COVID lesson: Address the social determinants of health

With health data showing COVID is taking its greatest toll on poor communities, experts are highlighting the role of social determinants in the pandemic – and calling on leaders to address social determinants to prepare for future outbreaks and meet global health goals.

“Data from the United States, Brazil, and elsewhere clearly demonstrates that the poor are more likely to be infected, to get severe disease, to be hospitalized, and they are more likely to die of COVID," said Dr. Cesar Victora at the International Center for Equity in Health, Federal University of Pelotas. "This is because the poor rely on public transit, often can’t work remotely, they have poorer nutrition, are more likely to have underlying health conditions, and live in more overcrowded and substandard housing. The poor also have less information, less access to personal protective equipment and other means for keeping themselves safe, and often less access to vaccines."

The social determinants of health are, broadly speaking, the conditions within which people live. The social determinants involve people’s access to power, money, information, and resources (including healthcare). In his seminal Lancet article on the subject Michael Marmot, a professor of epidemiology and public health at University College London, dubbed the social determinants “the causes of causes” and quoted F. Scott Fitzgerald’s short story The Rich Boy to illustrate his point: “Let me tell you about the very rich. They are different from you and me.”

Experts say addressing these disparities will not only reduce the vulnerabilities that the COVID virus has so deftly exploited, it will also help accelerate progress toward our preparing for future pandemics and addressing global health goals. A recent WHO report on the subject made the assertion that “a social determinants approach should be integrated into pandemic prevention, preparedness, response and recovery – to manage COVID-19, to build back fairer and to prepare for future outbreaks.”

Exemplars in Global Health research across health topics provides further compelling evidence to support a focus on the social determinants of health. EGH research partners found that countries investing in strategies to address social determinants of health have accelerated their progress from stunting reduction to addressing under-five mortality. Dr. Victora, an advisor for Exemplars in Global Health, highlighted four investments that Exemplar countries have prioritized to reduce inequity and address the social determinants.

Dr. Victora, an advisor for Exemplars in Global Health, highlighted four investments that Exemplar countries have prioritized to reduce inequity and address the social determinants.

Education: Brazil, Ethiopia, and Nepal, among others, prioritized, over many years, improving equity in education. For example, Ethiopia notably increased expenditures on education – with one quarter of the national budget routinely earmarked for education. As a result, since the early 1990s, the number of schools has tripled, enrollment in primary school has quadrupled, and literacy has more than doubled. Girls, who used to be underrepresented at all school levels, have now achieved parity in primary school enrollment.

Universal access to health: Peru and Brazil both implemented programs to expand access to healthcare for the poorest of the poor. Peru’s insurance program (SIS), which provides health insurance for more than 70 percent of the poor and 40 percent of the country’s population, is credited with expanding health seeking behavior and improving health generally in Peru. Brazil’s Unified Health System SUS established the largest, universal, free public health system in the world, covering nearly 160 million people, or 60 percent of Brazil’s population. It helped cut under-five mortality by more than two-thirds and maternal mortality ratio from 143.2 to 59.7 per 100 000 live births between 1990 and 2015.

Cash Transfers or Universal Basic Income: Kyrgyzstan’s small but effective Universal Monthly Benefit program, a means-tested cash benefit, provided the poorest families with children an unconditional monthly benefit of about $1 – providing a cushion against total destitution. Peru’s conditional cash transfer program, Juntos, provided a similar cushion and helped the country’s poorest families improve child nutrition. This conditional cash transfer program required families to engage in health seeking behavior with their children and enroll them in school, demonstrating another key investment to support the social determinants of health – early child development.

Mainstreaming equity through coordinated cross-sectoral antipoverty strategies: Brazil demonstrated this not only through its community health worker program which called on CHWs to address the social determinants of poor health by helping families access other government services, but also through the country’s focus on ensuring equity was part of every policy from transportation and communications to utility services. Similarly, the Rwandan government sought to ensure that public health progress touched all economic classes and extended to every corner of the nation’s geography. Tools for achieving this included the national community-based health insurance plan (Mutuelle de Sante) and the construction and expansion of hospitals and health centers nationwide.

Although researchers have recognized the importance of the social determinants of health for nearly a century and the World Conference on the Social Determinants of Health in 2011 elevated the need to address health inequities, progress on this issue has been uneven.

Addressing the social determinants of health is challenging because it requires multi-sectoral approaches, as the examples above illustrate. A group of researchers led by Luiz Odorico Monteiro de Andrade from the Oswaldo Cruz Foundation and School of Medicine, Fortaleza, Brazil outlined the challenge in a Lancet article, “Policies and actions from economic, education, transport, housing, agriculture, and other sectors are needed to improve social determinants of health. Therefore, the health sector needs to act as a leader to catalyse intersectoral actions aimed at addressing disparities in social determinants of health, improving health, and reducing health inequities.“

Countries that have introduced public policies that integrate health, social, and economic policies and programming to support multisectoral interventions have often done so as part of historic transformative reforms during pivotal moments in their history. In the case of Peru and Brazil, both countries developed and institutionalized policies and programs to address the social determinants of health in the throes of historic broad civil society movements that forced government action. In Rwanda, a focus on the social determinants of health was largely a response to the horrors of the 1994 genocide. Likewise, Bangladesh’s leaders saw health inequities, especially the position of women in society, as an existential crisis to the country that demanded immediate attention.