies
tocollectinformationshouldfeedintopersonalisedpatientcare,programmedesign,commissioning
andpolicydecisions.TheRobertWoodJohnsonFoundation[59]suggeststhatevidencecollection
should:
1. buildasharedvalueofhealththatincorporatestheroleofsocialcohesionsothatindividuals
feelasenseofcommunityandtheroleofcollectiveaction
2. foster collaboration to improve well-being across sectors (e.g. hospitals, other healthcare
institutionsschools,government,businessandcommunitybased-organisations)
3. createhealthierandmoreequitablecommunityenvironmentsbybuildingasciencearound
thepoliciesandpracticesthatmeasurablyreducehealthinequalities
4. transformhealthandhealthcaresystems
Monitoring and evaluation should happen both at the national and local level. SDH should inform
monitoringintwoways.Firstly,thereisaneedtoevaluatesocialinterventionsmoreaccuratelyto
ensurethattheseprogrammesareaccuratelyandeffectivelydesignedtoreducehealthinequality.
SDH should also be used as indicators in health services to monitor at risk populations. At the
individuallevel,anexamplecanbefoundinSection3,workingwithindividuals,wherewediscussthe
OntarioCollegeofFamilyPhysicians’PrimaryCareInterventionsinPoverty.[60]Thisprovidesatool
forphysicianstomonitorforpovertybutimportantlythiswaslinkedwiththeactionofsignposting
patientstoappropriateservicesandensuringthattheyreceivedallthebenefitstowhichtheywere
entitled.
25
NATIONALLEVEL
Tounderstandhealthinequalitiesataregionalandnationallevel,thereisaneedtohaveaccurate
monitoringsystemsinplace.Thesesystemsshouldincorporatehealthoutcomessuchaslife
expectancyandmorbiditywithwidersocialleveldatathatareknowntoimpactonhealthe.g.
housingsituation,employment,education,ethnicity,socialprotection.Thesenationalleveldatacan
helppractitionerstoprioritiseactionwhereneedisgreatestandtoevaluatethesuccessoftheir
strategies.
SDHINDICATORSINENGLAND
In England, the UCL Institute of Health Equity produce SDH indicators in England for every local
authority.TheygiveapictureofhowEnglandisdoingoverallforeachindicatorandhoweachlocal
authorityisdoinginrelationtotheEnglandandregionalaverages.Thisidentifiesgoodpractice,
outliers and changes over time. [61] The Public Health Outcomes Framework has also been
developedbyPublicHealthEngland,anditprovidesamoregeneraloverviewofpublichealthat
thenationalandlocallevel,andhassomespecificindicatorstomeasurethewiderdeterminantsof
health.[62]Thesecouldbeutilisedbyhealthprofessionalsforadvocacypurposes.
Incountrieswhereaccesstohealthservicesarehigh,suchservicesprovideanidealplacetomonitor
health determinants in a country, as can be seen in the example below of a GP survey in the
Netherlands.
DUTCHNATIONALSURVEYOFGENERALPRACTICE(DNSGP)[63]
TheDutchMinistryofHealthhaveconductedaseriesofNationalSurveysofGeneralPractice
(DNSGP1andDNSGP-2)tomonitorpublichealthandhealthinequalitiesintheNetherlands
throughgeneralpractice.IntheDutchhealthcaresystemalmostallDutchresidentsare
registeredwithaGP,whicharebasedincommunitiesandtheaccessibilityofgeneralpracticeis
consideredgood.Thedataincludebackgroundinformationonpatientscollectedviaacensus,
approximately12000healthinterviewsurveyspertimepointandmorethanonemillion
recordedcontactsofpatientswiththeirGPsinbothyears.Theresultsclearlyshowedthatwhile
loweducationalattainmentplayednopartinpresentinghealthproblemstotheGPinthe
Netherlands,itwasassociatedwiththedevelopmentofchronicconditionsandself-reportsof
goodhealth.Thiswasparticularlyevidentfordiabetesandmyocardialinfarction.
LOCALLEVEL
Many health services and doctors regularly engage with social interventions that could positively
impactontheSDH.However,theseinterventionsarerarelymonitoredandevaluated.Forexample,a
reviewintheUKofsocialprescribing(asdiscussedinsection3)foundthat60%oftheprogrammes
includedinthisreviewhadnotbeensubjecttoanyformalmeansofassessment.[64]Therearemany
advantages to setting up SDH based interventions with methods of evaluation in place from the
beginning,tocomparebaselinemeasure.However,thereisnouniversalevaluationmethodologythat
should be applied as the extent of this evaluation should depend on a number of factors such as
budget,expectationsoffundersandavailableresourcesaswellassuitableoutcomemeasuresand
needsofparticipants.Anexampleofawellevaluatedinterventionisoutlinedbelow
26
WELLLONDON:ACLUSTER-RANDOMISED-TRIALANDLONGITUDINALQUALITATIVE
EVALUATION[65,66]
WellLondonisamulticomponentcommunity-engagementprogrammepromotinghealthyeating,
physicalactivityandmentalwell-beingindeprivedneighbourhoodsinLondon.
Toevaluateoutcomesoftheinterventions,aclusterrandomisedtrial(CRT)wasconductedthat
includedalongitudinalqualitativecomponent.Theevaluationconsideredimpactatseverallevels:
individual'participant'level,projectlevel,programmelevel,communitylevelandwhole
populationwidelevel.Inthefirstphaseoftheprogrammeincluded14interrelatedprojectsin20
neighbourhoodsusingacoproductionapproach.Theprogrammesfocusedonphysicalactivity,
healthyeating,mentalwellbeing,localenvironments,andartsandculture,aimedtobuild
communitycapacityandcohesion.Phasetwoexpandedtheprojectintoafurthernine
neighbourhoods.
Theprimaryobjectiveoutcomesoftheinterventionswerechangestohealthyeating,physical
activityandmentalwell-being.Theseweremeasuredbyindividualseatingfiveportionsof
fruit/vegetablesaday,physicalactivitywasmeasuredbyindividualsdoingfive30-minute
moderate-levelphysicalactivitiesaweekandmentalwellbeingwasmeasuredusingtheGHQ-12
andWEMWBS.
TheCRTcomparedthe20targetedneighbourhoodswith20matchedcontrolsiteswhichdidnot
receiveanyinterventions,beyondroutinepublichealthinterventions.Individualswererandomly
selected(approximately100ineachneighbourhood)andsurveyedbeforeandafterthe
interventionacrossallsitesgivingasampleofaround4000.Qualitativeinterviewsandan
environmentalauditwerealsoconductedtocaptureneighbourhoodcharacteristicsand
qualitativeinformation.
Whiletherewasnostatisticalsignificantdifferencesintheprimarymeasuresofoutcomes,two
secondaryoutcomesweresignificant;theinterventiongroupatemorehealthilyandthoughtthat
peoplepulledtogethermoretoimprovethelocalarea,comparedwithcontrols.Lowparticipation
andpopulationchurnwerehighlightedaspotentialissuesthatmayhavecompromisedimpact.
Qualitativeanalysishighlightedsomekeycharacteristicsthatmodulatedanybenefits.Hoghest
levelsofchangewerefoundinthepresenceof:
•
•
•
socialcohesion,(pre-existingandcohesionfacilitatedbyWellLondonactivities);
personalandcollectiveagency;
involvementandsupportofexternalorganisations.
Inplaceswherethephysicalandsocialenvironmentremainedunchanged,therewasless
participationandfewerbenefits.
Akeylessonforthestudywasthelimitationofusingareabasedcensusdefinedneighbourhoods,
asopposedtonaturalcommunitiesassitesforintervention.Duringphasetwoofthisprojectthis
lessonwasemployedforfuturesites.Phase2isalsoexploringhowtheseinterventionscanbe
scaleduptoasystemwidehealthcareintervention.
At the hospital level, data collection of social determinants of health, enables hospitals to focus
resourceswheretheyareneeded,asoutlinedinthecasestudybelow.
27
CASESTUDY:BAYLORHEALTHCARESYSTEM,DALLAS,TEXAS,USA
BaylorHealthCareSystem(BHCS)isanintegratedhealthcaresystemwhichincludes26hospitals,
morethan100ambulatoryfacilitiesandmorethan4,500affiliatedphysiciansthatservenorthern
Texas.In2006,BHCSestablishedtheOfficeofHealthEquity(OHE)withthepurposeofreducing
variationinhealthcareaccess,caredelivery,andhealthoutcomesdueto:
•
•
•
•
•
Raceandethnicity
Incomeandeducation(i.e.,socioeconomicstatus)
Age
Gender
Otherpersonalcharacteristics(e.g.,primarylanguageskills)
Since2009,patientshaveself-declaredtheirrace,ethnicity,andprimarylanguageatthepointof
service,andthedatahavebeenanalysedtoidentifydisparitiesincare.Theequitymeasuresare
aggregatedintoseveraldichotomousvariables:
•
•
•
Race:whitevs.non-white
Ethnicity:Hispanicvs.non-Hispanic
SES(socioeconomicstatus)proxy:commercially-insuredvs.self-pay/Medicaid
OHEidentifiesandtracksthesevariationsbyproducinganannual“BHCSHealthEquityPerformance
Analysis”(HEPA)thatreportsdataon:
Inpatientperformancemeasures:
•
•
•
•
•
Qualityofcaremeasures(JointCommissioncoremeasures)
Experienceofcaremeasures(patientexperience/satisfaction)
Outcomesmeasures(inpatientmortalityand30-dayreadmission)
Outpatientperformancemeasures:
Qualityofcaremeasures(diabetes,asthma,andchronicheartfailureprocessesofcare)
The annual HEPA report is used by the physicians’ quality improvement committee to focus
resourcesandeffortstoreduceobservedinequalitiesandimprovethequalityofcareamongthe
patientsandcommunitiesitserves.Thesedatabecameapowerfultoolforcreatingorganisational
prioritisationandimprovementmomentum.Theinformationallowedservicestobedesignedalong
theprinciplesofproportionateuniversalism,sothatservicescouldbetargetedproportionateto
theneedsofspecificgroups.
Forexampleapersistentinequalityindiabetescarewasfoundinthepercentageofnon-Hispanic
andHispanicpatientswithsuperiordiabetescontrol(HgbA1clevelslessthan7%),withHispanics
meetingthemanagementgoalsignificantlylessoftenthannon-Hispanics.Asaresult,asuccessful
pilot project, the Diabetes Equity Project (DEP) was launched. This provides diabetes selfmanagementeducationandpatientadvocacyforsomeofthearea’sunderservedpopulations.Early
resultshaveshownasignificantincreaseinthenumberofnon-whitepatientsattainingsuperior
diabetes control (HgbA1c<7%). Based on this, the project was scaled up to a further four
experiencinglowdiabetescaremanagementperformanceamongHispanicpatients.
USINGTECHNOLOGY
Thecurrentlandscapeondatacollectionischangingduetotechnologicaladvancesandthisisgrowing
inLMICs.Thereare5.3billionphonesubscribersworldwide,andmorethan330millionsubscribers
28
liveinsub-SaharanAfricaalone.[67]Althoughitisnotfullyunderstoodhowthiswillimpactonhealth,
it has the potential to help collect information and data, which can help shape policies and
interventionstoimprovetheSDHandmonitorthelikelyimpactofpoliciesonsocialdeterminants.For
example, it allows health workers on the ground to collect current information on previously
unrecordedpopulationsandshareitwithhealthcareproviders,policymakers,andthegeneralpublic.
[67]Thiscanbeusedtobuildrelationshipswiththelocalcommunityandinformactiononanumber
oflevels.Casestudiesdemonstratinginnovativewaysinwhichtechnologyisbeingusedtotacklethe
socialdeterminantsofhealthareoutlinedbelow.
CASESTUDY:ANAPPFORASTHMARESEARCH[68]
TheIcahnSchoolofMedicineatMountSinaihavecreatedtheAsthmaMobileHealthStudyAppto
create a personalised tool for patients to educate themselves and to self-monitor their asthma,
tracking individual symptom patterns, promotes positive behavioural changes and adherence to
treatmentplans.Thedatafromtheappisalsobeingusedtobetterunderstandtriggersforthe
disease and to design personalised treatment plans. This has the potential to tackle health
inequalityinanumberofways.Firstly,itcouldbeusedtoempowerpatientsandinformcareplans,
asdiscussedinSection3.Itcanalsobeusedtolookatthewiderdeterminantsoftheillness,which
couldbeusedtoadvocateforpolicychange.Ifhealthrecords,airqualityreports,housingquality
andinformationfromschoolswereaggregated,aclearerviewoftheproblemcouldbeunderstood
andwiderconditionswhichleadtoorworsenasthmacanbeimproved.Physiciansshouldlookat
researchandtreatmenttoolstoconsiderwhethertheinformationanddatetheyprovidecanbe
usedbeyondthetreatmentofindividuals,forbroaderpreventionworkatacommunitylevel.
29
WHATTHEWMACANDO
•
•
•
providetraininginmonitoringandevaluation
publishexamplesoftrainingprogrammes
connectpeopledesigninganddeliveringtraining,enablingthesharingofresources
WHATNMASCANDO
•
•
•
supportphysiciansonthegroundtomonitorandevaluateSDHinterventions
campaignforsocialdeterminantsdatatobecollectedthroughcensusandhouseholdsurveys
nationally
promoterecognitionoftheimportanceofmonitoringandevaluation,includingtonational
regionalandlocalgovernmentandotheragencies
WHATDOCTORSCANDO
•
•
•
•
expandsocialhistories,thiscanbeassimpleasaskingpatientsiftheyhadtroublemaking
endsmeetinthelastmonth,orcouldincludeadetailedsocialhistorytaking(annually)that
could be done by the doctor, support staff, or through IT systems. Where appropriate,
assessments should be followed by interventions (e.g. signposting individuals who have
troublepayingtheirbillstoappropriateadviceservices).
demandtraininginmonitoringandevaluationatalllevelsofmedicaltrainingincludingwithin
CPD
shareexperienceswithotherphysiciansandwithotherhealthcareprofessionals
considertheinformationobtainedformmonitoringsystemsincludingapps,inparticularfor
usefulnessbeyondthecareofindividualpatients
30
3. THECLINICALSETTING:WORKINGWITHINDIVIDUALSANDCOMMUNITIES
Theconsultationisoftenthefirstpointofcontactapatienthaswiththemedicalprofessionandits
aimistosupportandguideapatient’sjourneythroughthehealthcaresystem.Thepatient-physician
relationship(PPR)isattheheartofmedicalpractice,andisakeyareawherehealthprofessionalscan
tacklethesocialdeterminantsofhealth.Manydoctorsseeestablishingatrustingrelationshipwith
patientsisanaturalpartofdoctor’srole,andmanypatientshaveverygoodrelationshipswiththeir
doctors. The OECD captured patient’s perspective of their healthcare in up to 14 high-income
countries.[69]Itfoundthat87.1%ofpatientsreportthattheirregulardoctorspendsenoughtime
with them in the consultation, 89.3% believes that doctors gave them the opportunity to ask
questions;91.1%saytheirdoctorprovidedeasy-to-understandexplanationsand86.1%believethat
the doctor involved them in the decisions about their care and treatment. This report will outline
aspects of these successful relationships, and outline how they can be used to tackle the social
determinantsofhealth.
Itisdifficulttogeneraliseabouttherelationshipbetweenpatientsandphysicians,asitisdependent
onanumberoffactors,suchasthecontext,purposeandexpectationsofthepatientandphysician
whicharenoteasilyuniversalised.Studiesoneffectivebehaviourchangemethodologieshighlightthe
importanceofworkingcollaborativelywithpatientsandtoempowerhealthierlifestylechoicesand
collectively exploring the wider social determinants of health. [70] This has meant that in many
countries, the traditional paternalistic approach, where patients are seen as passive recipients of
medicalinformation,isbeingreplacedwithothermodelsthatviewthePPRasmoreequal.Recently,
research looks at how doctors can motivate patients, and utilise the individuals, families and
communitiesstrengths.Specificskillsandtacticsincludetakingextensivesocialhistories;motivational
interviewing;careplanningandsocialprescribing.
CONSULTATIONS
CONSULTATIONTIMES
Inorderforphysicianstodiscussandaddressthesocialfactorsaffectingthehealthoftheirpatients,
they need to spend adequate time with them. Wilson & Childs reviewed available literature and
determined that doctors with longer average consultation lengths prescribed less, incorporated
lifestyleactivitiesandpreventativeactivities,dealtwithmoreproblemsatonceandexchangedmore
information.Theysuggestedthatthismayexplainwhysomestudiesfoundlongerconsultationtimes
wererelatedtolowerconsultationrates,asthewiderdeterminantsofthepatients’healtharebeing
dealt with [71]. Howie et al. compared consultation length in Edinburgh, Scotland, and found that
independentofdoctorstyle,'long'consultations(10minutesorover)wereassociatedwiththedoctor:
dealingwithmoreofthepsychosocialproblemswhichhadbeenrecognizedandwererelevanttothe
patient's care; dealing with more of the long term health problems which had been recognized as
relevant;andcarryingoutmorehealthpromotionintheconsultation[72].InastudyintheUK,where
themedianconsultationtimeforthegroupstudiedwassixminutes,anincreaseofconsultationtimes
to10minuteswasassociatedwithanincreaseinrecordingofhealthpromotionactivitiesbygeneral
practitioners[73].
31
Manyhighincomecountrieshavemeanconsultationtimesfarabove10minutes,forexampleSweden
(21minutes)Switzerland(15.6minutes);Belgium(15minutes).[74]However,asdiscussedinsection
4, LMIC countries have fewer doctors and are often working in high-pressure environments and
thereforeareoftencharacterisedbyashortermeanconsultationtimeandlowerconsultationrates
ascanbeseenintheAsia/Pacificregion.[75]Withincountries,increasingsocioeconomicdeprivation
isassociatedwithshorterconsultations.[76]Thisisanaspectoftheinversecarelaw,whichstates
that the availability of good quality medical care is inversely proportional to its need. [77] In the
Netherlands,patientswithhighereducationhadonaveragelongerconsultationsthanthoselesswell
educated,andbothpatientandGPtalkmorewithpatientsbeingmoreinvolvedinthedecisionmaking
process[78]
CONSULTATIONFORMAT
Consultationscantakemanyforms,forinstancegroupconsultationsofmorethanonepatient;with
morethanoneclinician;overemailorSkype;orwithmoreflexiblelengthsofappointmentaccording
toapatient’sneeds[79].Whilechangestothestructureofconsultations,anduseoftechnologyare
interesting ways that health inequality can be tackled, this report will focus on changes to the
relationship with the patient, what doctors ask patients, how they motivate patients, plan their
treatments,andworkwithotherhealthcarestaffandthecommunity,astheseinterventionsarenot
costly,yetcanhavealargeimpactonindividualshealthoutcomesandreducehealthinequality.
Recently, research is demonstrating the benefits of moving towards a partnership approach to
consultationinawiderangeofsettingsfromacutementalhealthtomusculoskeletalsupportgroups
tohealthtrainersworkinginpulmonaryrehabilitation.AUKstudyfoundthatsuccessfulinterventions
havethefollowingincommon[79]:
•
•
•
•
valuing patient experience and new professional and non-professional roles as sources of
expertise;
havingaflexibleapproachtotheformatoftheconsultationaccordingtowhatismostuseful
tothepatient,notmostconvenienttotheinstitution
movingtheconversationtowardsafocusonpatients’goalsandoutcomesbycreatingcare
plansacrossanentirepathwayandasystemofreferraland
socialprescriptionincorporatingnonmedicalprovision.
In Bromley-by-Bow Centre, discussed in section 5 on partnerships, the majority of patient
consultations lead to social prescriptions, as they say this is essential to provide the best care for
patients.
Constraintstomovingtowardsthismodelincludeconsultationtimesasdiscussed,andsupportwithin
andwithoutthehealthcaresystem.
32
INTERVENTIONS
SOCIALHISTORY
Foraphysiciantobeabletoassistapatientwiththesocialandeconomicfactorsoftheirlifethatmay
beimpactingontheirhealth,itisessentialthattheyknowwhattheseare.Thesimplestwaytodothis
istoaskthepatient.Manyphysicianshavearguedthattakingacompletesocialhistoryisasimportant
astakingacompletemedicalhistory.
Behforouzetalrecommendamoreextensivesocialhistorythaniscommonlyused,thatincorporates
more detailed questions in six categories: individual characteristics, life circumstances, emotional
health, perceptions of health care, health related behaviours [80]. They recommend that this
informationisgatheredovertime,asarelationshipoftrustisbuiltupandthatthedoctorsownsocial
historyshouldalsobeexplored,asunexploredprejudiceswillinfluenceadoctor’sabilitytoobtainor
actonimportantinformation.Moscrop&MacPhersonsuggestthatrecordingpatientsincomeisa
usefuladditiontomedicalhistories[81].Blochandcolleagueshavedevelopedasimpletooltoallow
physicianstoscreenforpovertyandimportantlytointervenetoreducepoverty,DoctorsoftheWorld
takedetailedsocialhistoriesofpatientswhentheyworkwithmarginalisedindividualswhoarenot
accessinghealthservicesinanumberofcountriesinEurope,asoutlinedbelow.
CASESTUDY:POVERTYTOOL:ACLINICALTOOLFORPRIMARYCARE,ONTARIO
CANADA[60]
InOntario,CanadaaPovertyInterventionToolkithasbeendeveloped,andworkisunderwayto
developitfurther.Itprovidesthreesimplestepstotacklehealthinequality:
•
•
•
Screenforpoverty,
Adjustriskand
Intervene
1:Screenforpoverty
Inapilotstudyitwasdeterminedthatthequestion“Doyou(ever)havedifficultymakingendsmeet
at the end of the month?” was a good predictor of poverty (sensitivity 98%; specificity 60%)
especially when combined with two additional questions about food and housing security
(sensitivity64.3%;specificity94.4%;OR30.2).[82]85%oflow-incomerespondentsfeltthatpoverty
screening was important and 67% felt comfortable speaking to their family physician about
poverty.
2:AdjustRisk
This tool suggests that poverty should be considered in clinical decision making considering the
evidenceofthelinkbetweenpovertyandanumberofconditionsincluding:cardiovasculardisease,
diabetes, mental illness, some cancers (and cancer screening and mortality); having multiple
chronicconditions;infantmortalityandlowbirthweight.Theysuggest,forinstance,ifanotherwise
healthy 35 year old comes to your office, without risk factors for diabetes other than living in
poverty,youshouldconsiderorderingascreeningtestfordiabetes.
3:Intervene
33
The tool suggests poverty interventions available to physicians in the context of Canada. These
include ensuring that patients are receiving income benefits that they are entitled to and
signpostingthosetorelevantinformationandorganisationsthatcanhelpthemapplyforrelevant
benefitsandsupport.
ST.MICHAELSHOSPITAL,ONTARIOCANADA
Whenpatientsenterthehospital,thereisacomputerthatcollectssocio-demographicinformation
aboutthem,namely:
•
•
•
•
•
•
•
•
Language
Immigrationstatus
Race/ethnicity
Disabilities
Genderidentity
Sexualorientation
Income
Housing
Thehospitalemploysanumberofstaffthatsupportpatientswhoareflaggedasneedingsupport:
•
•
IncomeSecurityHealthPromoter(providesindividualincomeinterventions,educationand
advocacy)
Medical-legalPartnership(Individuallegalservices,healthprovidertraining,patientrights
educationandsystematicadvocacy)
CommunityEngagementSpecialist(Bringinginthecommunityvoice,andoutthehealthteamvoice,
andworksasanadvocate)
CASESTUDY:CONSULTATIONSWITHPATIENTS:
MEDECINSDUMONDE(MDM)(DOCTORSOFTHEWORLD)EUROPE:[83]
In 25 European cities MdM provide free consultations with vulnerable groups such as migrants
(regardlessoftheirlegalstatus),homelesspeopleandsexworkers.Theaimistoprovidemedical
andsocialwelfareadviceforpeoplewhohavefallenthroughthegapsandreintegratetheminto
themainstreamhealthcaresystem.Akeypartofthisistoprovidepatientswithinformationabout
theirrightsandhelpingthemtoexercisetheserights.Forexample,inMytilene,Greece,medical,
psychologicalandlegalassistanceisofferedtomigrantsarrivingontheislandbyboatandrequiring
internationalprotection.IntheUnitedKingdom,MdMrunsahealthcareandadviceclinicwhere
volunteers, doctors, nurses, support workers and social workers offer primary healthcare to
excludedgroups,especiallymigrantsandsexworkers.Alargepartofthecentre’sworkinvolves
helpingpatientstoregisterwithageneralpractitioner,theentrypointtothehealthcaresystem.In
theNetherlands,MdMoffersundocumentedmigrantsweeklyadviceclinicsinAmsterdamandThe
Hague. People are provided with information about their rights and directed towards health
34
professionals in the mainstream healthcare system, especially general practitioners, in order to
guaranteecontinuityofcare.
Manyofthepatientsattendingtheseclinicshaveanumberofbarriersinaccessingcare,basedon
theirsocialandeconomicposition.Forexample,91.3%ofallpatientsattendingtheseclinicswere
livingbelowthepovertyline.In2014,84.4%reportedhavinghadatleastoneviolentexperience
(e.g.hadlivedinacountryofwar,violencebypoliceorarmedforces,sexualassaultandrape).
55.3% of the pregnant women who attended consultations were living in an unstable housing
situation, and 30.3% of pregnant women said they had a poor level of moral support. Asking
patientsthesequestionsisroutinetoallconsultationsandallowstheteamtoacquireafullsocial
historyofthepatient,andallowsthemtosignpostpatientstoappropriateservices.Thisrequires
that a large amount of time is spent with the patients, usually up to an hour in the social
consultation(withanon-clinician,supportworker),thenonaverage45minuteswithaclinician.
The support worker and clinician work together to make referrals for wider support, e.g.
immigrationadvice,peersupportetc.[84]
WORKINGWITHPATIENTS
Manyofthekeyhealthbehaviourssignificanttothedevelopmentofchronicdiseasefollowthesocial
gradient: smoking, obesity, lack of physical activity and unhealthy nutrition. Prevention requires
interventionsfromarangeofactorsandshouldincludepartnershipbetweenthehealthservice,the
voluntary sector, local government, communities and individuals (as discussed in section 5).
Supportingpatientstochangebehavioursshouldthereforebeunderstoodinthebroadercontextof
theirlives.Patientswithchronicconditionsthatfailtofollowtreatmentscitelackofcapacity,skills
and knowledge as the main reasons for non-adherence. [85] Research demonstrates that when
patients’ psychological needs for autonomy, competence and understanding is supported by
healthcare practitioners they are more likely to choose to engage in treatment and demonstrate
betteroutcomesovertime.Healthprofessionalsshouldbetaughteffectivetechniquestomotivate
patientsandco-createcareplans.Itisimportanttoconsidertheseasakeyskillforphysiciansduring
their education or CPD. In the UK for example, the ‘making every contact count’ includes a
competence framework to train health professionals on individual behaviour change. [70] These
techniqueshavebeenshowntobemoreeffectivethantraditionalinformationsharing.[23]
CAREPLANNING
Careplanningcanhelptoprovideaframeworkforadifferenttypeofconsultationthatismoreequal.
Whilethemedicalprofessionalbringsprofessionalexpertise,clinicalexcellenceandsupport,patients
bringtheirownskillsandknowledgeabouttheirsocialsituation;lifestyle;strengthsandgoals.
Care planning (sometimes called pathway planning) is a process that involves assisting a patient
identify and compile their health and wellbeing goals; set achievable targets for progress towards
theseandputsinplacethesupportandresourcestogettherewhichofteninvolvesupportinthe
community. These resources could involve social prescribing, as discussed later, peer support, and
advocacy. Often this process is done in collaboration with the patient, however in some
circumstances,suchasinthecasestudybelow,thisisdoneprivatelybythepatientfirst,beforebeing
discussedwithhealthprofessionals.
35
TEAWA–ASELF-ASSESSMENTTOOLFORABORIGINALPEOPLESINNEWZEALAND[86]
The tool, Te Awa, is a self-assessment or analysis tool that is given to aboriginal individuals and
familiesinNewZealand.Itisa50-itemmeasurethatconsistsofsevensectionscoveringethnicity,
gender,howparticipantsfeelaboutwideraspectsoftheirlife,andthebarrierstoachievinghealth,
wellbeingandsuccess.Italsoaskshowsatisfiedtheyarewiththeskillstheyhaveinvariouspersonal
areas of their lives, and prioritise areas they would like to change or develop. These items
encompassalltheelementsofwellbeingandhealthidentifiedbyMaoripeople,andrecognisethe
interconnectedness of health, education, housing, justice, welfare, employment, and lifestyle as
elements of whanau (family) wellbeing. It allows these aspects to be measured, and offers selfdirectedactionswithaccompanyingtimelysupport.Ahealthserviceprovideralsoaddssupport,
alongsidereferralinformationbasedontheresponses.
Thetoolgivesindividualsandfamiliesanopportunitytoself-identifyareasofpriorityandcreates
buy-in to the change required for individuals and their whanau (extended family). Analysis
conductedbytheNationalHauoraCoalitionfoundthatthetoolallowsprogresstobemeasured
over time, and when combined for a population at the community level it can inform service
planninganddelivery.Forexampleifdietandnutritionisanareaofconcernforalargepercentage
of the community, wider scale interventions can be designed. Te Awa has been adopted by a
numberofagenciesthroughoutthecountryoverthepastseveralyears.
Integrating referrals, or social prescribing, with a care planning process gives clinicians an explicit
mandatetorefertoservicesoutsidethehealthserviceaprocessknownassocialprescribing.
SOCIALPRESCRIBING
Socialprescribingdescribestheprocessofidentifyingnon-clinicalneedsofpatientsthatimpacton
their health, and referring them to appropriate non-clinical support in the community with the
underlyingaimofimpactingonthewiderdeterminantsofhealth[87].Thesesocialpresritionscan
takemanyforms,suchas‘ArtsonPrescription’;‘BooksonPrescription’;‘EducationonPrescription’
and‘ExerciseonPrescription’.Somelesserknownmodelsinclude‘GreenGyms’andother‘Healthy
LivingInitiatives’;‘InformationPrescriptions’;‘SupportedReferral’;‘SocialEnterpriseSchemes’and
‘Time Banks’. [64] They can also directly impact on financial support for example, the poverty
interventiontooldemonstratedthatreferringpeopleindebt,todebtcounsellingservicesorvarious
othersupportservices.Toworkeffectivelyitshouldbeaclear,coherentandcollaborativeprocessin
whichhealthcarepractitionersworkwithpatientsandserviceuserstoselectandmakereferralsto
community-based services. Such schemes typically have dedicated staff such as community
developmentworkerswithlocalknowledgewhoarelinkedtoprimaryhealthcaresettings.Branding
andHousehighlightedthatpatientswiththefollowingcharacteristicsaremostlikelytobereferred
byphysicians:
•ahistoryofmentalhealthproblems
•frequentattendersofprimarycareservices
•twoormorelong-termconditions
•sociallyisolated
36
• untreatable or poorly understood long-term conditions such as irritable bowel syndrome and
chronicfatiguesyndrome
•notbenefitingfromclinicalmedicineanddrugtreatment.
Evidence suggests that social prescribing increases people’s confidence, provides opportunities to
buildsocialnetworks,increasesself-efficacyandcanincreasepeople’sengagementwithweightloss
and exercise programmes. [79] Programmes are more successful when they involve organisations
frombeyondthehealthservicesuchassocialenterprisesandvoluntaryorganisations.[79]Because
socialprescribingcanresultinpatientsusingarangeofservices,demonstratingimpactandvaluecan
bedifficult.Itisimportanttoensurethattherearesystemsinplacetocapturedataontheoutcomes
ofsocialprescribing.
ROTHERHAMSOCIALPRESCRIBING,SHEFFIELDHALLAMUNIVERSITY, UK[88][89]
TheRotherhamSocialPrescribingServicehelpspeoplewithlongtermhealthconditionstoaccess
awidevarietyofservicesandactivitiesprovidedbyvoluntaryorganisationsandcommunitygroups
inRotherham.GPsleadcasemanagementteamsandareresponsibleforidentifyingpatientswho
are eligible for the scheme. This model includes a Voluntary and Community Sector Advisors
(VCSAs)whoreceivereferralsfrom28GPpracticesinRotherham.Patients'progresstowardssocial
outcomesismeasuredthroughan'outcomesstar'styletooldevelopedspecificallyfortheservice.
Initial analysis of this data shows that patients are making positive progress: 78 per cent made
progressonatleastoneoutcomeaftersixmonths.Themostcommontypesofservicesthathave
beenaccessedare:communitybasedactivity;informationandadvice;befriendingandcommunity
transport.SixmonthsafterthereferralsystemwasinitiatedAccidentandEmergencyattendances
reducedby21percent;hospitaladmissionsreducedbyninepercent;outpatientappointments
reducedby29percent.Althoughitisnotpossibletodirectlyattributethischangetothesocial
prescribingintervention
TRAININGHEALTHCARESTAFFONINTIMATEPARTNERVIOLENCEINTHEDOMINICAN
REPUBLIC,THEROLEOFREFERRALS[90]
IntheResolutiononViolenceagainstWomenandGirls,theWMAdefinesviolenceagainstwomen
asahealthdeterminantthatdoctors,NMAsandtheWMAshouldbetacklingashealthservicesare
wellplacedforidentifyingwomenandofferingthemreferralorsupportserviceswhenpossible.
[91]Thisrequiresthatphysicianseducatethemselvesabouttheeffectsofviolence,andstrategies
forprevention,assessforriskduringconsultations,buildrelationshipsoftrustwithabusedwomen
andchildrenandsupportglobalandlocalaction.
IntheDominicanRepublic,Profamilia(anNGOwithsixreproductivehealthclinicsandamental
healthcentre)workswithhealthprovidersthathavebeensensitisedandtrainedtorecogniseand
respondtoviolence.
All clients, unless they refuse, are screened for IPV by a physician using a form, with questions
rangingfromemotionalviolencetochildhoodsexualabuse.Aboutoneinsevenwomenrespond
positively to at least one of the screening questions, they are then informed that support is
available,buttheyarenotpressuredtotakeaction.Fewerthanhalfacceptareferralforaction.
Thewomanisthenprovidedwithapsychologistoracounsellor.Otherclinicsintheareacanalso
refer clients to this service. The referral system includes a referral network documented in a
directorywithinformationonservicesoffered,thepopulationserved,andhoursofoperationand
meansofcontactthatisavailabletophysicians.Atwopartreferralformisusedwherethephysician
37
fillsinthefirstpartwithinformationontheclient’sneeds,theclienttakestheformtotheprovider,
whodescribesthevisitandthefollowupplanwhichcanbereturnedtotheclinic.
Profamilia’sexperiencehighlightsthatthewholeinstitutionshouldbeinvolvedinthis,involving
sensitisationofallstaff,includingreceptionistsandsecuritystaff;modifyingthephysicalspaceof
clinics for privacy and confidentiality; changing patient flows; and developing protocols, an
informationsystem,andastrongnetworkforreferral.
DOCTORSANDTHECOMMUNITY
A body of evidence demonstrates that community and neighbourhood level interventions can
improvehealthoutcomesgenerally,andparticularlyfordisadvantagedgroups[92].Interventionscan
includeactivetravelarrangements,provisionofgoodqualitygreenspaces,decenthousing,accessible
services and social/community centres, good quality early years provision, local policies to ensure
goodqualityair.Behforouz[80]recommendthatdoctorsvisittheneighbourhoodswherethemajority
of their patients live, as it can enhance their social perspective and help them understand their
patients’“healthhomes.”Healthcareprofessionalshavethepotentialtooccupyauniquespacein
thecommunityandthehealthservice,astheyareoftenseenasleadersinbothfieldsandcanbe
highlyeffectiveadvocatesforhealthyplaces.
Burt [93] described the potential of this role as a ‘boundary crosser’, who can operate as opinion
leadersandcanbridgethecommunityandhealthcaresystem.Itisimportantthatdoctorsareableto
workwithearlyyear’sstaff,schools,planners,housingproviders,transport,environmentalhealthetc.
Theimportanceofdevelopingthesepartnershipsisdiscussedinalatersection.
WORKINGWITHINDIGENOUSCOMMUNITIESTOIMPROVEHEALTHOUTCOMES
Indigenouspeoplesarerecognisedasbeingamongtheworld’smostvulnerable,disadvantagedand
marginalisedpeoples.Theyarespreadacrosstheworld,inaround90countries,numberingaround
370million.[94]TheUNDeclarationontheRightsofIndigenousPeoples,approvedbytheUNGeneral
Assemblyin2007,identifiesnumerousareasinwhichnationalgovernmentscouldworktoimprove
thesituationofAboriginalpeoples,givingprominencetocollectiverights.Indigenouspeoplesinmany
countrieshavesecuredmorecontrolovercommunitybasedhealthservices,inthehopeofimproving
accessandresponsiveness.[94]
WORKINGWITHABORIGINALCOMMUNITIESINCANADA
AboriginalpeoplesinCanadaincludeFirstNations,Dene,Metis,andInuit,andestimatessuggestthey
willmakeup4.1%oftheCanadianpopulationby2017.[95]Aboriginalstatushasbeenhighlightedas
a social determinant of health in Canada [96] and researchers have emphasized that Aboriginal
CanadianscontinuetoexperiencehealtheffectsrelatedtoCanada'scoloniallegacy.[97]Theyhavea
lowerlifeexpectancythanthetotalpopulation(e.g.in2017,anInuitmancanexpecttoliveto64
years, 15 years less than the total population at 79 years). [95] Illicit and prescription drug use
disordersaretwotofourtimesmoreprevalentamongAboriginalpeoplesinNorthAmericathanthe
general population. [98] However, a growing pool of evidence is demonstrating that Aboriginal
38
communities and culture are important means of protecting and promoting Aboriginal health. For
exampleastudyofillicitdrugtakingofaboriginalpeoplesinamid-sizedcityfoundthatAboriginal
enculturation was a protective factor associated with reduced risk of illicit and prescription drug
problemsamongAboriginaladults[98].Communitybasedhealthserviceshavebeenpromotedasa
meansofreducinghealthinequality,andasofMarch2008,83%ofeligibleFirstNationcommunities
are involved in managing their own community-based health services, to varying degrees. [99]
Researcherssoughttodocumenttherelationshipbetweenlocalaccesstoprimarycare,measuresof
community control, and the rates of hospitalisations for First Nations on-reserve populations in
Canada. [100] The study found that the longer community health services have been under
communitycontrol,thelowerthehospitalizationrateinthearea.Acommunityownedhealthservice
andanurbanstrategyforoff-reserveaboriginalsareoutlinedbelow.
WorkingwithMāoriNewZealanders
Māori New Zealanders are more likely to like in deprived communities and have the worst health
outcomesinNewZealand.TheavoidablemortalityrateforMaoriis2.3timestherateofotherNew
Zealander’s [101]. Even when income is accounted for, wealthier Māori still have worse health
outcomes than wealthier non-Māori. [102] The New Zealand government have created the Māori
Health Strategy, He Korowai Oranga to tackle this disparity for Māori people. These guidelines
highlighttheimportanceofcommunityempowermentandprovidingeffectivehealthservicesthatare
tailoredforthecommunity.Māoriculturalprocessesareusedasabasisfordevelopinganddelivering
healthservicesthatsupportself-sufficiencyandMāoricontrol.FromaMaoriperspective,healthhas
four cornerstones: te taha wairua (a spiritual dimension), te taha hinengaro (a psychological
dimension), te taha tinana (a bodily dimension) and te taha whanau (a family dimension) [103].
Incorporating this understanding has been identified as crucial to the success of these provider
organisations. [104] The New Zealand Ministry of Health highlight successful examples of these
principles being incorporated at the clinical level, and two examples of this are highlighted below.
Recentlythehealthinequalitygaphasbeguntoclose,andmanysitetheimportanceof‘ByMaorifor
Maori’participationasakeyreasonforthis.[105]
KAHNAWAKE,MOHAWKNATIONINQUEBEC,CANADA[106]
KahnawakeisaMohawkNationcommunityofabout8,000peoplethatmanageitshealthsystem
through the Kahnawake Health and Social Services Commission. Health is seen as integrally
connectedtonationbuildingandself-determinationofthecommunityanditspeople.Thehealth
system includes a community health unit offering public health services, a hospital with an
extensive complement of health professionals for both inpatient and outpatient care, a medical
centreofferingspecialtyservices,adentalclinic,andadiabeteseducationprogram.Acommunity
service centre provides a comprehensive range of mental health and social services including
alcoholanddrugabusetreatment.Thecommunityhasalsoconstructeda20-bedElderslodge.The
directors of the various health and social programs meet regularly to create long-term global
communityplanning,reduceduplicationandshareresources.Thereisasharedcommunityvision
ofanAboriginalhealthsystemwithholisticpractices.Inthefuturethecommissionwouldlikeall
institutions and health professionals working in the community to be internally regulated and
licensedtoprovideadirectlineofaccountabilitytothecommunity.
39
ABORIGINALHEALINGANDWELLNESSSTRATEGY(AHWS),HEALTHCENTRES,ONTARIO,
CANADA[107]
TheAHWSisacollaborationoffourOntariogovernmentministriesandfundsanumberofhealth
streamssuchascommunityworkersandhealthoutreach;shelters,healinglodgesandtreatment
centres;healthcentres;maternalandchildcentre;andtranslatorandadvocateservices.Thehealth
centresarelocatedoff-reservebutmanyserveon-reservepopulationstoo.Theyprovideprimary
careandincorporateAboriginalcultureandbeliefs.Theycompriseofaphysicianandanurse,often
anursepractitioneraswellasamixofotherprimaryhealthprofessionalssuchasanutritionist,
psychologist, traditional co-ordinator, diabetes educator, or exercise therapist. A six year
longitudinalevaluationofthecentresidentifiedcorecomponentsofaneffectiveservicedelivery:
•
•
•
integrated interventions that combine traditional and western approaches to care,
includingculturalteachingsandspiritualdevelopmentcombinedwithseekingabalancein
thephysical,mental,spiritual,andemotionalaspectsofaperson
supportiveenvironments
community development and empowerment through the use of centres as community
resources
The health centres incorporate community into service delivery for example videos or plays are
producedandperformedbycommunitymembersdepictingpersonalexperienceswithHIV/AIDSor
culturalteachingsusedtoframehealthylifestylechoices.
NGATIHINETRUST-NEWZEALAND[108]
TheNgatiHineTrustisthelargestMāorihealthproviderintheTeTaiTokerau.Servicesarewhānau
(family)focusedanditsaimistopromotethesocialandeconomicadvancementofwhānau,hapū
andiwi(family,clansandtribes).AnumberofservicesareprovidedsuchasGPservices;oralhealth;
primary nursing; disability support; home support services; health promotion and
education/training; Family Start programme; restorative justice programmes; mental
health/addition programmes; Radio Ngati Hine FM. The Trust is in the process of developing an
IntegratedFamilyHealthCentre(IFHC)toallowfamiliestoaccessallthekeyprimarycareservices
theyneedfromasinglefacility.TheTrusthasalsodevelopedanearlychildhoodcentre,withthe
understandingthateducationisapre-determinantforgoodhealth.Peopleenrollingtheirchildren
in the centre are signed up to a GP service and nurse. Depending on their needs they are also
offeredenrolmentinAukatiKaiPaipa(quitsmokingservices),oralhealthandotherservices.
HEALTHCAREINOTANGAREI:TEHAUAWHIOWHIOOOTANGAREIWHĀNAUORA
COLLECTIVE-NEWZEALAND[109]
Afternoticingthattheclinic,whichserves98%Māori,weretreatingsimilarconditionsregularly
includingdogbites,infectiousskininfections,andcutsunderfoot.Theteamsuspectedthatthe
reasonmightbethatmanychildrendidn’twearshoesandthatalmosteveryhouseholdhadadog
orcat.Theirsolutionwastoholdapetoutreachcliniconceeverytwoweeksonthelawnofthe
clinic.Thisclinicbecameverypopularandinthefirst6monthsoftheclinics,anobviousdecline
was seen not only in skin infections and dog bites but also in the number of dogs loose on the
streets.Thisalsoprovidedtheclinicwithanopportunitytoprovidecommunityoutreachespecially
topeoplenotengaginginthehealthsystem.Theycouldtappeopleontheshoulderwhilethey
were waiting and inviting them to pop in for their smears or immunisations, or confirming
appointments for another day. By understanding a community need that wasn’t directly health
related,theypositivelyimpactedontheoverallhealthofthecommunity.
40
SYSTEMSWHICHSUPPORTDOCTORSTOTAKEACTIONONSDH
System wide factors that improve an individual physicians’ ability to work collaboratively with
individualsandcommunitiestotackletheSDHinclude:
•
•
•
System Commitment: A system wide commitment to tackling the wider determinants of
healthgivescliniciansbothasupportedmeanstotacklehealthinequality,butalsoamandate
todoit.
Communityengagement/facilitatorrole:Withalloftheavailablecommunityoptions,itisnot
always possible for doctors to act as ‘boundary crossers’, and it can be hard for busy
healthcareprofessionalstomakeinformedreferralsintheirlocalcommunity.Asignposting
or facilitator role that can act as a bridge between healthcare professionals and social
activitiesissoimportant.Thiscanbeperformedbyavarietyofpeople,theymaybepaid
members of the local community; nurses, pharmacists or other health practitioners with
additionaltraining;volunteersorpeers;receptionistsoradministrationstaff;ornewtypesof
professionalrolescreatedforparticularservices.Evidenceshowsthatwhenthisfacilitatoris
embeddedinclinics,healthcareprofessionalscangettoknowandtrustthemandunderstand
theirrolebetterwhichassiststheminsocialprescribing.[110]
Capacity of the community to engage: The level at which a community can engage and
partnerwithhealthservicesisdeterminedbythecommunity’sresourcesandsocialcapacity.
These resources include financial assets, physical infrastructure (facilities and equipment),
individual knowledge and skills, relations amongst people and organisations, relationships
betweenlocalpeopleandorganisationsandthecommunity’sexternalenvironment,access
to services, and community attitudes etc. [111] Tools have been developed to asses
communitycapacity,forexampleVersionC2007[112]whichmeasures17capacitiesineach
oftheeightsocialfields.Bymeasuringacommunity’scapacity,communityinterventionscan
identifycommunitystrengthsandneeds,andassistinprioritizingtheseneeds.
However,evenwithoutthesefactors,healthcareprofessionalscanmakesomesmallstepstoengage
more with individuals and the community, for example, education on motivational interviewing,
carrying out more extensive social histories, visiting the community and advocating on behalf of
individualsandcommunities,asdiscussedinothersections.
41
WHATTHEWMACANDO
•
•
•
•
•
provideeducation-skillstraining
recogniseandpromotetheimportanceofdevelopinganddeliveringeducationforallhealth
professionals
collaboratewithotherhealthprofessionalorganisations
collectevidenceofeffectiveindividualandcommunityinterventionsattheinternationallevel
todevelopanevidencebasetobedisseminated
support physicians in providing care that is empowering to the patient and utilises the
strengthsofthecommunity
WHATNMASCANDO
•
•
•
•
•
•
provideeducation-skillstraining
collectevidenceofeffectiveindividualandcommunityinterventionsatthenationallevel
shareevidenceofwhatworks
advocatetogovernmentandotheragenciestoensuresupportfortheprovisionanduptake
ofeducation-skills
aupport physicians in providing care that is empowering to the patient and utilises the
strengthsofthecommunity
workwithgovernmentstoensurebetterinclusionofallpatientgroups,includingtraditionally
hardtoreachgroups,inpatientcentredcare
WHATDOCTORSCANDO
INDIVIDUALRELATIONSHIPWITHPATIENTS
Attheclinicallevelthereisasignificantamountthatcanbedonetotacklehealthinequalityandtackle
thesocialdeterminantsandprovideculturallyappropriatecareiskey:ensurethatstaffarerecruited
withthisinmindandensureadequatetrainingisprovided.
•
•
•
•
patient-doctor Relationship: Creating a supportive environment, Motivational interviewing
training;Integratecareplanningintoconsultations
clinicaroundpatient,notpatientaroundclinic:wherepossible,providecarethatisculturally
appropriate,safe,intherightlocation,attherighttimee.g.non-traditionalofficehours,office
locationconvenientforcommunity;
individual advocacy: write letters to housing, schools etc. on behalf of patients and their
families
reflectivepracticetoexaminethedoctorsownprejudicesasthesemightimpactonhis/her
assumptionsaboutpatients
RELATIONSHIPWITHCOMMUNITIES
Makebetteruseoflocalopportunitiesthatcouldbenefitpatientsandwhichmightbenefitthelocal
community
42
•
•
•
•
workingwithCommunity:Socialprescribingtolocalserviceswhenappropriate,linkpatients
to supportive community programmes. If this is not available, advocate for community
assessmentsinlocalareaandforsupportstaff
maketacklinghealthinequalitiesacomponentoftheirroleasalocalcommunityemployer.
Employingmembersofthecommunityismutuallybeneficial.Forthehealthsystem,localstaff
have a wealth of knowledge about the community, know culturally appropriate ways to
engage.Italsobringsemploymenttothecommunity.
community advocacy: Use position of power and trust to speak to improve the social and
economicconditionsoftheircommunityandreducehealthinequalitiesintheirlocalarea
community engagement beyond the role of a clinician, demonstrating that they see
themselvesasapartofthecommunity
43
4.ASANEMPLOYER,MANAGERANDCOMMISSIONER
Whilethehealthserviceimpactsonhealthandinequalitythroughdirectinteractionswithpatients
andcommunitiesitalsohasahighlysignificantroleasanemployer,managerandcommissioner.The
healthcaresystemisasignificantemployerinmanycommunities–includingthoseemployeddirectly
inhealthcareorganisationsandthoseemployedindirectlythroughthesupplychain.Theseinclude
occupationsthatareunskilledorsemi-skilledanddonotrequireaprofessionalqualification.Thisgives
thehealthcareindustryanimportantopportunityandresponsibilitytoreducehealthinequalitiesby
providinggoodqualityworkandconditions,andensuringsafeworkingconditions,aswellasworking
toincreaseemploymentopportunitiesforpeoplefromdisadvantagedbackgrounds.Thehealthcare
systemcanthushaveapositiveimpactbyboostingeconomicactivityindeprivedcommunities.That
is,aswellashelpingindividualsitcanhelpcommunities
Healthcareworkersareexposedtoanumberofrisksduetothenatureoftheirworkincludingshift
work,musculoskeletaldisordersandsharpinjuries.Thisiscoupledwithaconcerninggrowthinattacks
onhealth-carefacilitiesandhealthworkersinconflictandcrisissetting.InlateDecember2014,the
UNGeneralAssemblypassedaresolutioncallingforconcertedandspecificactionsbyStatestoprotect
healthworkersfromviolenceandtoassurepatientsaccesstohealthcareinsituationsofconflictand
insecurity.[113]InBahrainandTurkeyhumanrightsandinternationalhumanitarianlawwereviolated
whenhealthcareworkerstreatinggovernmentprotestorswerearrested,inFebruary2015theWMA
demandedthatallchargesbedroppedagainstTurkishdoctors.[114]
Thehealthandsocialworksectorisalsoahighrisksectorforadversepsychosocialconditionsthat
are related to increases in stress.[115, 116] These include conflicts within the workplace, lack of
autonomy and control, low pay and insufficient hours, temporary work, insecurity and the risk of
redundancy[117]Studieshaveshownthattheseadversepsychosocialconditionsareassociatedwith
an increased risk of coronary heart disease [118]. Many doctors are leaders in the health system,
sittingoncommissioningboards,asmanagersandasemployers.Itisthereforeimportantthatthis
role is understood in terms of the social determinants of health. This includes ensuring safe work
practices,demandingsafeandhealthenhancingworkingconditionsforstaffthroughprocurement,
andworkingtowardstheemploymentandtrainingoflocalstaff.
THEHEALTHCAREWORKFORCEANDTHESOCIALDETERMINANTSOFHEALTH
ASEMPLOYERS
According to the ILO, over the next five years public services in health care, education and
administration will continue to be a major source of employment representing 15% of total
employment in the world, signalling the emergence of a large ‘care economy’. [119] More effort
should be made to ensure that everyone has an opportunity to access these jobs, including the
medical profession, and particularly people from disadvantaged communities. This requires active
outreachtocommunities,suchthemultiagencypartnershiptotransitionthelong-termunemployed
intoalliedhealthcareersintheUSA,andrecruitinglocalpopulationsascommunityhealthworkersin
Zambia,asoutlinedinthecasestudiesbelow.Thereisaneedforthisworkisofagoodquality,as
discussedinthenextsection.
44
CASESTUDY:TRANSITIONINGTHELONG-TERMUNEMPLOYEDINTOALLIEDHEALTH
CAREERS[120]
In2011,multiagencypartnershipwassetupinNorthCarolina,USA,toaddresstherelativelyhigh
long term unemployment rate at 9 percent, half of whom are unable to secure a job within six
months.Whilejobgrowthwasstagnantgenerallywithgrowthat3%,healthcarejobsincreasedby
46percent.
Stakeholders representing healthcare employers, community colleges, workforce development
boards, social services, funders and the long-term unemployed living in rural communities
identifiedfourkeychallengesthatthelong-termunemployedinruralcommunitiesmayexperience
as they navigating the career pathway of allied health professionals, including career guidance,
limitedresources,individualsupportsandemployercollaboration.
As of March 2015, over 205 unemployed persons were assessed, enrolled into training, and
supportedtocontinuetraining.Servicesincludedcareercounselling,academic/trainingvouchers,
books,uniforms,immunizations,transportationandprofessionaldevelopment.Projectionssuggest
that 25% or more will gain employment upon successful workforce training. Human Resource
Developmentdepartmentsatcommunitycollegeshavetheabilitytosustaintherecruitmentand
implementationbeyondthefundingcycleoftheproject.(progressreportfromAliceSchenall)
CASESTUDY:RECRUITINGQUALITYCOMMUNITYHEALTHWORKERSINZAMBIA
In2010,theGovernmentoftheRepublicofZambia(GRZ)launchedaprogramtocreateanewcivil
service position: the Community Health Assistant (CHA) in an attempt to formalise and
professionalise community-based lay health workers common in Zambia and to address staff
shortagesinruralareas.Theaimistotrain5,000newCHAsby2017.CHAsundergoayearofformal
training,andthenreturntotheirruralhomecommunitiestowork.TheCHAs’maintaskistovisit
households to conduct environmental inspections (safe water practices, household waste
management, sanitation, hygiene and ventilation), advise on women and children’s health, and
refer them to the health post (the first-level health facility in rural Zambia) as needed (e.g. for
routinechecksforchildrenandpregnantwomen,orforgivingbirth).Theyalsospendonedaya
week in the community health post and organise community health-education meetings at the
healthpostandinschools.TheMinistryrequiresCHAstoworkfortwoyearsbeforeapplyingfor
promotion.
Researcherstestedhowindividualincentives(opportunitiesforpromotionandfurtherprofessional
development),affecttheskillsandmotivationofapplicantsforthisroleandhow,inturn,thisselfselectionaffectsjobperformance.[121]Halfofthedistrictshadrecruitmentpostersemphasizing
the“social”benefitsofbecomingaCHA,suchasservingandbeingaleaderinone’scommunity.In
the other half, recruitment materials emphasized the “career” benefits of becoming a CHA, i.e.
career development. Once deployed, actual benefits were identical between the two treatment
groups,asaresult,anydifferenceinperformancewasduetotheselectioneffectoftheincentives.
Career incentives attracted CHAs that were more qualified and had the same level of pro-social
preferences as CHAs recruited by making social incentives salient. These CHAs consequently
performedbetteronthejob.CHAsinbothgroupsleadtoincreaseduseofhealthservicesbyrural
communities,butthisincreasewashigherincommunitieswithCHAsrecruitedbymakingcareer
45
incentives salient (e.g. a 31% increase in women giving birth at the health centre). Applicants
recruitedbymakingcareerincentivessalientweremoreambitiousregardingcareeradvancement:
alargerportionaspiredtoholdahigher-rankinggovernmentpositioninthenext5-10years,such
as a Clinical Officer, Nurse or Environmental Health Technologist. In Zambia promoting highperformingCHAstonursingandotherhigher-levelcadresislikelytobeabenefitforthehealth
service.
Providinggoodqualityskilledworkatanentrylevelinthehealthsectortothelocalcommunityhas
thepotentialtoreducehealthinequalityinthreeways.Firstly,byadvertisingthecareerprogression
opportunitiesitleadtobetterhealthprovisionforruralcommunitiesandbetteruptakeofhealth
servicesbythecommunity.Secondly,itprovideshealthprotectiveworktotheruralcommunity,
wherecurrentlyinZambiatheagriculturesectoristhelargestemployer.Thissectoroftendoesn’t
payforwork(61%ofwomenand39%ofmenarenotpaidatallfortheirwork.Ontheotherhand,
85%ofwomenand91%ofmeninthenon-agriculturalsectorarepaidincash).[122]Thirdly,by
recruitinginlocalruralareasforentrylevelpositionsthatincludethepossibilityofprogressionin
thehealthservice,theGRZincreasesthelikelihoodofhavingamorediverseworkforce.
ASMANAGERS
As discussed, those employed by the health and social sectors are at an increased risk of adverse
physicalandpsychosocialworkingconditions.Improvingthequalityoftheworkingenvironmentcan
greatlycontributetotheeliminationoftherisksofassociatedwiththesesectors.Thisincludesboth
the physical and organisational setting. The importance of this is increasingly recognised, and
attentionisfocusedontheeliminationormitigationofthecausesofworkrelatedstressandother
adverseworkingconditionsbycreating‘goodwork’[116].
Whilethereisnouniversallyaccepteddefinitionofwhatconstitutesgoodworkmanyofthedifferent
definitionsavailableallsharecommonfeatures.ForexampletheInternationalLabourOrganisation,
the Trade Union Congress, and the Employment Conditions Knowledge Network, all highlight the
followingconditionsthatareassociatedwithgoodwork:somethingthatbothsustainstheworker
financially,providingsecurity,butalsoenrichestheworker’slifethroughagoodwork–lifebalance
andpromotinggoodphysicalandmentalhealth[123][124][125]
Whilenotalwaysthecase,physiciansoftenmanagehospitals.Someresearchsuggeststhathospitals
performbetterwhendoctorsmanagehospitals.Across-sectionalstudyofthetop-100U.S.hospitals
(accordingtotheUSNewsandWorldReport’s“BestHospitals”rankingofqualityin2009)inthree
specialties: Cancer, Digestive Disorders, and Heart and Heart Surgery, found a strong positive
associationbetweentherankedqualityofahospitalandwhethertheCEOisaphysicianornot(p<
0.001).Whenphysiciansareinapositiontomanagestaff,effortshouldbemadetoensurethatgood
physicalandpsychosocialworkisprovidedtoallstaff,asthecasestudiesdemonstratebelow.
CASESTUDY:HEALTHWISE:IMPROVINGSAFETYANDWORKPRACTICESINHEALTHCARE
The ILO and WHO have developed HealthWISE- a practical manual [126] and guide [126] that
encouragesmanagersandstafftoworktogethertopromotesafeandhealthyworkplacesandto
improveworkpractices.Theseincludemodulesontopicssuchascontrollingoccupationalhazards
46
andimprovingworkplacesafety;biologicalhazardsandinfectioncontrol;tacklingdiscrimination,
harassmentandviolenceattheworkplace;andpromotinggreenerandhealthierworkplaces.In
Senegal,apilotprojecthasbeenimplemented,wherethenewapproachledtobetterinformation
and practices on working conditions and sensitization of health workers in hospitals about HIV.
HealthworkersbenefitedfromtrainingsessionstoincreasetheirknowledgeofHIVinfectionand
ofsaferworkpractices.Inthefutureanetworkoflocaltrainersandpractitionerwillbedeveloped
topromotepracticalapproachestostrengthenhealthsystemsintheirowncountries.
ASCOMMISSIONERS
Healthcareprovidersoftencommissionandprocureservicesfromthirdparties,indirectlyaffecting
the pay and conditions of many workers and, through that, health outcomes. It is important that
healthcare commissioners consider local employment conditions when allocating resources. In
England,researchhasshown[127]thatbyallocatingadditionalinvestmentandresourcesinareaswith
higherlevelsofsocioeconomicdeprivation,thehealthservicehasprobablyreducedinequalitiesin
populationillhealth.
IntheUK,bylaw,thesocialvalueofNHScommissioningmustbetakenintoconsideration[128].The
RoyalCollegeofPhysicianshasrecentlyauditedNHStrustsandfoundthat83percentreportthatfair
termsandconditionsareincludedintheprocurementconditionsand68percentsaythattheyinsist
onalivingwage(aroundhalfofallNHShospitaltrustsintotal).In2012BlackburnwithDarwenCare
Trust Plus established and developed a Social Value Self-Assessment tool (joining the Dots paper)
[129].TheInstituteofHealthEquityhaswrittenabouthowthesocialdeterminantsofhealthapproach
could inform procurement and commissioning practices, so that procurement directly improves
conditionsinthesocialdeterminants.FigureXadaptedfromthis[130]
FIGURE 5 HOW THE SOCIAL DETERMINANTS OF HEALTH APPROACH COULD INFORM
PROCUREMENTANDCOMMISSIONINGPRACTICES[130]
Marmot policy Socialvalueareasforaction
objective
Beststartinlife
•
•
Lifecourseapproachtoplanningservices
Familyfriendlyemploymentpractices
Maximise
capabilities and
control
•
•
•
•
•
Skilldevelopmentprogrammes
Trainingandapprenticeships
Volunteering
Workingwithschoolsandyoungpeople,includingcurriculumsupport,
careersadvice
Buildingindividualresilienceandmentalhealthprotection
Supporting people with a learning disability or service users into
trainingoremployment
Trainingforexistingstaff
•
•
Localresidentsemployed(inlocallabourmarket)
Reduceunemploymentthroughtargetedrecruitment
•
•
Employment and
goodwork
47
•
Employmentofparticulargroupse.g.ex-offendersandthosewithlongtermhealthconditions
Youthemployment
Localeconomicregeneration
Improvement in terms and conditions of employment, including
security
Jobswithhighlevelofcontrolforemployees
Standardofliving
(income)
•
•
•
•
•
Debtandwelfareassistanceadvice
Livingwage
Increaseinmedianwageofemployees
Reducinggapbetweenhighestandlowestpaid
Parityinincomebetweenemployees
Healthy
and
sustainable
places
and
communities
•
Environmental improvements, including recycling, carbon reduction,
energyefficiencyandwastereduction
Stimulatingdemandforenvironmentally-friendlygoods,servicesand
works
Safetyandanti-socialbehaviourprojects
Communitycentres
Socialinclusionandintegration,andtacklingsocialisolation
Investmentinthelocalareae.g.viaprivatesectorthroughcorporate
socialresponsibility(CSR)strategies
Increase number of local organisations with social purpose linked to
communities, socially responsive governance, with fair and ethical
trading
Encouragelocalsupplychains
Investmentinparticularprogrammese.g.fuelpovertyreduction
•
•
•
•
•
•
•
•
•
•
•
•
Publichealthand
prevention
•
•
•
•
•
Healthimprovements
Healthandsocialcareschemes
Peoplesupportedtoliveindependently(e.g.olderpeople)
Reduce sick absence of employees through improved health and
wellbeingsupport
Reduceavoidablehospitaladmissions
CASESTUDYUSINGSDHINCOMMISSIONINGOFPRODUCTSANDSERVICES[130]
In 2012, Blackburn with Darwen (BwD) Care Trust Plus (an integrated adult social care /PCT
commissioningbody)developedalocalstakeholdergroupforsocialvaluedevelopment.Blackburn
withDarweniscurrentlydoingthreethingstogeneratesocialvaluefromtheirlocalspend:
1.developingalocalsocialvalueself-assessmenttoolandpilotingitwithinspecificpublichealth
contracts
2.analysingandmaximisinglocalpublicsectorspendwithlocalbusinesses
3.investinginlocalsocialenterprisesaspartofitspublicservicesreform
48
Theapproachhasbeenledbythecouncil,withtheinvolvementoflocalNHSbodies,providersand
thecommunity.Anexampleofsocialvalueinprocurementincludesthesupportforalocalsocial
enterprise in Darwen – Café Hub– that provides a drug- and alcohol-free venue for people in
recovery.Thecouncilhasalsomovedtoane-procurementsystem(thechest)thatprovidesgreater
accesstolocal,registeredsuppliersandthusincreaseopportunitiesforlocalspend.Atotalof120
council officers have been trained on this e-procurement system and 600 local suppliers have
registeredtobenotifiedofopportunities.In2012/1348%ofthecouncil’stotalspendwaswith
Lancashire-basedsuppliers;in2014/15thisincreasedto55%.
CASESTUDY:BRITISHMEDICALASSOCIATION:FAIRMEDICALTRADE[131]
TheNationalHealthServiceintheUKspendsover£40billionperannumonprocuringgoodsand
services.Thisisaglobalsupplychainwithmillionsofemployeesaroundtheworld.However,in
somecases,thebasicemploymentrightsofpeopleinthischainareinfringed,affectingtheirhealth
duetounsafeworkingconditionsandunfairwages.TheBMAhascampaignedforfairandethical
tradeinmedicalsuppliessince2007,andencouragesitsmemberstodothesameby:
•
•
•
•
Educatingthemabouttheissue.TheBMAprovidesanonlinelearningcourse,andcreated
acampaignfilm:TheHumanCostofHealthcare[132]
Raisingawarenessamongstcolleagues
CampaignfortheirNHSorganisationtopurchasemedicalsuppliesethically
Askhealthcaresupplierswheretheyproducetheirgoods
Becauseofthiscampaign,manyClinicalCommissioningGroups(whichareledbyphysicians)are
adoptingsustainableprocurementandcommissioningpolicies.Forexample,theCityandHackney
Clinical Commissioning Group now include a commitment in their CCG Constitution to only
commission services from providers who can demonstrate a commitment to their social
responsibilitiesandtosustainabilityprinciples.
49
WHATTHEWMACANDO
•
•
•
•
access to health professional training and employment: The WMA should devise an action
plan of what can be done to improve access to the health professions. This is especially
importanttothephysicians,butshouldbeconsideredateverylevelofthehealthcaresystem
includingauxiliaryandsupportstaff.
providesupportformemberAssociationsseekingtoensureaccessbyallpopulationstohealth
careprovision
protectandadvocateforgoodqualityworkingconditions,healthandwellbeingofphysicians
andotherstaffworkinginthehealthsystem,includingnon-professionalstaff
advocatethatallstaffworkingwithinthehealthcaresectoraretreatedwithrespectandare
enabledtolivewithdignity,includingbeingabletofeedandhousethemselves
WHATNMASCANDO
NMAs should work to improve access to the healthcare professions and to protect the working
conditionsofpeopleworkinginthehealthcareprofession:
•
•
•
•
•
accesstothehealthprofession:Promotingaccesstothehealthprofessionbypeoplefrom
lowersocioeconomicpositionsandmarginalisedgroupsshouldbeakeypriorityforNMAs
promoteasafeworkingenvironmentforallhealthcareworks,enablingthemtoprotectand
assisttheirpatientsandcommunities
protectandadvocatefortheworkingconditions,healthandwellbeingofphysiciansandother
healthprofessionalsandothersworkinginthehealthsystem
supportlocalemploymenttoencourage/fostergreaterequity
support health care systems considering the welfare of those providing resources, and
ensuringnoworkersareexploitedunfairly
WHATDOCTORSCANDO
•
•
•
•
ascommissioners:Oftenhealthcaresystemschoosethecheapestoption,anddonotcostthe
social value. When commissioning primary care and community clinics, and hospitals,
commissionerscouldlookformorethanjustmedicalcare.Theycouldfocusonimprovingthe
socialconditionsoflocalareasandthroughthatthehealthofdeprivedcommunitiesandalso
lookforprovidersthatcouldrespondtothewiderneedsofthecommunity,bethathaving
healthtrainers,navigatorsorcommunity-basedservices.
support staff: Consider and where possible advocate for the working conditions of lower
skilled,lowpaidprofessionsinhealthcare,includingcarersandvolunteers.
as managers of hospitals: Include patients social status and complexity as a component of
ward budgets; have the goal of health equity at all levels; develop expert clinics for
marginalisedgroupse.g.migrants.Ensurethatyourhospitalhasanactiveoccupationalhealth
policy
getinvolvedinlocaloutreachasacommunitymemberaswellasinyourmedicalrole
50
5.WORKINGINPARTNERSHIP:WITHINTHEHEALTHSECTORANDBEYOND
Asdescribedabove,themostsignificantinfluencesonpopulationhealthlieoutsidethehealthcare
sector.AdoptingtheSDHapproachmeansthathealthprofessionalsformalliancesandpartnerships
with those working in other sectors in order to improve health. Improving conditions in the social
determinantsofhealthisamulti-sectorendeavour–itinvolvescollaborativeactioninearlyyears,
education,employmentandhousingforinstance.Actiontoimprovehealthinequalitymusttherefore
be based on partnerships with all these sectors. Health care professionals should partly view their
workasbeingapartnerwithstakeholderstoimproveawiderangeofsocialandeconomicfactorsthat
willaffectpeople’shealth.Doctorsneedtobetrainedtodevelopskillstobeeffectivechampionsof
theSDHapproachandtoformcollaborationsandpartnershipswithothersectors.AdoptingtheSDH
approachrequiresanuancedunderstandingofleadership,facilitationandpartnershipbetweenthe
healthcare sectors, other government sectors (such as social protection, early years, transport,
education,housingandurbanplanning),communityandthirdsectororganisationsandtheprivate
sector–whichhaveresponsibilitiesasemployers.[133]
PARTNERSHIPSOUTSIDETHEHEALTHSECTOR
Partnerships between the health sector and those outside the health sector can have a significant
impact on health inequality, but are often underutilised. Any action with health services will be
strengthened if wider policies in other areas are also being implemented. The CSDH stated that
tacklinghealthinequalitiesshouldbeapriorityacrossawiderangeofareas.[3]Thesepartnerships
should go beyond information sharing to facilitate joint planning, commissioning and delivery.
[23]Thesepartnerscouldincludeothersectors,localgovernment,policeandfireservices,charities,
theprivatesector,placesofworkandschools[6].Thesocialdeterminantsofhealthcaninformthese
partnershipsthroughtakingalifecourseapproachtohealth,highlightingtheneedforproportionate
universalismasmentionedintheintroduction.Twoexamplesbelowhighlightthelastingbenefitsto
local communities and a reduced pressure on the healthcare system when these are taken in to
consideration.
51
CASESTUDY:BROMLEYBYBOWCENTRE[134][135]
BromleybyBowcentreisahealthylivingcentrethathasbeenpartofthecommunityforthirty
years.Itprovidesthecommunitywitharangeofservicesthatareavailabletoeverybody.Thereis
aGPsurgeryalongwithadiverserangeofservicesforthecommunity.Thisincludesaccredited
educational and learning courses including English for Speakers of Other Languages (ESOL),
numeracyandliteracycoursesandaccesstofamilylearning,employmentserviceswithbespoke
programmes, a children’s centre, artists’ studios, outreach programmes and a range of advice
services.Theseservicesareintegratedandco-operativeinnature.ThisapproachenablesGPsto
referpatientstoservicesthathelptotacklethesocialdeterminantsofillhealth,includingwelfare,
employment,housinganddebtadviceservices.Theirservicesaretailoredtotheneedsofthewhole
community, and allows for focused interventions for specific groups - families, young people,
vulnerableadultsandelders.Thismodelis73%social(employment,enterprise,arts,skills,welfare
etc.)&just27%clinical.
Theyaimtosupportpeopleacrossarangeofprojectsandservicesin4mainways:
1.supportingpeopletoovercomechronicillnessandunhealthylifestyles;
2.enablingpeopletolearnnewskills;
3.supportingpeopletobecomelessgrantdependentandtofindwork;
4.providingpeoplewiththetoolstocreateanenterprisingcommunity.
Aswellasthehighlevelsofchronicphysicalillnessestherearealsosignificantlyhighlevelofmental
healthproblems,whichoftenroutebacktothesocialcircumstanceswithinwhichpeopleareliving.
SUCCESSFULLYINTEGRATINGEARLYYEARSINTERVENTIONSINTOTHEHEALTHSERVICE-
FROMHOSPITALSTOCOMMUNITIES:MALNOURISHEDCHILDREN’SPROGRAMME
JAMAICA[136]
Healthservicesareoftentheonlygovernmentsectorroutinelymakingcontactwithchildrenunder
3 years in Jamaica, and in many LMICs. Therefore integrating early year’s interventions into
healthcareservicesisarelativelycosteffectivewaytopromotehealthequityinLMICs.TheTropical
Metabolism Research Unit of the University Hospital of the West Indies established the
MalnourishedChildren’sProgrammeinJamaicain1994afterhospitalpersonnelnotedthatmany
childrenadmittedwithmalnourishmentthatrecoveredandweresenthome,hadtobere-admitted
for the same condition after a comparatively short time. A number of interventions such as
nutritionalsupplements,psychosocialstimulation,motherandfamilysupporthavebeenevaluated
inisolationandincombinationsincethen.Theresultsdemonstratedthatbiomedicalinterventions
suchasnutritionalsupplementswerefarmoreeffectivewhencombinedwithbroaderpsychosocial
interventionsand family support. This points fortheneedtointegrateabroaderfocusonearly
yearsthanthetraditionalbiomedicalfocusofhealthservices.
The programme aims to address early deficiencies of children hospitalised for malnutrition by
conductingfollow-uphomevisitstomonitorchildrenwhoaredischargedfromthehospital.Home
visitsareorganisedwiththeaimofidentifyingspecificandinterconnectedsocialdeterminantsof
children’s and their families’ health. Paraprofessional health staff (health aides) delivered the
interventioninadditiontotheirusualduties.Stafffocusonstimulation,environmentalfactorsand
52
nutritionalstatusofchildren.Theyalsoworktoincreasetheeconomicstabilityoffamilies.Parents
are enrolled in a weekly parental education programme and social welfare project. They are
supportedtodevelopincome-generatingskills,findjobsandshelter.Theymakejobreferralsand
sponsor parents to take advantage of skills training opportunities. Food packages, bedding and
clothingforneedy,unemployedparentsareprovided.Acommunityoutreachprogrammehasbeen
developedinthreelocationsinpoorareaswithhighprevalenceofmalnutrition.Theprogramme
includespsychosocialstimulationofchildrenuptoagethree,andamobiletoy-library.
Evaluationsofinterventionsrevealedanumberofimportantfindings.Interventionsthatincluded
nutritional rehabilitation alone were shown to be insufficient to reduce malnourished children’s
developmentaldeficit,demonstratingthatmedicalandnutritionalcareisnotsufficienttoreduce
the long-term effects of this health inequality. When this was combined with home visits that
includedaplayprogrammewiththeaimofpromotingmother-childinteractionandself-esteem,
overathree-yearperiod,malnourishedchildrenwereshowntocatchuptothenourishedgroup
after24months.Whilethisdippedoncetheinterventionfinished,itremainedsubstantiallyabove
the control malnourished group. Their IQ levels were between both groups. Mothers in the
intervention group had improved knowledge of child rearing and reductions in depressive
symptoms. A twenty-two-year follow up study demonstrated benefits through to adulthood in
areas such as cognition, educational attainment, mental health and reduced violent behaviour.
[137]Thegroup’sresearchhasalsodemonstratedthatitisfeasibleandeffectivetointegratethe
interventionsintoprimarycareserviceswithbenefitstochildren’sdevelopmentandmothers’child
rearingknowledgeandpractices.[138]
WORKINGWITHCOMMUNITIES
Asdiscussedinsection3,thereisaclearneedtoworkwiththecommunitiesthatpatientsliveinto
understand and intervene on the social determinants of health for patients. Many countries have
createdaroleinthehealthservicewithaspecificfocusofengagingwiththelocalcommunityand
creatingalinkbetweencommunitiesandthehealthservice.Communityhealthcanbeeffectivein
tacklingSDHandsupporthealthprofessionalsmoregenerallytotakeactiononSDH.CHWshavebeen
shown to be an effective way for health care systems to target marginalised communities with
unequalaccesstohealthcare,especiallywhenrecruitedfrompopulationstheyserve[139][140].In
a review of 100 studies Prasad & Muraleedharan (2007) demonstrated the critical factors which
influencetheoverallperformanceofCHWsincludesthenatureofemployment,careerprospectsand
incentivesandtraining.Areview[141]foundevidencethatCHWsandcommunityparticipationwere
mosteffectivewhentheywerelargeinscale,andintegratedthroughoutthehealthservicesandother
sectors and services outside health care.. An example of doctors, nurses and community health
workersworkinginpartnershipwithcommunitiestotacklehealthinequalitycanbefoundinBrazil,as
outlinedbelow.
CASESTUDY:PRIMARYCARETEAMSINBRAZIL:THEROLEOFCOMMUNITYHEALTH
WORKERS
Primary care teams, composed of a doctor, nurse and at least four Community Health Workers
(CHWs)areakeypartoftheBraziliangovernments’SistemaUnicodeSaúde(SUS)orUnifiedHealth
System,providinguniversalcarefreeatthepointofdelivery.SUSattemptstoreachthehardto
reachbyemployinghealthworkersfromthelocalcommunity.Aswellasamethodforthehealth
service to target people in remote communities, it is also a source of local employment and
communityempowerment[142].Themethodhasbeendemonstratedtobecost-effectiveandhas
53
highlevelsofusersatisfaction[143].TheCHWsaretrainedforuptothreemonthsandcarryouta
range of activities including basic triage, chronic disease management, breastfeeding support,
immunisations,householddatacollection,healtheducation.Theirrolealsoincludesamorespecific
mandatetoworkwiththelocalcommunitybyidentifyinghouseholddeterminantsofillhealthand
acting as a liaison between the health service and community leaders as well as acting as a
community leaders themselves [144] Each CHW visits every household in their micro-area
(approximately100-150)everymonth.CHWshavebeenworkinginBrazilforovertwentyyearsand
asof2013,therewere257,265layCHWsinBrazil,covering54%oftheBrazilianpopulation.Since
theirimplementation,Brazilhasseensignificanthealthimprovementsandareductioninhealth
inequality[145]whichresearchershaveattributedtotheprogramme[144].Improvementsinclude
a reduction in infant mortality, hospitalisations due to primary care sensitive conditions,
improvementsinscreeninguptake,improvementsinbreast-feedinguptake,antenatalcare,mental
healthproblemsandimmunisationcoverage[144].
SELF-EMPLOYEDWOMEN’SASSOCIATION(SEWA)HEALTHSERVICESINGUJARATINDIA
[146][147]
SEWA is a trade union of self employed women from the informal sector in India. It has been
registeredsince1972andhasover900,000members[147]Thoseintheinformalsectorarenot
entitledtowelfarebenefitsandoftendonothavearegularsalary.However,theinformalsectoris
byfarthelargestsourceofemploymentinIndia.[148]SEWA’smaingoalsaretoorganisewomen
workersforfullemployment-withjob,income,foodandsocialsecurity.
SEWAmembersareatanincreasedriskofdevelopingillness,disabilityandprematuredeath,and
SEWAhavebeenengagedinmanydifferentformsofpreventativeandprimaryhealthcaretoits
members,andthelocalcommunity-particularlythosenotservedbyotherhealthproviders.Initially
this included health education and provision of maternity benefits. They also work to build the
capacity of local women (especially local midwives called dais). Today SEWA Health works with
primary health care professionals in stationary health centres, mobile clinics, provides health
educationandtraining,localcapacitybuilding,occupationalandmentalhealthfacilities.Themobile
campsareledbyaphysician.
Theyprovidereproductivehealthprovisionandeducation,tuberculosisdetectionandtreatment.
AstudyoftheprimaryusersofSEWAHealthservicesfoundthatinAhmedabadCity,serviceswere
useddisproportionatelybythepoor,whilethepopulationdidn’tvarysignificantlyinotherareas
(particularlyruralareas).Qualitativeanalysisfoundthatsuccessinreachingthepoorinthisarea
wasachievedthroughthefollowingelements
•
•
•
•
•
providingpoorpeoplewithrespectand‘warmth’
servicesaregenerallyfreeorlowcost
convenienttimes
locationinthecommunity
providedbyawomenledgrassrootsorganisationgeneratedafeelingoftrustandsecurity
Thesefindingshighlighthowdeliveryofservicesthroughagrassrootsorganisationcanfacilitate
equitabledeliveryofservices
COMMUNITYLEADERS/FAITHLEADERS
54
Partneringwithcommunityleaderscanbeaneffectivewaystoengagehardtoreachpopulationsand
createaculturethatencourageshealthybehaviourchange.Theexamplebelowdemonstrateshow
faithbasedandcommunityleadershelpedtofacilitateCVDchecksforSouthAsianpopulationsinthe
UKandhelpedtocreatea‘communityspirit’forlifestylechanges.
CVDCHECKSINFAITHANDCOMMUNITYBASEDORGANISATIONSFORSOUTHASIAN
POPULATION[149]
IntheUKpeopleofSouthAsianethnicoriginonaverageexperiencemyocardialinfarctionratesat
anearlieragethanCaucasianpopulations.Thisistrueforbothmigrantpopulationsinhigh-income
countries and populations resident in South Asia. Hindu temples, a Mosque and a Bangladeshi
communitycentrewereusedtoconducthealthcheckstargetingthispopulationinLondon,UK.The
teamincludedfamilydoctors,healthcheckteammembersandtemplecommunityleadersanda
Bangladeshi community leader. All attendees of the check were positive about the checks, and
mentionedtheconvenienceandmotivatingattitudeofstaff.Byworkinginreligiousandcommunity
venues,therewasahighrecruitmentofthetargetpopulationincludingindividualswhohadnot
registeredwithadoctor,anopportunitytoeducatewholefamilies,andafeelingofmutualsupport
in the community. Some attendees noted that the community centre leant itself to a patientcentred rather ‘GP-centred’ consultation. However, some disadvantages, such as concern that
privacywassuboptimalandaneedtobetterensuredatatransfertohealthservicesforfollow-up
aschannellinghighriskpatientsbackintomainstreamservicesiskey.
Manyofthecommunityandreligiousleadersaddedtotheprogrammeinanumberofways.The
health care team highlighted the importance of community volunteers and ‘champions’; who
assistedwiththeadministrationoftheprogrammeandinspiredcommunityparticipation.Inthe
temple communities, prior to the visit, health education programmes were used to ‘prime’ the
targetpopulation.Theyalsoorganisedhealthpromotionactivities(e.g.healthycookingclasses),
whichcreatedacommunityspiritandmotivationtoenactlifestylechangesafterwards.
PARTNERSHIPSWITHCHARITYSECTOR
Thecharitysectoroftenhasastrongcommunityfocusandcanbeakeyplacetohelpshapethewider
socialdeterminantsofhealth.Becauseofthisdoctorsshouldconsidertheirroleinreferringpatients
tocharityandsupportservicesandhealthprofessionalsprovidingadvocacyandsupporttocharities
thatarehelpingtackleSDHandimprovinghealthequity.Forexamplethehospitalcharitypartnership
totacklehomelessnessdescribedbelow,demonstratehowthiscanbeeffective.
PATHWAY:CHARITYSECTORPARTNERSHIPTOTACKLEHOMELESSNESS[150]
Homelessness is an independent risk factor for premature mortality [4] and is associated with
extremesofdeprivationandmulti-morbidity.Theannualcostofunscheduledcareforhomeless
patientsiseighttimesthatofthehousedpopulation[1]andhomelesspatientsareoverrepresented
amongstfrequentattendersintheemergencyroom.Theaverageageofdeathforhomelesspeople
intheUKisjust47years(Themostcommonageatdeathwas86formenand89forwomenin
2011-2013). [151] Four acute hospitals, with a high proportion of homeless people who are
frequentattenders,havehighadmissionsandnumberofbeddays,havepartneredwiththecharity
pathwaytoprovidemoretargetedcarethataddressesthewiderdeterminantsofpeople’shealth.
55
The charity has developed a service that includes a GP, nurse and ‘care navigator’ (people with
experienceofhomelessnesswhoprovidepeersupportonthewardandforatimeafterdischarge)
thatarehiredonhonoraryhospitalcontracts.Thenurseinterviewsallpatientsinthehospitalwith
nofixedaddressorusingahosteladdresstodiscussthepatients’medicalandsocialhistoryandto
askthepatientwhattheywouldliketogainfromtheadmission.TheGPreviewsthegoalsandcare
plans,andplansthepatientsdischargewiththepatient.Oneofpathwayskeyrecommendations
followingfromreviewsistheneedformultiagencymeetingstocoordinatecare.Theyfoundthat
attendancewasimprovedbyhavingthebackingbyaseniorhospitalstaffmember.Thesemeetings
areattendedbywardstaff,localhousingoptionsmanager,socialworker,drugandalcoholworkers,
psychiatrists,streetoutreachworkers,hostelkeyworkersandmembersofthepathwayhomeless
team.Fromthese,anideal’multiagencyplanissketchedforthehomelessteamtodevelop.
Areviewoftheprogrammefoundadecreaseintheaveragelengthofhospitalstayforthisgroup,
andadownwardtrendinbedoccupancy.[152]
NATIONALPARTNERSHIPS
Theneedtoaddressthewiderdeterminantsofhealth,andreducethecostofhealthinequalityhas
leadanumberofgovernmentstodeveloptheHealthinAllPolicies(HiAP)approach.WhentheHiAP
approachisincorporatedintopolicymaking,theimpactonthehealthofthepopulationandhealth
inequalityaretakenintoaccountbyallsectorsandlevelsofpolicy-making(international,national,
regional and local). The approach aims to create synergies between the health sector and other
sectors and improve accountability of policymakers by emphasizing the impact to health systems,
determinantsofhealthandwellbeingofpolicies.ThisapproachhasbeenadoptedinSouthAustralia,
[153] Finland [13] and Wales in the UK [154]. In Norway, the Public Health Act of 2012 places
responsibility for public health work as a whole-of-government and a whole-of-municipality
responsibilityratherthanaresponsibilityforthehealthsectoralone[155]Doctorscanplayaleading
roleindevelopingHiAPsandassessingthelikelyimpactofotherpoliciesonhealthandparticularly
health equity. The Finnish governments have adoption of this principle to ensure that health
professionalsareseenaspartnersindecisionmakingisoutlinedbelow.
CASESTUDY:HEALTHINALLPOLICIES-FINLAND
Finlandisaworldleaderinpublichealthandhealthinequalitieshasbeenhighontheagendasince
the1980s,leadingtothedevelopmentofaninter-sectoralhealthpolicywasdevelopedtheNational
HealthforAllprogramme.[156]ThisprocesswasrevisedwhenFinlandenteredtheEuropeanUnion
in 1995 but remains high on the government agenda and the strategy was renewed with the
GovernmentresolutiononHealth2015.Internationally,theypromotedtheHealthinAllPolicies
agenda while EU presidents in 2006. Municipalities have a legislative duty to reduce health
inequality, promote health and wellbeing and report annually on this. There are clearly defined
responsibilitiesandco-operationbetweenadministrativesectors,privateenterpriseandotherlocal
actors.Thehealthcaresectorcontributesexpertisearoundhealth[156].
For example, an unhealthy diet was common in the 1980s especially for people in lower
socioeconomic groups, which increased the risk of CHD. In response the Finish government
developed a health-based policy to nutrition. This was developed by a number of ministries
56
includingtheMinistryofAgricultureandForestry,MinistryofFinance,MinistryofEducationand
MinistryofTradeandIndustry.Althoughfoodsafetyisnotthehealthsectorsresponsibility,there
wascollaborationwiththehealthsectortodevelopandadviseonthisprogramme.Thehealthand
educationsectorshavecollaboratedtodeveloppoliciesinareassuchashealthenhancingphysical
activityandhealthynutrition.Inaddition,freefoodcateringincomprehensiveschools,aswellas
subsidizedmealsforstudentsandworkerswereintroducedtoreducehealthinequalitiesassociated
withdietandnutrition.Whiledifferencesbetweenpopulationsisstillsignificant,thiscollaboration
andfocusonhealthinequalityareconsideredashavingcontributedtotheFinnishdietbecoming
healthierandthisgapbeingreduced[157]
At a symposium, Taru Koivisto, Director Ministry of Social Affairs and Health highlighted the
importanceofinvolvingthehealthsector,whichrequiresthatpeoplewithinthehealthsectorhave
time,resourcesandsufficientknowledgeofpoliciesinothersectorstoengagewithadialogue.There
isaneedforthehealthsectortobeawareoftheirownhealthprioritiesandhowthesefitwiththe
prioritiesofothersectorsformutualbenefit.[58]Thissuggeststhatthedevelopmentofthesocial
agencyofthemedicalprofessionshouldbeencouragedthroughouttheireducation,asdiscussedin
Section1.
RWANDA:CROSS-SECTIONALPLANNINGANDCOLLABORATIONTOTRAINHEALTH
PROFESSIONALSANDDELIVERACOMPREHENSIVECERVICALCANCERPROGRAMME
In1994lifeexpectancyinRwandawas28yearsand77.8%ofthepopulationwasbelowthepoverty
line[158].The1994genocidedecimatedanalreadyweakhealthsystemandworkforcewhofledor
werekilled,infectiousdiseasesandchildmortalityrapidlyincreased,with25%ofchildrendying
before reaching the age of five. [159] However, years of intensive rebuilding has led to
improvements,in2011lifeexpectancyhadincreasedto63years;thepercentageofthepopulation
belowthepovertylinehadreducedto44.9%in2012andunder-fivechildmortalityreducedby
70.4%between2000and2011.Rwandaisontargettoachieveeachofthehealthtargetssetinthe
MillenniumDevelopmentGoals.[160]Strategicpartnershipbetweendoctors,Rwanda’sMinistryof
Health, researchers, universities and development partners have led to a strengthened health
systemcapableofdeliveringthegovernmentvisionlaidoutinVision2020,[161]astrategyforsocial
andeconomicdevelopmentthatincorporateshealthinequality.RwandaisthefirstAfricancountry
to develop and implement a national strategic plan for cervical cancer vaccination, screening,
treatmentandcare.Cervicalcancerisoneofthemostcommoncancersaffectingwomenaround
theworld[162]anditdisproportionatelyaffectsthepoorestpopulationswith77%ofnewcasesand
88%ofdeathsattributedtocervicalcanceroccurringinthedevelopingworld[163].Toeffectively
deliver the vaccine throughout the country, the national government partnered with private
companies,communityleadersandthecommunitytodelivertheHPVvaccine,alongwithother
healthpreventioninitiatives.
In2009theRwandanMinistryofHealthformedapartnershipwithapharmaceuticalcompanyofa
HPVvaccineforanationalrollout.Teachersandvillageleaderswereenlistedinsensitizationefforts
andcommunityhealthworkers(CHWs)weremobilisedtotraceout-of-schoolgirls,morelikelyto
be in poverty. By doing this the principle of proportionate universalism was applied, a universal
programmewascombinedwithtargetedeffortstoreachthoseatriskofnotreceivingtheservice.
Since 2011 three ‘health days’ are organised each year to vaccinate girls in grade 6 of primary
school. These days also include the dissemination of adolescent health messages and the
dewormingof3.8millionchildren.In2012itwasplannedduringRwanda’sannualMaternaland
57
Child Health Week, which involves sensitisation about hand hygiene and reproductive health,
deliveryofmebendazole,ironandfolicacidtopregnantwomen,andtheprovisionofvitaminA
supplementationtochildrenandbreastfeedingwomen.Thishasledto93.2%coverageforallthree
doses of the HPV vaccine among eligible girls in 2011. [164] School based HPV vaccination
programmeshowtheeffectivenessofhealthauthoritiespartneringwithMinistriesofEducation,
Gender, and Local Government as well as development partners, religious organisations, and
communitymembers.
Thekeylessonsfromthisinitiativeincludethevalueofcross-sectoralcollaborationandplanning,
conducting sustained campaigns of communication and social mobilisation by using locally
employedCHWsandpartneringwithlocalleaderstoensurethattheuniversalservicewasdelivered
witheffortproportionatetotheneedsofdifferentgroups.
INTERNATIONALPARTNERSHIPS
PartnershipisakeypartofWMAsrole,andtheyhaveanofficialrelationshipwiththeWorldHealth
Organization (WHO) and other UN organisations and agencies as well as partnerships with
international health professional organisations, patient and student organisations. Professional
bodiescanalsopartnertomakejointstatements,whichaddsextraauthoritytothestatement.The
WMAhassuccessfullyworkedwithotherworldassociations.Forexample,In2008,theWMAandthe
InternationalCouncilofNurses(ICN)submittedajointstatement[165]totheHumanRightsCouncil
withaviewtoembeddingtheautonomyandfreedomfromreprisalofhealthprofessionalswithinthe
existingmandateoftheUNSpecialRapporteurontheRighttoHealthandtoincludingsurveillance
andactiononhumanrightsviolationsrelatedtohealthprofessionals.TheWMAisalsoamemberof
theWorldHealthProfessionsAlliance(WHPA),whichincludestheInternationalCouncilofNurses,the
InternationalPharmaceuticalFederation,theWorldConfederationforPhysicalTherapy,theWorld
DentalFederationandtheWorldMedicalAssociation.[166]In2013,theWHPAissuedastatement
outlining the importance on inter-professional collaboration and the importance of health system
infrastructure, governance, educational programmes, use of evidence and monitoring and the
importanceofpersoncentredpractice[167]Otherinternationalbodiesarealsovitallyimportantfor
health such as ILO, UNICEF, UNDP and UNICEF. It is imperative to partner with a broad range of
internationalorganisationstoeffectivelychampiontheSDH.
58
WHATTHEWMACANDO
•
•
•
•
developbetterinterprofessionalunderstandingandthuspartnershipworking
developideasforcollaborativework
work with other health professional representative groups, and other agencies, and
professionstoprepareguidanceandpolicyconceptstopromoteinter-professionalandcross
professionalworking,aswellascommunityintegration
createonlineregionaldiscussionsbetweenNMAse.g.AfricanForumontheSDH.
WHATNMASCANDO
•
•
•
•
•
•
disseminating the message that physicians should be working in partnership with health
professionals,localgovernmentsandcommunities
producingguidanceforphysiciansonpartnershipsintheircountry’scontext
createnetworksofphysicianstosharegoodpracticeanddevelopbestpractice
work with national governments to develop policies to reduce health inequality and
incorporatehealthconsiderationsintoallpolicydecisions
promotecommunityownershipofpublicpolicy
createactionplans:Createworkinggrouptodevelopactionplanstotacklehealthinequality
thatincludesalliedhealthprofessionals,andifpossible:publichealth,primaryandsecondary
providers.Theinvolvementofthelocalcommunityisalsoimportant.
INDIVIDUALANDCOMMUNITY
•
•
support physicians in providing care that is empowering to the patient and utilises the
strengthsofthecommunity
involvecommunityinpartnershipswiththehealthcaresectortodesignanddeliverhealth
careactionontheSDH.
WithWiderPublic:
•
shapenationalnarrativeanddebatebyengagingpolicymakersandthegeneralpublicutilising
socialmediawhereappropriate
WHATDOCTORSCANDO
•
•
•
work with others, including non-health workers to create networks based upon
empoweringpatientsandapersoncentredapproachtocare.
shareexperiencesofwhatworks
feedbacktoNMAsonthechangesneededwithinhealthpolicytoreinforcebestpractice
59
6.ASADVOCATES
A doctors’ role as an advocate is stated in various professional charters and standards around the
world.[168]Howeverhowthisisconceptualisedineverydaypracticeislessclearandhasledtoa
debatewithintheprofession.Traditionallyadvocacyhasfocusedonincreasingaccesstoservicesand
drugs.Whilethisisavitallyimportantrolefordoctors,theSDHmodel,whichframeshealthwithin
thebroadercontextofpeople’slives,meansthatadvocacyneedstohaveabroaderremitifitisto
effectivelyreducehealthinequality.Doctorsroutinelyusetheirknowledgeandskillstoadvocatefor
healthcareandhealthcaresystemsimprovement;itisessentialthattheyalsoadvocateforbroader
changes that will reduce health inequities by tackling the social determinants of health. In its
DeclarationofOslotheWMAhascommittedtothis,andthroughthisreportandotherworkseeksto
help physicians and national Medical Associations take effective actions. Based on their skills and
experiences, doctors have substantial contributions to make at all stages of the decision-making
process.Thereareinspiringexamplesfromaroundtheworldofindividualdoctors,groupsofdoctors
andmedicalassociationsadvocatingforindividualpatientsandthecommunitiesthattheyserve,for
thehealthsystemandstaff,andthebroaderpolicylevel(nationalandinternational)whichwillimpact
onthehealthofindividualsandthepopulation.
ADVOCATINGFORINDIVIDUALSANDCOMMUNITIES
Advocacyforpatientsisgenerallyconsideredanappropriateroleformanydoctorsandotherhealth
professionals. This often includes advocacy outside the health care system. For example, a doctor
couldwritetohousingauthoritiesonbehalfofachildwithasthmalivinginadamphome,ontheneed
for refurbishment or rehousing. If a detailed social history is taken of patients, as outlined in the
sectiononworkingwithindividualsandcommunities,aclearerunderstandingoftheneedsofpatients
can be understood, and therefore, more effective advocacy would be possible. Doctors have also
gotteninvolvedinadvocatingfortheneedsofspecificcommunities,suchasthecollectiveadvocacy
ofdoctorsinSpainfollowingtheRoyalDecree-Lawasoutlinedbelow.
MEDICALORGANISATIONSADVOCATINGFORPOLICYCHANGEINSPAIN:
SociedadEspañoladeMedicinadeFamiliayComunitaria–semFYC(theSpanishSocietyforFamily
andCommunityMedicine)andMédicosdelMundo-MdM(DoctorsoftheWorldSpain)
On20April2012theRoyalDecree-Law16/2012waspassedinSpain,whichledtotheexclusionof
undocumented migrants from access to healthcare, tied healthcare coverage to employment
status,andincreasedout-of-pocketchargesformedication.Theonlyremainingpointofentryfor
manypeoplewasthroughhospitalaccidentandemergencyservices,whichmeanthat,increasingly,
diseasesandvictimsofviolencewerenotidentifiedandgiventhenecessarycareandtreatment.
Excludingvulnerablegroupsfromaccesstohealthcarewillincreasehealthinequalityandhavean
effect on the whole of the population. Some experts have already predicted that, as a result of
denialofaccesstohealthcareandmedicationsforabout2%ofthepopulation,therewillbean
increaseofcommunicablediseasessuchasHIVandtuberculosisinthepopulationasawhole.Other
experts warned of the probability of an increase in mental health problems, including cases of
suicide.ManyhumanrightsgroupsincludingAmnestyinternationalsaidthatthelawbrokemany
existinginternationalacts.
60
In2012the“DerechoaCurar”(RighttoCare)campaignwaslaunchedbysemFYC,MdMandother
organisationsinvolvedinprimaryandspecialisthealthservices,aswellasarangeofsocialsector
organisations and European networks engaged in defending migrants’ rights. They mobilised
medical personnel, calling on them to object on grounds of conscience to the new measures.
Variouspromotionalmaterialsweremadeavailableonlinetoprovidepublicityforthecampaign,
disseminate information and enable health professionals and the general public to support the
campaign.Theseincludedposters,videos,carstickersandwidgetsforsocialmedia..Anumberof
campaignvideosweremadeandhadbeenviewedbyover253,000peopleinafewmonths.When
theprotestcampaignagainstthelawwasre-launchedinthesocialmediainsummer2013withthe
videoseries#leyesquematan(lawsthatkill),itbecameatrendingtopiconTwitter.In2013,the
Nadie Desechado campaign revealed how the healthcare reform, announced as affecting ‘only’
migrants, also excludes all of society’s most vulnerable groups from the healthcare system, in
particularpeoplewithchronichealthconditions.Tensofthousandsofsignaturesinsupportofthe
campaignwerecollected.
MdM has promoted the establishment of ‘observatories’ to document as accurately as possible
casesencounteredandbarrierstoaccessinghealthcareandsofarrecordedmorethan1,000cases
ofviolationoftherighttohealthcare,andhaspreparedreportswhichhavebeensubmittedtothe
HealthCommissionoftheCongressofDeputiesandtotheOmbudsman.
MdMandsemFYCurgeshealthworkerstoresistandtoobjecttothelawongroundsofconscience,
andtocontinuetotreatallpeopleinneedofhealthcare,regardlessoftheiradministrativestatus.
During the first phase of the campaign, more than 2,000 health professionals formally declared
theirrefusaltoimplementtheexclusionsrequiredunderlaw.Inaddition,19,000signatureswere
collectedinsupportofalettersubmittedtotheMinisterofHealthatthebeginningofJanuary2014.
A number of regions such as Andalusia and Catalonia kept providing health care to illegal
immigrants.
InMarch2015,justbeforeageneralelection,governmentoverturnedthelaw.[169]ThePrime
MinisterRajoycitiedrationalefromthecampaignwhenexplainingthechangeinpolicy“Itseems
moresensibleandmorereasonableforprimaryhealthcaretobecarriedoutinhealthcentresso
that,amongotherthings,emergencycentresarenotoverwhelmed.”[170]
ADVOCATINGFORTHEWORKINGCONDITIONSOFDOCTORS,ANDOTHERHEALTHSTAFF
Adverseworkingconditionsofhealthcarestaff(andstudents)willnotonlyhaveanadverseeffecton
individualshealthandwellbeing,butcanleadtoreducedqualityofcareforpatientsincludingpatient
safety.[171] Burnout is a long-term stress reaction often seen in human service professions. It is a
“psychological syndrome of emotional exhaustion, depersonalization and reduced personal
accomplishment”. [172] Changes in medical practice across the world over the last 20 years have
resultedinadeclineinautonomy,diminishedstatusofphysiciansandincreasedworkpressurehas
ledtoincreasedburnoutintheprofession.[173]Servicestosupportthehealthandwellbeingofhealth
professionalsareinconsistentandoftenlacking.Thereisalsoinequalityinwhohasaccesstothese
serviceswhentheyarepresent.Forexample,intheUKanauditrevealedthatstaffworkinginNHS
servicesthatarenotdirectlycontractedbyNHSorganisationsdonothavethesameaccesstosupport
ascolleagueswhoaredirectlyemployedbyNHSorganisations,[171]Self-careandadvocatingforthe
healthandwellbeingofallstaffandstudentsinthehealthsystemwillleadtoaworkforcemoreready
61
totacklethesocialdeterminantsofhealth.TheWMAsupportsthehumanrightsofdoctorsandoften
intervenesonbehalfofdoctorswhohavebeenpersecutedorimprisonedfortheirhumanrights.
MEDICALPROFESSIONASADVOCATES
WMAASADVOCATES
Astheonlyorganisationrepresentingthevoiceofthemedicalprofessionglobally,theWMAconsiders
advocacyoneofitskeyprioritiesontheinternationalscene.TheWMAhasalonghistoryofadvocacy
inarangeofareas.Inthefieldofethics,WMAiscelebratingthe50thanniversaryoftheDeclaration
ofHelsinki,oneoftheWMA’sbestknownpolicystatementofethicalprinciplesformedicalresearch
involvinghumansubjects,includingresearchonidentifiablehumanmaterialanddata.[174]Thiswas
originallyaresponsetothesystematisedabuseofmedicalresearchinthe1930sand1940s,buthas
developed to reflect the development of a more sophisticated understanding of patients’ rights,
including autonomy, and the involvement of patients and community members in monitoring the
qualityofhealthcareresearch.[175]Ithasbeenhugelyinfluentialtheworldover.
TheWMAhasadvocatedforthedevelopmentofcoordinatedpublichealthpoliciesinordertoprevent
disease,prolonglifeandimprovehealthstatusofallinareassuchastobaccocontrol[176],violence
against women [177] and the social determinants of health [18]. The WMA also has a role in
encouragingandeducatingdoctorsinbecomingleadersandadvocates,andhasdonethis through
initiativesliketheWMACaringPhysiciansoftheWorldInitiativedescribedbelow.
WMA:CARINGPHYSICIANSOFTHEWORLDINITIATIVE[178]
TheWMAadvocatesforthedevelopmentofcomprehensive,sustainable,fullyfunctioninghealth
caresystems(includingmedicaleducation).PastPresidentofWMAYankD.CobleJr.MD(2004)
introducedtheCaringPhysiciansoftheWorldInitiative.Itspurposewastocelebrateandinspire
doctorsoftheworld,andencouragethemtobecomeadvocatesandleaders.Theinitiativeincluded
the development of a book and a training course that ran over a number of years to develop
physician’sleadershipskills.
TheDeclarationofOslo,onthesocialdeterminantsofhealthhasnowbeenformallyadoptedbythe
WMACouncilmeetingin2015[19].TheWMA’srolegoingforwardistobuildonthisDeclarationand
utiliseitsinfluenceandroleasanadvocatetopushthisagendaforward.TheWMAshouldalsosupport
medicalassociationstocreatecountryspecificactionplans.
MEDICALASSOCIATIONSASADVOCATES
Manymedicalassociationsconsideradvocacyoneoftheircoreaims,particularlyinfluencingpublic
policy to promote best practice in healthcare, guaranteed to citizens.For example the Bangladesh
62
Medical Association states one of its aims to: Consider and express its views on all the laws
promulgated in Bangladesh in connection with medical profession, medical practice or medical
education,andtokeepakeeneyeoverlegislationinBangladeshwhichconcernspublichealth,medical
professionormedicaleducationandtakesuchstepsandadoptsuchmeasuresfromtimetotimeas
may be deemed expedient. [179] The Finnish Medical Association state that they ‘believe that the
expertiseofdoctorshavealottoaddtopublichealthpolicy.’[180]TheIrishMedicalOrganisation
havelaunchedacampaigntoensurehealthcareiscentrestageatthenextelection,andhavereleased
apolicydocumentoutliningthekeypressuresonthehealthserviceandsuggestedareasthatshould
befocusedon,includinghealthinallpolicies.[181]Thisroleneedstobeharnessedtoaddressthe
socialdeterminantsofhealthintheirowncountries.NMAsshouldworktogethertoincreasetheir
powerasadvocates.
DOCTORSASADVOCATESFORPOLICYCHANGE
Asoutlinedinprevioussections,doctorshavearoleinadvocatingforSDHtobemoreincorporatedin
medicaleducation,withindividualpatients,theirlocalcommunity,andthoseemployedwithinthe
health sector. Their role as advocates should be supported by NMAs and WMAs, and encouraged
througheducationaltraining,whereskillsandleadershiptrainingshouldbeprovided.Althoughnot
compulsory,doctorscanalsohavearoleininformingpublicdebateandencouraginghealthprotective
policies, as the case study below demonstrates. This role is part of many charters on professional
responsibility, such as the American Medical Association’s (AMA) Declaration of Professional
Responsibility:Medicine’sContractwithHumanity,statesthatdoctorsshould“Advocateforsocial,
economic,educational,andpoliticalchangesthatamelioratesufferingandcontributetohumanwellbeing.”[182]
PHYSICIANSFORABASICINCOMEGUARANTEEINONTARIOCANADA[183][184]
InAugust2015,194physiciansinOntarioCanadasignedalettertotheMinisterofHealthandLongTermCareaskingforleadershipinintroducingatrialforaBasicIncomeGuarantee(BIG).
They define a BIG as “ensures everyone an income sufficient to meet basic needs and live with
dignity, regardless of work status.” A BIG for all: “ensures that everyone can meet their needs,
participateinsocietyandlivewithdignity.Itreducessteepincomeinequalitiesandcontributesto
betterhealthandfewersocietalproblems,openingthedoortolong-termsavingsinhealthcare
andotherpublicservices.Itenablespeopletomanagetransitionsandsetbacks,supportscreativity
andentrepreneurship,andkeepsmoneymovingandproducinginoureconomy.”[185]Along-term
aimofthispolicywouldbetoreducehealthinequality.
STUDENTSASADVOCATES
As demonstrated in the example below, student doctors are often very committed advocates for
improving health equity. However, during the education process this passion often dissipates. A
longitudinalstudyofempathyscoresintheUSAfoundthattheempathyofmedicalstudents’scores
diminish throughout their education, most notably in their third year, when they begin to interact
withpatients.[186]Thismatchesotherstudies,whichfoundasimilardeclineinempathy,compassion
andhumanitarianattitudesbymanystudentsastheyprogressthroughtheirmedicaleducation[187]
[188].Effortshavebeenmadetounderstandwhythisoccurs.Qualitativeanalysissuggeststhatfactors
63
such as lack of adequate role models, a demanding curriculum, time pressure, sleep deprivation,
dominanceofthebiomedicalmodelineducationwhichpromotesclinicalneutralityandemotional
detachment,lackofappreciationandafearofmakingmistakeswerealloutlinedascontributingto
this marked decline in empathy or ‘socialised amnesia’. [189] While patients are taught that they
should be empathetic in order to provide more patient centred care and to act as advocates for
patients,anumberoffactorscreatebarriersforthistohappen.
STUDENTSADVOCATINGFORTHESOCIALDETERMINANTSOFHEALTH:IFMSA[190]
In2011,theInternationalFederationofMedicalStudents’Associations(IFMSA),whichrepresents
1·2millionmedicalstudentsworldwide,madehealthinequitiesandactiononsocialdeterminants
of health a key policy focus. It proposed that propose that civil society groups, for example,
concerned with HIV/AIDS, maternal and child health, non-communicable diseases, and climate
change,bringtheiragendastogetherunderthebannerofthesocialdeterminantsofhealthtoturn
current disease orientated silos into a global coalition for health equity. It recommended that
globallyagreedindicatorsofhealthinequalitywereestablishedandusedforcountriestomeasure
progress. They proposed that students from disciplines beyond the health sector, such as law,
economics,business,politics,andenvironment,alsoreceivetraininginthesocialdeterminantsof
health.
64
WHATTHEWMACANDO
•
•
•
•
BuildontheDeclarationofOslo
promoteSDHinallitpublications,policiesandspeeches
advocateataninternationallevelforSDHandhealthinequality
workwithothers,includingtheWHPA,todevelopaninter-professionalunderstandingofSDH
WHATNMASCANDO
•
•
•
•
•
•
advocateforchangetotheeducationsystemtoincludetheSDH
advocateforpolicychangesatthelocalandnationallevel
advocateonbehalfoftheirworkforce
advocateatnational,regionalandlocallevelforpolicieswhichrecognisetheimportanceof
anSDH-based/lifecourseapproachincludingconsiderationofHealthinAllPolicies
undertakeadvocacyonbehalfoftheirmembership,involvingthosememberswhofeelable
toworkasadvocates
advocateforindividualsandcommunities
WHATDOCTORSCANDO
•
•
•
•
•
•
usetheavailableevidenceinalldiscussionsonhealthtodemonstratewhytheSDHmatter
andtopromotetheirinclusionattheheartofpolicymaking
advocateforSDHtobemoreincorporatedinmedicaleducation,withindividualpatients,their
localcommunity,andthoseemployedwithinthehealthsector.
advocateonbehalfofindividualpatientsandimprovementsinconditionsintheSDH
insistontheirmemberorganisationsundertakingadvocacyonanationalbasis
providematerialsincludingcasestudiestoinformadvocacyandtodemonstratetheperson
attheheartoftheactivity
advocateonbehalfofcommunitiesandimprovementsinconditionsintheSDH
WHATSTUDENTSCANDO
•
•
studentgroupscouldproduceaco-writtenstatementaskingforthesocialdeterminantsof
healthtobeincludedontotheeducationcurriculum
student groups should work with trained colleagues to provide convincing arguments for
reshapingcurricula
65
CONCLUSION
TheWMAhasprioritisedtheimportanceofaddressingthesocialdeterminantsofhealthaskeyto
tacklinghealthinequality.[19]Thisisinresponsetoagrowingbodyofevidencedemonstratingthe
powerful effect of doctors working at all levels to tackle health inequality. This ranges from
consultationswithpatientstoengaginginpublicdebate.Doctorshavealwaysbeenattheforefront
oftacklinghealthinequality,anditisclearthatdoctors,NMAsandtheWMAhaveakeyroleintackling
healthinequalityinternationally,atanationallevel,atthelocallevel,andforindividualsandtheir
families.Inresearchingthisreportwehavebeeninspiredbythewiderangeofareasinwhichdoctors
areattheforefrontofaddressingthesocialdeterminantsofhealththeworldover.Whetheritwas
studentsadvocatingformarginalisedcommunitiesorseniordoctorsdesigningprogrammestofitthe
needs of communities, or working with government to create more equitable health policies. This
reportaimstohighlightthesestoriesandtofocusonthekeyareasbywhichdoctorscouldinfluence
healthinequality.Thisrequiresactioninthefollowingareas:
1.theeducationandtrainingofdoctors:toequipdoctorswiththenecessaryskillsandinspirethem
totaketheagendaforward
2.effectivemonitoringandevaluationofprogrammes,tobetterunderstandtheimpactofthesocial
determinantsofhealthatthelocalandnationallevel,andimportantlytoprovideanimperativefor
action
3.workingwithindividualsandcommunities:byre-evaluatingthepatientphysicianrelationship,and
therelationshipofdoctorsinthecommunity,sothathealthservicescanbebetterdesignedtomeet
theneedsofthosemostinneed
4.tacklinginequalitywithinthehealthsystem:asalargesourceofemploymenttheworldover,the
healthsystemhasalargeabilitytoimproveinequalitybysettinganexampleasaproviderofgood
qualityworktoeveryoneitemploysandsetastandardinemploymentforthosecontractedthrough
procurement.
5.workinginpartnership:canensurethatcommunitiesandthehealthserviceareeffectivelyengaged
toaddressissuesatthelocal,nationalandinternationallevel
6.actingasadvocates:doctorshavearesponsibilitytoadvocateonbehalfofpatients,thisshouldbe
extendedtoincludebroadersocialdeterminantsofhealth.
Thepriorityforactionwilldependonthelocalcontextandavailableresources,andmanyNMAsand
doctorswillbeconstrainedbylimitedresources.However,thisdoesnotmeanthatanyactionisnot
possible.Effectiveactionrangesfromverysmallchangesinwhatdoctorsregularlydo,tosystematic
changesatthenationallevelaswasillustratedwiththecasestudiesthroughoutthereport.
Thisreportisjustthefirststepinalargerbodyofworktobetterintegratethesocialdeterminantsof
healthintotheeverydayworkofdoctorstheworldover.TheWorldMedicalAssociationplanstobe
attheforefrontofthisshiftinfocusandharnessthepotentialofdoctorstoreducehealthinequality.
Itisclearthatwhilemuchisbeingdone,thereisaneedfordoctorstodosomething,domore,do
better.
66
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