Policy to tackle the social determinants of health

Policy to tackle the social determinants of health: using conceptual models to understand the policy process Mark Exworthy

Accepted 22 June 2008

Like health equity, the social determinants of health (SDH) are becoming a key

focus for policy-makers in many low and middle income countries. Yet despite

accumulating evidence on the causes and manifestations of SDH, there is

relatively little understanding about how public policy can address such complex

and intractable issues. This paper aims to raise awareness of the ways in which

the policy processes addressing SDH may be better described, understood and

explained. It does so in three main sections. First, it summarizes the typical

account of the policy-making process and then adapts this to the specific

character of SDH. Second, it examines alternative models of the policy-making

process, with a specific application of the ‘policy streams’ and ‘networks’ models

to the SDH policy process. Third, methodological considerations of the preceding

two sections are assessed with a view to informing future research strategies.

The paper concludes that conceptual models can help policy-makers understand

and intervene better, despite significant obstacles.

Keywords Policy process, social determinants of health, health inequalities, research

methodology

‘What is striking is that there has been much written often

covering similar ground . . . but rigorous implementation of

identified solutions has often been sadly lacking.’ (Wanless

2004, p.3)

This quote was written about UK policy addressing the social

determinants of health (SDH) but is applicable to most high or

low and middle income countries. Despite mounting evidence

of the causes of health inequity, even in the latter countries,

attention on the policy process is a notable omission. This may

reflect the epidemiological emphasis on SDH research and/or a

lack of engagement between public health and policy analysts.

This article seeks to remedy that by closely examining the

nature of the SDH policy process, how it might be conceptua-

lized and researched.

Re-visiting the policy-making process The term ‘policy’ is so widely used that it often obscures

meaning. Searching for definitional clarity can be misleading.

Its various uses denote the significance attached to it by mult-

iple stakeholders (Hogwood and Gunn 1989; Buse et al. 2005)

KEY MESSAGES

� Social determinants of health (SDH) represent major challenges to health policy-makers in all countries.

� Models of the policy process are often ill-suited to local contexts and the nuances of SDH.

� A sensitive application of models such as ‘streams’ and ‘networks’ offers significant insights into the nature of SDH policy and the opportunities/constraints facing policy-makers.

� Understanding and explaining SDH policy processes need to be undertaken sensitively, recognizing peculiar methodological challenges.

School of Management, Royal Holloway-University of London, Egham, Surrey, TW20 0EX, UK. E-mail: M.Exworthy@rhul.ac.uk

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

� The Author 2008; all rights reserved. Health Policy and Planning 2008;23:318–327

doi:10.1093/heapol/czn022

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and/or the multiple levels at which it is developed. A useful way

of understanding ‘policy’ is in terms of context, content, process

and power (Walt 1994). First, context is the milieu within

which interventions are mediated; it therefore shapes and is

shaped by external stimuli like policy. Second, content refers to

the object of policy and policy analysis, and may be divided into

technical and institutional policies (Janovsky and Cassells

1996). Third, Wildavsky’s (1979) reminder that ‘policy is a

process, as well as a product’ is crucial because it draws

attention to the course of action over time. Finally, power

draws attention to the interplay of interests in negotiation and

compromise.

The ‘policy process’ is often presented as a linear, rational

process moving from formulation to implementation; for

example:

� ‘Politicians identify a priority and the broad outlines of a solution . . .;

� Policy-makers . . . design a policy to put this into effect, assembling the right collection of tools: legislation, funding,

incentives, new institutions, directives;

� The job of implementation is then handed over to a different group of staff, an agency or local government;

� . . . the goal is (hopefully) achieved’ (UK Cabinet Office 2001, p.5).

This is an over-simplistic view. The distinction between

formulation and implementation is rarely clear-cut; intentions

and action are often hard to distinguish. It may be more helpful

to view the ‘policy process’ as disjointed and ‘messy’. For

example, John (2000) argues that there is often no start or end

point, only a middle. Policies are developed within a pre-

existing context that effectively constrains new opportunities.

The legacy of former decisions creates conditions from which

policy-makers may find it difficult to diverge, a condition

known as ‘path dependency’ (Greener 2002). Most resource

decisions, for example, only consider marginal changes rather

than taking fundamental re-assessment of principles. Path

dependency limits the range or possibility of radical changes of

direction, at least in the short term—often called ‘increment-

alism’ (Lindblom 1959). This perspective also contends that the

policy process can often be static for relatively long periods,

only to be disturbed by moments of change—disjointed

incrementalism and punctuated equilibrium. As a result, the

policy process is characterized by (positive and negative)

feedback loops and rarely reaches completion. However, Clay

and Schaffer (1984), for example, demonstrate the ‘room for

manoeuvre’ that policy-makers can enjoy.

The health policy process is also characterized by other

features. First, policy decisions rarely take place at a single

point in time and can be protracted over months or even years.

It is therefore difficult to discern if/when a specific decision was

made. Policy decisions often reflect a broad direction (despite

conflict) so as to mollify stakeholders’ concerns or to denote

their power. Second, policy-making rarely occurs in public but

rather behind ‘closed doors’, despite some attempts to make it

more transparent. Third, policy-making often results in no

decisions or non-decisions. The lack of (observable) action or

outcome may actually signify a complex set of forces that have

stifled a decision or prevented proposals from being enacted

(Lukes 1974). Finally, much of the evidence on the policy process

originates from high income countries (HICs); there is thus an

empirical question as to whether typical approaches and under-

standing are valid in low and middle income countries (LMICs).

Questions about similar translations between demographic/

population and income groups may also be posed.

SDH offer an insightful case study of health policy processes

because they have in recent years assumed a more central place

in policy processes of many HICs and LMICs; previously, policy

analysis has tended to overlook the issue in favour of other

policy imperatives. It is, therefore, instructive to learn how the

specific nuances of these complex phenomena are articulated

in the content, context and process of health policy processes.

Such a case study is significant because, on the one hand,

SDH are more prominent in topical debates about MDGs and

poverty reduction, and on the other, SDH are illustrative of

increasingly complex developments in policy process (such as

governance and internationalization). However, each aspect

that public policy in each country seeks to address is, more or

less, a particular configuration of issues. Practically, these issues

need to be understood and explained by academics and by

policy-makers that they may assess the likely impact of SDH

policy.

Broadly, eight challenges to addressing SDH through public

policy can be identified. Defining clearly the features of SDH

helps to draw sharper implications for policy development and

implementation. First, SDH are multi-faceted phenomena with

multiple causes. Models of SDH are useful conceptual devices to

identify the causal pathways which have differential impacts on

health (see Figure 1).

However, SDH models rarely offer policy-makers a clear

direction for policy development (Graham 2004). First, some

policy-makers believe that the lack of a ‘simple problem’

hinders the development of ‘simple policy solutions’ or that

policy is ineffective in the face of wider social forces (such as

globalization). Others see SDH as ‘invisible’ (Dahlgren and

Whitehead 2006, p.15). As a result, there has often been no

policy response to ‘act upon SDH’ or, where there has been

some attempt, a diffuse approach. This has often been

hampered by the lack of consensus among academics and

policy-makers about the policy solutions required.

Second, the life-course perspective (Blane 1999) presents a

challenge to policy-making processes whose timescales are

rarely measured over such long periods. The life-course perspec-

tive posits that early life influences (say, upon diet or educa-

tion) have life-long impacts that will only be evident many

years hence. This perspective contrasts with the tenure of

elected and/or appointed officials (which is usually measured

in years, rather than decades), the electoral cycles in

parliamentary or presidential democracies (usually measured

from 5 to 7 years), and organizational reporting cycles (e.g. for

budgetary purposes usually measured annually). Moreover,

coalitions of interests in support of SDH policies may be

unsustainable over the time periods necessary to witness

significant change, thereby presenting a challenge to create

and sustain commitment to and involvement in the policy goals

and process. Partly as a result, attention of the public (often

supported by the media) and some practitioners has tended to

reinforce such short-term timescales. This second feature is

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thus a challenge to integrate long-term approaches with short-

term organizational/political imperatives.

Third, SDH necessitate policy action across different organiza-

tions and sectors (not least, the health care sector) (Hunter 2003;

Gilson et al. 2007). Often, policy responses are only disease-

specific rather than addressing SDH. Inter-organizational and

inter-sectoral partnerships are critical to formulating and

implementing policy towards SDH. However, evidence shows

that partnerships at all levels are hampered by cultural,

organizational and financial issues (Lee et al. 2002; Sullivan and

Skelcher 2002). Different values, different accountabilities and

performance measures/criteria, and different reasons for colla-

borating are among the challenges for partnerships. Moreover,

the ‘health’/SDH agenda may be marginal to collaborating

organizations, SDH being perceived as beyond their core purpose.

It can also be argued that action on SDH requires intervention

beyond state/government, by civil society organizations or even

private sector agencies. Such collaboration regarding SDH is likely

to be even more problematic.

Even within governments, inter-organizational collaboration

has often been poorly developed. Traditionally, government

agencies tend to be organized vertically (Ling 2002; Bogdanor

2005). For example, education ministries are largely focused on

running schools, health ministries on delivering health care

services, etc. Yet, such ‘silo’ or ‘chimney’ approaches are not

well suited to tackle cross-cutting issues. A strong coordination

role, say, across government or by an external (international)

agency might offset the ‘silo’ approach but the balance of power

usually remains with ministries.

Fourth, SDH are one of many competing priorities for policy-

makers’ attention and resources. Economic, foreign or devel-

opment policies might take precedence over SDH, inter alia.

More specifically, SDH may be over-shadowed in the policy

process by health care itself. As most states take a prominent

role in the financing and/or delivery of health care to its

population (Saltman 1997), it is perhaps inevitable that states

take a close interest in such matters. However, this health care

focus is often to the neglect of health and SDH per se (Gilson

et al. 2007). That said, other spheres of policy (such as

education or transport) can be informed by SDH.

Fifth, SDH are so complex that the cause-effect relationships

are not readily apparent. Moreover, some evidence is equivocal

about these associations. For example, statistical correlations

are common in epidemiological studies which inform policy-

making, but they rarely demonstrate causation. Knowing and

understanding causal pathways is a first step in devising

appropriate policies but many gaps in knowledge remain,

especially in LMIC contexts. Attributing policy mechanisms to

their impact upon health can often be obscured because:

‘Policy cannot be intelligently conducted without an under-

standing of mechanisms; correlations are not enough’

(Deaton 2002, p.15).

As a result, policy levers (such as legislation and resource

allocation) are seen as blunt instruments in tackling SDH,

whose consequences are not, and sometimes cannot be,

ascertained with sufficient clarity.

Attribution of policy interventions to outcomes is problematic.

Such outcomes may not be evident for many years, if at all, as

indicated by the life-course perspective. Consequently, there is

often a reliance on ‘process’ measures as indicators of progress,

assuming that they are associated with outcomes. This may be

particularly problematic the higher the level of analysis, such as

macro-economic policy (Turrell et al. 1999), or as policy is

transferred from HICs to LMICS. Attribution may also pose

dilemmas for targets given the multi-faceted nature of policy

outcomes.

Sixth, the identification, monitoring and analysis of epide-

miological changes over time, is crucial to inform the policy-

making process. Yet, routine data are not always available, are

of poor quality or have been collected over insufficient periods

Figure 1 The main determinants of health. Source: Dahlgren and Whitehead (1991).

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to aid policy-making (Center for Global Development 2006;

Exworthy et al. 2006). Data categorization by population groups

(e.g. ethnicity, gender) or geographically is often poor.

However, whilst data are necessary, they alone are not

sufficient to secure policy implementation.

Seventh, globalization and multi-lateralism are significant

factors in delivering ‘global public goods’ such as health (Chen

et al. 1999) but such goods have been influenced by the

changing role of the nation state in policy-making (Lee et al.

2002; Labonte and Schrecker 2007). Powers have been re-

located to supra-national organizations such as the European

Union, World Trade Organization, International Monetary Fund

and World Bank. In particular, these supra-national institutions

tend to promote a neo-liberal agenda (Raphael 2003).

Governments’ ability to shape and mould the SDH with the

goal of improving their population’s health is becoming limited

as many of the ‘causes’ of poor health (Wilkinson and Marmot

2003) no longer fall within their responsibility. They, therefore,

need to rely on influence and leverage in multi-national

networks. By contrast, decentralization to regions and cities

has had a similar effect on the policy-making capacity of

governments. Decentralization in HICs and LMICs can be seen

as an attempt to make public services more responsive to local

needs (and in that sense, improve intra-area/population equity).

However, despite its popularity, decentralization in LMICs and

HICs is rarely achieved in full or within parameters defined by

central government (Bossert 1998; Atkinson et al. 2002). As

such, decentralization might be seen as less of a threat to

national policy-making than globalization, since the implemen-

tation of the former lies mainly within governments’ control

These seven challenges of the contemporary policy process as

applied to SDH are summarized in Table 1.

The challenges demonstrate that, despite the growing volume

of evidence on SDH, understanding of the particular demands

of the policy process around SDH in particular contexts has

been limited. In short, despite the growing attention on SDH,

understanding of the policy process in particular contexts has

been missing. Policy models and frameworks can help in

developing the theory and practice of policy development to

tackle SDH.

Policy models and their application to SDH Conceptual models can provide tools to describe, understand

and explain policy processes. Such models are important for

two reasons. First, much health policy practice has been

developed (and researched) in HICs and ‘transferred’, often

uncritically to LMICs. However, the variability of context and

nuances of individual policies make generalizability proble-

matic. Exporting policies within or between countries is often

discounted on the basis that the ‘context’ is different and hence

lessons from host countries cannot be learnt. However, a focus

on conceptual models can obviate some of these problems by

addressing key issues such as power and resistance. By applying

concepts of the policy process, it is thus possible to discern

meanings and motives, similarities and differences in patterns

and practices across context. Second, as SDH present specific

challenges to the policy process, the configuration of SDH and

policy context in each country demands that typical policy

frameworks are adapted to local contexts.

Despite the extensive literature on this topic and for sake of

brevity, this article focuses on selective models as illustrations

of the ways in which they contribute to improved under-

standings of how the SDH policy process, specifically, may be

approached by policy-makers. The three models do represent,

however, major approaches within the extensive literature,

though they do not provide, by any means, a comprehensive

assessment:

1. streams

2. networks, and

3. stages.

’Streams’ model

This model is concerned with how issues get onto the policy

agenda and how proposals are translated into policy. Kingdon

(1995) argues that ‘windows’ open (and close) by the coupling

(or de-coupling) of three ‘streams’: problems, policies and

politics. The model (and its variants) has been applied to

analysis of policy change around health inequalities and SDH

(e.g. Exworthy et al. 2002; Sihto et al. 2006). This model is

especially pertinent to SDH because, in many (HIC and LMIC)

countries, SDH have struggled to reach the policy agenda, let

alone become implemented. This is despite mounting (epide-

miological) evidence (Wilkinson and Marmot 2003) and policy

proposals.

Problem stream

Conditions or issues (such as SDH) only become defined as

‘problems’ when they are perceived as such. Often, only those

‘problems’ which are (potentially) amenable to policy remedies

Table 1 Link between features of social determinants of health (SDH) and the impact on policy-making

Features of SDH Impact on policy-making

Multi-faceted phenomena with multiple causes Coordinated strategies are difficult to achieve

Life-course perspective Long-term approach does not match policy timetables

Inter-sectoral collaboration and partnership Partnerships are problematic

Dominance of other priorities SDH often neglected

Cause-effect relationships are complex; attribution difficulties Attribution problems hamper policy; reliance on process measures

Data Routine data that is of high quality, timely and available, are often lacking

Globalization (and decentralization) Policy-making involves more stakeholders at multiple levels, hampering governmental action

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are recognized; many will remain unaddressed. The issues

might be brought to attention by:

1. Key events (such as crises or critical incidents) and/or

2. Publication of ‘evidence’ (such as research studies or

inquiries) and/or

3. Feedback from current policies (via the media or public

opinion).

The growing volume of research evidence has highlighted SDH

but many ‘policy-makers may even be unaware of the

magnitude and trends of existing inequities in health among

their people’ (Dahlgren and Whitehead 2006, p.16). This

underlines the fact that researchers are but one stakeholder

and evidence is just one source of information in policy

processes (Trostle et al. 1999). The lack of consensus about

evidence among the research community may hamper their

influence in defining the ‘problem’. The role of key events and

feedback (e.g. funding crises or negative public opinion) should

not be overlooked in accounting for the policy experience of

specific countries. Also, stakeholders or interest groups (e.g.

medical profession or community groups) might play a

prominent role in highlighting specific issues and bringing

them to the attention of policy-makers (often via the media).

The publication of a key research report [such as the UK

Acheson Inquiry (1998) on health inequalities or the World

Health Organization Commission on SDH] may be such a

prompt (Exworthy et al. 2003).

Policy stream

The multiple strategies and policies may be advanced not just

by civil servants or professionals but also by interest groups.

Some may be ‘kite-flying exercises’ (testing support for

particular strategies) or concrete proposals. However, for any

strategy to be enacted, it must meet a minimum threshold of:

1. Technical feasibility,

2. Congruence with dominant (socio-political) values, and

3. Anticipation of future constraints of the strategy being