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 REFERENCES 1. Marmot,M.,Fairsociety,healthylives:theMarmotreview;strategicreviewofhealth inequalitiesinEnglandpost-2010.2010:[S.l.]:TheMarmotReview. 2. WorldHealthOrganization,Worldhealthstatistics2015,WorldHealthOrganization,Editor. 2015:Luxembourg 3. WHOCommissiononSocialDeterminantsofHealth,ClosingtheGapinaGeneration:Health EquityThroughActionontheSocialDeterminantsofHealth:CommissiononSocial DeterminantsofHealthFinalReport.2008:WorldHealthOrganization. 4. Roberts,J.,MarmotIndicators2015:Apreliminarysummarywithgraphs.2015,UCL InstituteofHealthEquity. 5. DemographicandHealthSurvey.STATcompiler.[cited201509/10/2015];Availablefrom: http://beta.statcompiler.com/. 6. Marmot,M.,etal.,Fairsociety,healthylives:Strategicreviewofhealthinequalitiesin Englandpost-2010.2010. 7. Bassett,M.T.,#BlackLivesMatter—AChallengetotheMedicalandPublicHealth Communities.NewEnglandJournalofMedicine,2015.372(12):p.1085-1087. 8. Marmot,M.G.,ReviewofsocialdeterminantsandthehealthdivideintheWHOEuropean Region:finalreport.2013:WorldHealthOrganization,RegionalOfficeforEurope. 9. Giele,J.Z.andG.H.Elder,Methodsoflifecourseresearch:Qualitativeandquantitative approaches.1998:SagePublications. 10. Kawachi,I.,etal.,Socialcapital,incomeinequality,andmortality.Americanjournalofpublic health,1997.87(9):p.1491-1498. 11. WorldHealthOrganizationRegionalOfficeforEurope,Reviewofsocialdeterminantsandthe healthdivideintheWHOEuropeanRegion:finalreport.2014,WorldHealthOrganization RegionalOfficeforEurope:Brussels,. 12. Mendelsohn,R.,A.Dinar,andL.Williams,Thedistributionalimpactofclimatechangeon richandpoorcountries.EnvironmentandDevelopmentEconomics,2006.11(02):p.159178. 13. Stahl,T.,etal.,HealthinAllPolicies:Prospectsandpotentials.2006,MinistryofSocialAffairs andHealth:Finland. 14. WorldHealthOrganization,Healthinallpolicies:trainingmanual,V.Stone,Editor.2015: Italy. 15. PublicHealthEngland,HealthEquityinAllPoliciesMasterclass:Executivesummary,L. Toleikyte,Editor.2015:London. 16. WorldMedicalAssociationandonbehalfoftheWorldHealthProfessionsAlliance, StatementontheSocialDeterminantsofHealth,inWorldHealthAssembly.2009:Geneva. 17. WorldMedicalAssociation,WMAStatementonInequalitiesinHealth,inWMAGeneral Assembly.2009:NewDelhi,India. 67 18. WorldMedicalAssociation,WMAStatementonSocialDeterminantsofHealth,inWMA GeneralAssembly.2011:Montevideo,Uruguay. 19. WorldMedicalAssociation.WMADeclarationofOsloonSocialDeterminantsofHealth.2015 [cited201517/12];Availablefrom:http://www.wma.net/en/30publications/10policies/s2/. 20. Popay,J.,etal.,Socialproblems,primarycareandpathwaystohelpandsupport:addressing healthinequalitiesattheindividuallevel.PartI:theGPperspective.JournalofEpidemiology andCommunityHealth,2007.61:p.966-971. 21. Franks,P.andK.Fiscella,ReducingDisparitiesDownstream:ProspectsandChallenges. JournalofGeneralInternalMedicine,2008.23(5):p.672-677. 22. Clarke,E.,L.Fitzgerald,andA.Mutch,Theroleofprimarycareinaddressingthesocial determinantsofhealth:Asystematicreviewofrecommendationsforgeneralpractice. [Forthcoming]. 23. Allen,M.,etal.,Workingforhealthequity:theroleofhealthprofessionals.2013,UCL InstituteofHealthEquity:London. 24. TheFutureHospitalCommission,Futurehospital:caringformedicalpatients.2013,Royal CollegeofPhysicians:London. 25. RoyalCollegeofGeneralPractitioners,ImprovingaccesstohealthcareforGypsiesand Travellers,homelesspeopleandsexworkers:Anevidence-basedcommissioningguidefor ClinicalCommissioningGroupsandHealth&WellbeingBoards.2013,RoyalCollegeof GeneralPractitioners:London. 26. Taylor,J.,D.Wilkinson,andB.Cheers,Workingwithcommunitiesinhealthandhuman services.2008:OxfordUniversityPress. 27. AustralianMedicalAssociation.SocialDeterminantsofHealthandthePreventionofHealth Inequities.2007[cited201509/10/2015];Availablefrom:https://ama.com.au/positionstatement/social-determinants-health-and-prevention-health-inequities-2007. 28. Frenk,J.,etal.,Healthprofessionalsforanewcentury:transformingeducationtostrengthen healthsystemsinaninterdependentworld.Thelancet,2010.376(9756):p.1923-1958. 29. ChinaMedicalBoard.HealthProfessionalsforthe21stCentury.[cited201501/04]; Availablefrom:http://www.chinamedicalboard.org/health_professionals_21st_century. 30. GeneralMedicalCouncil,Nationaltrainingsurvey2013:socioeconomicstatusquestions. 2013,GeneralMedicalCouncil:London. 31. MedicalSchoolsCouncil,AJourneytoMedicine:StudentSuccessGuidance2014:London. 32. BMAEqualOpportunitiesCommittee,EqualityanddiversityinUKmedicalschools.2009, BritishMedicalAssociation:London. 33. Rao,V.andG.Flores,Whyaren'ttheremoreAfrican-Americanphysicians?Aqualitative studyandexploratoryinquiryofAfrican-Americanstudents'perspectivesoncareersin medicine.JournaloftheNationalMedicalAssociation,2007.99(9):p.986. 68 34. Kington,R.,D.Tisnado,andD.M.Carlisle,Increasingracialandethnicdiversityamong physicians:aninterventiontoaddresshealthdisparities.Therightthingtodo,thesmart thingtodo:Enhancingdiversityinthehealthprofessions,2001:p.57-75. 35. Cohen,J.J.,B.A.Gabriel,andC.Terrell,Thecasefordiversityinthehealthcareworkforce. HealthAffairs,2002.21(5):p.90-102. 36. UniversityofGlasgow.Wideningopportunitiesforalltostudymedicine.2014[cited2015 09/10];Availablefrom: http://www.gla.ac.uk/news/archiveofnews/2014/december/headline_383033_en.html. 37. RepublicofRwanda,HumanResourcesforHealthProgram.Strategicplan2011-2016,M.o. Health,Editor.2011. 38. Huish,R.andJ.M.Kirk,CubanMedicalInternationalismandtheDevelopmentoftheLatin AmericanSchoolofMedicine.LatinAmericanPerspectives,2007.34(6):p.77-92. 39. Souers,J.CUBALEADSTHEWORLDINLOWESTPATIENTPERDOCTORRATIO;HOWDOTHEY DOIT?2015[cited201509/10];Availablefrom: http://www.socialmedicine.org/2012/07/30/about/cuba-leads-the-world-in-lowest-patientper-doctor-ratio-how-do-they-do-it/. 40. Porter,C.,Cuba-traineddoctorsmakingdifferencearoundtheworld,inTheStar.2012: Toronto. 41. PolicyTeam,Tacklingthesocialdeterminantsofhealththroughculturechange,advocacy andeducation.2010,RoyalCollegeofPhysicians,. 42. Maryon-Davis,A.,Howcanwebetterembedthesocialdeterminantsofhealthinto postgraduatemedicaltraining?ClinicalMedicine,2011.11(1):p.61-63. 43. O'Brien,M.J.,etal.,Trainingmedicalstudentsinthesocialdeterminantsofhealth:the HealthScholarsProgramatPuentesdeSalud.AdvMedEducPract,2014.5:p.307-14. 44. Berlin,A.,UCLMedicalSchoolSocialDeterminantsofHealthmoduleS.Thomas,Editor.2015. 45. LeedsSchoolofMedicine.WorkinginPartnershipwithpatients,carersandtheirfamilies. [cited201509/10];Availablefrom: http://medhealth.leeds.ac.uk/info/256/patients_and_carers//. 46. Gabriel,B.A.,BeyondHospitalWalls:TeachingStudentsAboutSocialDeterminantsof Health.2012,AAMCReporter:AssociationofAmericanColleges. 47. Suurmond,J.L.,P.Hudelson,andN.Dogra,Cultureandhealth.TheLancet,2015.385(9968): p.602. 48. Faulkner,L.R.andR.L.McCurdy,Teachingmedicalstudentssocialresponsibility:theright thingtodo.AcademicMedicine,2000.75(4):p.346-350. 49. Dharamsi,S.,etal.,Thephysicianashealthadvocate:translatingthequestforsocial responsibilityintomedicaleducationandpractice.AcademicMedicine,2011.86(9):p.11081113. 50. Wong,W.,SDHincurriculumforprimarycareHongKong,J.Allen,Editor.2015. 69 51. Vaidya,A.,etal.,Acquaintancewiththeactuality:communitydiagnosisprogrammeof KathmanduMedicalCollegeatGunduvillage,Bhaktapur,Nepal.2008. 52. WorldHealthOrganization,WHOeBookonintegratingaSocialDeterminantsofHealth ApproachintoHealthWorkforceEducationandTraining,inFirstMeetingoftheSteering Group.2014,WHO:Geneva. 53. Hunt,P.,Reportonprogressandobstaclestothehealthandhumanrightsmovement2007, OfficeoftheUnitedNationsHighCommissionerforHumanRights:Geneva. 54. Flowers,M.NationwideMedicalStudents'Die-In,#WhiteCoats4BlackLives.2014[cited2015 01/04];Availablefrom:https://www.popularresistance.org/nationwide-medical-studentsdie-in-whitecoats4blacklives/. 55. InternationalFederationofMedicalStudents'Associations.TheIFMSAGlobalHealthEquity Initiative.[cited201501/04];Availablefrom: http://www.ifmsa.org/Activities/Initiatives/The-IFMSA-Global-Health-Equity-Initiative. 56. AustralianMedicalStudents'Association,HealthInequitiesandTheirSocialDeterminants.. 2011. 57. Jong-wook,L.,AddresstoWHOstaff.2003,WHO:Geneva. 58. Buckley,J.,REPORTOFTHEGLOBALSYMPOSIUM:,inTheroleofphysiciansandnational medicalassociationsinaddressingthesocialdeterminantsofhealthandhealthequity.2015, CanadianMedicalAssociation:BMAHouse,London. 59. Plough,A.,DevelopingNewSystemsofDatatoAdvanceaCultureofHealth.eGEMs,2014. 2(4). 60. Bloch,G.,Poverty:AclinicaltoolforprimarycareinOntario,S.M.s.Hospital,Editor.2013, OntarioCollegeofFamilyPhysicians:Toronto. 61. UCLInstituteofHealthEquity.MarmotIndicators2014.201410/11/2014];Availablefrom: http://www.instituteofhealthequity.org/projects/marmot-indicators-2014. 62. PublicHealthEngland.PublicHealthOutcomesFramework.201416/05/2014];Available from:http://www.phoutcomes.info/. 63. Westert,G.,etal.,Monitoringhealthinequalitiesthroughgeneralpractice:theSecondDutch NationalSurveyofGeneralPractice.TheEuropeanjournalofpublichealth,2005.15(1):p. 59-65. 64. Thomson,L.J.,P.M.Camic,andH.J.Chatterjee,SocialPrescribing:Areviewofcommunity referralschemes.2015,UniversityCollegeLondon:London. 65. Phillips,G.,etal.,WellLondonPhase-1:resultsamongadultsofacluster-randomisedtrialof acommunityengagementapproachtoimprovinghealthbehavioursandmentalwell-being indeprivedinner-cityneighbourhoods.Journalofepidemiologyandcommunityhealth, 2014:p.jech-2013-202505. 66. Derges,J.,etal.,‘WellLondon’andthebenefitsofparticipation:resultsofaqualitativestudy nestedinaclusterrandomisedtrial.BMJopen,2014.4(4):p.e003596. 70 67. Project,M.V.SectorStrategy.2013[cited201509/10];Availablefrom: http://millenniumvillages.org/about/sector-strategy/. 68. Sinai,I.S.o.M.a.M.AsthmaMobileHealthStudy.2015[cited201509/10];Availablefrom: http://apps.icahn.mssm.edu/asthma/. 69. Garratt,A.,E.Solheim,andK.Danielsen,Nationalandcross-nationalsurveysofpatient experiences:astructuredreview.2008,NorwegianKnowledgeCentrefortheHealthServices (Kunnskapssenteret):Oslo. 70. NHSYorkshireandTheHumber,PreventionandLifestyleBehaviourChange:ACompetence Framework.2010. 71. Wilson,A.andS.Childs,Therelationshipbetweenconsultationlength,processandoutcomes ingeneralpractice:asystematicreview.BritishJournalofGeneralPractice,2002.52(485):p. 1012-1020. 72. Howie,J.,etal.,Longtoshortconsultationratio:aproxymeasureofqualityofcarefor generalpractice.BritishJournalofGeneralPractice,1991.41(343):p.48-54. 73. Wilson,A.,etal.,Healthpromotioninthegeneralpracticeconsultation:aminutemakesa difference.Bmj,1992.304(6821):p.227-230. 74. Deveugele,M.,etal.,Consultationlengthingeneralpractice:crosssectionalstudyinsix Europeancountries.Bmj,2002.325(7362):p.472. 75. OECD/WHO,Consultationswithdoctors,inHealthataGlance.2012:OECDPublishing. 76. Stirling,A.M.,P.Wilson,andA.McConnachie,Deprivation,psychologicaldistress,and consultationlengthingeneralpractice.BritishJournalofGeneralPractice,2001.51(467):p. 456-460. 77. Mercer,S.W.,etal.,Multimorbidityandtheinversecarelawinprimarycare.Vol.344.2012. 78. Westert,G.P.,L.Jabaaij,andF.G.Schellevis,Morbidity,performanceandqualityinprimary care:Dutchgeneralpracticeonstage.2006:RadcliffePublishing. 79. Hampson,M.,K.Langford,andP.Baeck,RedefiningConsultations:changingrelationshipsat theheartofhealth,J.Temperley,Editor.2013,NESTA:London. 80. Behforouz,H.L.,P.K.Drain,andJ.J.Rhatigan,RethinkingtheSocialHistory.NewEngland JournalofMedicine,2014.371(14):p.1277-1279. 81. Moscrop,A.andP.MacPherson,Shoulddoctorsrecordtheirpatients’income?British JournalofGeneralPractice,2014.64(627):p.e672-e674. 82. Brcic,V.,C.Eberdt,andJ.Kaczorowski,Developmentofatooltoidentifypovertyinafamily practicesetting:apilotstudy.Internationaljournaloffamilymedicine,2011.2011. 83. Chauvin,P.,etal.,Accesstohealthcareforpeoplefacingmultiplehelathvulnerabilitiesin health.2015,DoctorsoftheWorld:Paris. 84. Jones,E.,Consultationswithpatients,S.Thomas,Editor.2015. 85. Barber,N.,etal.,Patients’problemswithnewmedicationforchronicconditions.Qualityand Safetyinhealthcare,2004.13(3):p.172-175. 71 86. NationalHauoraCoalition,MāoriHealthInnovationProgramme:Sharingknowledge, innovation andsuccessfulpractises.2012,NationalHauoraCoalition,:Auckland. 87. Swift,J.,AnInvestigationintoGPsandSocialPrescribing.APilotStudy.2007,Glasgow CentreforPopulationHealth:Glasgow. 88. VoluntaryActionRotherham.SocialPrescribingService.[cited201509/10];Availablefrom: http://www.varotherham.org.uk/social-prescribing-service/. 89. Dayson,C.,N.Bashir,andS.Pearson,Fromdependencetoindependence:emerginglessons fromtheRotherham SocialPrescribingPilot.2013,SheffieldHallamUniversity:Sheffield. 90. PopulationCouncil,LivingUptoTheirName:ProfamiliaTakesonGender-basedViolence,D. Rogow,Editor.2006,PopulationCouncil:NewYork. 91. WorldMedicalAssociation,WMAResolutiononViolenceagainstWomenandGirls,in61st WMAGeneralAssembly,.2010:Vancouver,Canada. 92. Hunter,D.J.andA.Killoran,Tacklinghealthinequalities:turningpolicyintopractice.2004, NHSHealthDevelopmentAgency:London. 93. Burt,R.S.,TheSocialCapitalofOpinionLeaders.AnnalsoftheAmericanAcademyofPolitical andSocialScience,1999.566:p.37-54. 94. Gargett,A.,TheUnitedNationsDeclarationontheRightsofIndigenousPeoples:AManual forNationalHumanRights Institutions.2013,AsiaPacificForumofNationalHumanRightsInstitutionsandtheOfficeofthe UnitedNationsHighCommissionerforHumanRights:Geneva. 95. StatisticsCanada,ProjectionsoftheAboriginalPopulations,Canada,Provincesand Territories,2001to2017.2010. 96. Mikkonen,J.andD.Raphael,SocialDeterminantsofHealth:TheCanadianFacts..2010,York UniversitySchoolofHealthPolicyandManagement:Toronto. 97. Richmond,C.A.M.andN.A.Ross,ThedeterminantsofFirstNationandInuithealth:Acritical populationhealthapproach.Health&Place,2009.15(2):p.403-411. 98. Currie,C.L.,etal.,IllicitandprescriptiondrugproblemsamongurbanAboriginaladultsin Canada:Theroleoftraditionalcultureinprotectionandresilience.SocialScience& Medicine,2013.88:p.1-9. 99. HealthCanada,FirstNationsandInuitHealthStrategicPlan:Asharedpathtoimproved health.2012,HealthCanada:Ottawa. 100. Lavoie,J.G.,etal.,Haveinvestmentsinon-reservehealthservicesandinitiativespromoting communitycontrolimprovedFirstNations’healthinManitoba?SocialScience&Medicine, 2010.71(4):p.717-724. 101. Hefford,M.,P.Crampton,andJ.Foley,Reducinghealthdisparitiesthroughprimarycare reform:theNewZealandexperiment.HealthPolicy,2005.72(1):p.9-23. 72 102. Sporle,A.,N.Pearce,andP.Davis,SocialclassmortalitydifferencesinMaoriandnon-Maori menaged15-64duringthelasttwodecades.NZMedJ,2002.115(1150):p.127-31. 103. Durie,M.H.,AMaoriperspectiveofhealth.SocialScience&Medicine,1985.20(5):p.483486. 104. Crengle,S.,ThedevelopmentofMaoriprimarycareservices.PacificHealthDialog,2000. 7(1):p.48-53. 105. Ratima,M.M.,etal.,StrengtheningMaoriparticipationintheNewZealandhealthand disabilityworkforce.MedicalJournalofAustralia,2007.186(10):p.541. 106. MohawkCouncilofKahnawake,KahnawakeCommunityHealthPlan2012-2022.2013. 107. OntarioMinistryofCommunityandSocialServices.SupportingAboriginalpeople.2012 [cited2015;Availablefrom: http://www.mcss.gov.on.ca/en/mcss/programs/community/programsforaboriginalpeople.a spx. 108. NewZealand,M.o.H.,Nga¯Ko¯reroMaiiTeKeteHauora.2014. 109. Roberts,A.Improvingcommunityhealthonepetatatime.2015[cited201509/10]; Availablefrom:http://www.health.govt.nz/our-work/populations/maori-health/maorihealth-case-studies/improving-community-health-one-pet-time. 110. Langford,K.,P.Baeck,andM.Hampson,MorethanMedicine:newservicesforPeople PoweredHealth,J.Temperley,Editor.2013,NESTA:London. 111. Kilpatrick,S.,etal.,Boundarycrossers,communities,andhealth:Exploringtheroleofrural healthprofessionals.Health&Place,2009.15(1):p.284-290. 112. Keele,H.,TheCommunityCapacityAssessment(CCA)Tool.2007,Adelaide:PIRSA. 113. Lancet,T.,Don'tforgethealthwhenyoutalkabouthumanrights.TheLancet,2015. 385(9967):p.481. 114. WorldMedicalAssociation,TurkishGovernmentUrgedtoRestoreBasicHealthCaretoCities inConflict.2015. 115. HealthandSafetyExecutive,StressandpsychologicaldisordersinGreatBritain2013.2013. 116. DiMartino,V.,Relationshipofworkstressandworkplaceviolenceinthehealthsector.2003: Citeseer. 117. Durcan,D.,Promotinggoodqualityjobstoreducehealthinequalities.2015,UCLInstituteof HealthEquity:London. 118. Kuper,H.andM.Marmot,Jobstrain,jobdemands,decisionlatitude,andriskofcoronary heartdiseasewithintheWhitehallIIstudy.JournalofEpidemiologyandCommunityHealth, 2003.57(2):p.147-153. 119. InternationalLabourOffice,Worldemploymentandsocialoutlook2015:Thechanging natureofjobs.2015,ILO:Geneva. 73 120. InstituteforEmergingIssues,TransitioningtheLong-TermUnemployedinRuralNorth CarolinaintoAlliedHealthCareers:ADemonstrationModel&Suggestionsfor Implementation.2012,NorthCarolinaStateUniversity. 121. Ashraf,N.,O.Bandiera,andS.S.Lee,Do-goodersandgo-getters:careerincentives,selection, andperformanceinpublicservicedelivery.2014,SuntoryandToyotaInternationalCentres forEconomicsandRelatedDisciplines,LSE. 122. CentralStatisticalOffice(CSO)[Zambia],M.o.H.M.Z.,ICFInternational.,Zambia DemographicandHealthSurvey2013-14.2014,CentralStatisticalOffice, MinistryofHealth,andICFInternational:Rockville,Maryland,USA. 123. InternationalLabourOrganisation.DecentWork.24/10/14];Availablefrom: http://www.ilo.org/global/topics/decent-work/lang--it/index.htm. 124. TouchStoneExtras,InSicknessandinHealth?Goodwork–andhowtoachieveit.2010.p.3. 125. BenachJ,MuntanerC,andSantanaV,EmploymentConditionsKnowledgeNetwork (EMCONET)FinalReport.2007. 126. InternationalLabourOrganisationandWorldHealthOrganisation.HealthWISE-Work ImprovementinHealthServices-ActionManual.2014[cited201501/04];Availablefrom: http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/--sector/documents/instructionalmaterial/wcms_237276.pdf. 127. Barr,B.,C.Bambra,andM.Whitehead,TheimpactofNHSresourceallocationpolicyon healthinequalitiesinEngland2001-11:longitudinalecologicalstudy.BMJ,2014.348. 128. SocialEnterpriseUK,PublicServices(SocialValueAct):Abriefguide.2012,SocialEnterprise UK:London. 129. Gilroy,R.andM.Tewdwr-Jones,Joiningthedots–makinghealthcareworkbetterforthe localeconomy.2015,TheSmithInstitute:London. 130. Allen,M.andJ.Allen,UsingtheSocialValueActtoreducehealthinequalitiesinEngland through actiononthesocialdeterminantsofhealth.2015,PHEpublications:London. 131. BritishMedicalAssociation.FairMedicalTrade:Takeaction-Healthcareprofessionals. [cited201509/10];Availablefrom:http://bma.org.uk/working-for-change/internationalaffairs/fair-medical-trade/take-action/take-action-health-professional. 132. BMAtv.TheHumanCostofHealthcare.2012[cited201509/10];Availablefrom:TheHuman CostofHealthcare. 133. Marmot,M.,Fairsociety,healthylives.InequalitiesinHealth:Concepts,Measures,and Ethics,2013:p.282. 134. UCLInstituteofHealthEquity.BromleyByBowCentre.2012[cited201509/10];Available from:http://www.instituteofhealthequity.org/projects/bromley-by-bow-centre. 135. centre,B.b.b.OurImpact.2015[cited201509/10];Availablefrom: http://www.bbbc.org.uk/our-impact. 74 136. Young,M.,FromEarlyChildDevelopmenttoHumanDevelopment:InvestinginOur Children'sFuture.2002,Washington:WorldBank. 137. Walker,S.,etal.,Buildinghumancapacitythroughearlychildhoodintervention:theChild DevelopmentResearchProgrammeattheTropicalMedicineResearchInstitute,the UniversityoftheWestIndies,Kingston,Jamaica.TheWestIndianmedicaljournal,2012. 61(4):p.316-322. 138. Powell,C.,etal.,Feasibilityofintegratingearlystimulationintoprimarycarefor undernourishedJamaicanchildren:clusterrandomisedcontrolledtrial.BMJ,2004. 329(7457):p.89. 139. Labonté,R.,etal.,Implementation,effectivenessandpoliticalcontextofcomprehensive primaryhealthcare:preliminaryfindingsofagloballiteraturereview.AustralianJournalof PrimaryHealth,2008.14(3):p.58-67. 140. Prasad,B.M.andV.Muraleedharan,Communityhealthworkers:areviewofconcepts, practiceandpolicyconcerns.AreviewaspartofongoingresearchofInternational ConsortiumforResearchonEquitableHealthSystems(CREHS),2007. 141. Lehmann,U.andD.Sanders,Communityhealthworkers:Whatdoweknowaboutthem? Thestateoftheevidenceonprogrammes,activities,costsandimpactonhealthoutcomesof usingcommunityhealthworkers.WorldHealthOrganization,2007.2:p.1-42. 142. Harris,M.,Integratingprimarycareandpublichealth–learningfromtheBrazilianway. LondonJournalofPrimaryCare,2012.4:p.126-32. 143. Lewin,S.,etal.,Layhealthworkersinprimaryandcommunityhealthcareformaternaland childhealthandthemanagementofinfectiousdiseases.CochraneDatabaseofSystematic Reviews,2010(3):p.Cd004015. 144. Johnson,C.D.,etal.,LearningfromtheBraziliancommunityhealthworkermodelinNorth Wales.Globalizationandhealth,2013.9(25):p.10.1186. 145. Macinko,J.andM.Lima-Costa,HorizontalequityinhealthcareutilizationinBrazil,19982008.InternationalJournalforEquityinHealth,2012.11(1):p.33. 146. Ranson,M.K.,etal.,India:assessingthereachofthreeSEWAhealthservicesamongthe poor.ReachingthePoorwithHealth,Nutrition,andPopulationServices,2005:p.163-87. 147. Association,S.E.W.s.AboutUs.n.d.[cited201604/01];Availablefrom: http://www.sewa.org/About_Us.asp. 148. Sastry,N.,Estimatinginformalemployment&povertyinIndia.2004:HumanDevelopment ResourceCentre. 149. Eastwood,S.V.,etal.,CardiovascularriskassessmentofSouthAsianpopulationsinreligious andcommunitysettings:aqualitativestudy.FamilyPractice,2013.30(4):p.466-472. 150. Pathway.Transforminghealthservicesforhomelesspeople.2015[cited201509/10]; Availablefrom:http://www.pathway.org.uk/. 151. OfficeforNationalStatistics,Statisticalbulletin:NationalLifeTables,UnitedKingdom,20112013.2014. 75 152. Hewett,N.,A.Halligan,andT.Boyce,Ageneralpractitionerandnurseledapproachto improvinghospitalcareforhomelesspeople.BMJ,2012.345. 153. WorldHealthOrganizationandG.o.S.Australia,AdelaideStatementonHealthinAllPolicies movingtowardsasharedgovernanceforhealthandwell-being.2010,WorldHealth Organization, GovernmentofSouthAustralia:Adelaide,SouthAustralia. 154. HealthImprovementDivision,FairerHealthOutcomesForAll:ReducingInequitiesinHealth StrategicActionPlan2011,WelshAssemblyGovernmentCardiff,Wales. 155. MinistryofHealthandCareServices(MHCS)Norway,TheNorwegianPublicHealthAct(ACT 2011-06-24no.29)–forinternationalaudience,MinistryofHealthandCareServices(MHCS) Norway,Editor.2012. 156. Melkas,T.,HealthinallpoliciesasapriorityinFinnishhealthpolicy:acasestudyonnational healthpolicydevelopment.ScandinavianJournalofPublicHealth,2013.41(11suppl):p.328. 157. Raulio,S.,E.Roos,andR.Prättälä,Schoolandworkplacemeals–Dotheypromotehealthy foodhabitsinthepopulation?PublHealthNutr,2010.33:p.987-92. 158. Farmer,P.E.,etal.,ReducedprematuremortalityinRwanda:lessonsfromsuccess.Bmj, 2013.346. 159. UnitedNationsChildren’sFund,W.H.O.,WorldBank,UnitedNationsPopulationDivision, Levelsandtrendsinchildmortality. 160. Binagwaho,A.,etal.,TheHumanResourcesforHealthPrograminRwanda—ANew Partnership.NewEnglandJournalofMedicine,2013.369(21):p.2054-2059. 161. RepublicofRwanda,RWANDAVISION2020,MINISTRYOFFINANCEANDECONOMIC PLANNING,Editor.2000. 162. Ferlay,J.,etal.,Estimatesofworldwideburdenofcancerin2008:GLOBOCAN2008.IntJ Cancer,2010.127(12):p.2893-917. 163. Forouzanfar,M.H.,etal.,Breastandcervicalcancerin187countriesbetween1980and 2010:asystematicanalysis.TheLancet.378(9801):p.1461-1484. 164. Binagwaho,A.,etal.,AchievinghighcoverageinRwanda'snationalhumanpapillomavirus vaccinationprogramme.BulletinoftheWorldHealthOrganization,2012.90(8):p.623-628. 165. InternationalCouncilofNursesandWorldMedicalAssociation.Extensionofthemandateof UNSpecialRapporteurontherightofeveryonetotheenjoymentofthehighestattainable standardofphysicalandmentalhealthinordertoincludehealthprofessionals’autonomy andfreedomfromreprisal.2008[cited201502/04];Availablefrom: http://www.wma.net/en/20activities/20humanrights/10health/0102_Human_rights-revatt2.pdf. 166. Alliance,W.h.P.WhatistheWHPA?n.d.[cited201516/12];Availablefrom: http://www.whpa.org/whpa.htm. 76 167. WorldHealthProfessionsAlliance,WHPAStatementonInterprofessionalCollaborative Practice.2013. 168. Medicine,A.F.A.B.o.I.,Medicalprofessionalisminthenewmillennium:aphysiciancharter. AnnalsofInternalMedicine,2002.136(3):p.243. 169. Rodriguez,B.andS.Morris,Spaintoreinstateprimaryhealthcareforillegalimmigrants,in Reuters.2015:Online. 170. Frankham,S.,IllegalimmigrantstoregainrightstohealthcareinSpain,inEuroWeeklyNews. 2015:Online. 171. RoyalCollegeofPhysicians,WorkandwellbeingintheNHS:whystaffhealthmattersto patientcare.2015,RoyalCollegeofPhysicians,:London. 172. VanDierendonck,D.,W.B.Schaufeli,andH.J.Sixma,BurnoutamongGeneralPractitioners:A PerspectivefromEquityTheory.JournalofSocialandClinicalPsychology,1994.13(1):p.86100. 173. Linzer,M.,etal.,Predictingandpreventingphysicianburnout:resultsfromtheUnitedStates andtheNetherlands.TheAmericanJournalofMedicine,2001.111(2):p.170-175. 174. WorldMedicalAssociation,WMADeclarationofHelsinki-EthicalPrinciplesforMedical ResearchInvolvingHumanSubjects.1964:Helsinki,Finland. 175. Carlson,R.V.,K.M.Boyd,andD.J.Webb,TherevisionoftheDeclarationofHelsinki:past, presentandfuture.Britishjournalofclinicalpharmacology,2004.57(6):p.695-713. 176. WorldMedicalAssociation.WMAStatementonHealthHazardsofTobaccoProductsand Tobacco-DerivedProducts.1988[cited201605/01];Availablefrom: http://www.wma.net/en/30publications/10policies/h4/. 177. WorldMedicalAssociation.WMAResolutiononViolenceagainstWomenandGirls.2010 [cited201605/01];Availablefrom:http://www.wma.net/en/30publications/10policies/v3/. 178. Duncan,N.,CaringPhysiciansoftheWorld.NewYork:PfizerMedicalHumanInitiatives, 2005. 179. BangladeshMedicalAssociation.BMAActivities.2014[cited201605/01];Availablefrom: http://bma.org.bd/index.php?option=com_content&view=article&id=1262:bmaactivities&catid=106:sample-sports-news. 180. FinnishMedicalAssociation.TheFinnishMedicalAssociationHealthactor.2014[cited2015 09/10];Availablefrom:http://www.laakariliitto.fi/liitto/terveyspoliittinen/. 181. IrishMedicalOrganisation,2020VisionforHealth.2014,IMO:Dublin,Ireland. 182. AmericanMedicalAssociation.H-140.900ADeclarationofProfessionalResponsibility.2015 [cited201517/12];Availablefrom:https://www.amaassn.org/ssl3/ecomm/PolicyFinderForm.pl?site=www.amaassn.org&uri=/resources/html/PolicyFinder/policyfiles/HnE/H-140.900.HTM. 183. Upstream.Abasicincomeguaranteemaybethebestmedicine.2015[cited201509/10]; Availablefrom:http://www.thinkupstream.net/big_medicine. 77 184. Berger,P.andOnbehalfofthe194physiciansignatories,OntarioPhysiciansletter, M.o.H.a.L.-T.C.Hon.Dr.EricHoskins,Editor.2015:HealthProvidersAgainstPoverty. 185. BasicIncomeCanada.Abasicincomeguaranteeisanideathatworks.[cited201509/10]; Availablefrom:http://www.basicincomecanada.org/. 186. Hojat,M.,etal.,Thedevilisinthethirdyear:alongitudinalstudyoferosionofempathyin medicalschool.AcademicMedicine,2009.84(9):p.1182-1191. 187. Chen,D.,etal.,Across-sectionalmeasurementofmedicalstudentempathy.Journalof GeneralInternalMedicine,2007.22(10):p.1434-1438. 188. Woloschuk,W.,P.H.Harasym,andW.Temple,Attitudechangeduringmedicalschool:a cohortstudy.Medicaleducation,2004.38(5):p.522-534. 189. Hafferty,F.W.,Intothevalley:Deathandsocializationofmedicalstudents.1991:Yale UniversityPress. 190. InternationalFederationofMedicalStudents’Associations.IFMSAPolicyStatement:Health EquityandtheSocialDeterminantsofHealth.2011[cited201605/01]. 78