Promoting health equity.

The Commission on the Social Determinants of Health brought the reduction of avoidable health inequalities between social groups to the centre of the political stage. Its three key recommendations—to improve daily living conditions; to tackle the inequitable distribution of power, money, and resources; and to measure and understand the problem—have been widely welcomed. As the commission itself noted, such recommendations do not by themselves create a world in which all people have the freedom to lead lives they can value. To achieve this goal, sustained and systematic work is needed at national and local levels. Local government has a key role in delivering health equity, because it typically controls the planning or delivery of such key social determinants of health as education, transport, and spatial planning. A recent World Health Organization report builds on the work of the WHO Healthy Cities project and the Marmot review to make suggestions about what local governments in Europe can do to improve health equity. The central message of the report is to think about the social determinants of health and to act locally. The European Healthy Cities Network has been in operation since 1987 and now encompasses more than 90 cities in the WHOEuropean region. Its current fifth phase focuses on health and health equity in all policies. The recent WHO report is important, because it considers evidence from several cities and regions that do not belong to the Healthy Cities Network. It identified the lack of a strong international evidence base on what the social determinants of health are and how to measure them. It reinforces the existing evidence for tackling health inequalities and provides suggestions about how local governments can improve social justice and hence the social determinants of health by examining factors that impede efforts to embed health and health equity into all policies. It is much easier to gain broad agreement on the need for health inequities to be reduced than it is to deliver coherent policies that achieve this aim, which makes it challenging to act on the report and its accompanying Framework for Action. The power of local government is often limited by national policy frameworks, difficulties in ensuring cross sector working, and lack of resources. Other goals, such as driving economic growth, often overshadow health policies in practice. Currently, rather than channelling resources into health focused aspects of local government policy, such as spatial planning or transportation policy, existing programmes (such as targeted programmes and the provision of public health information) are being recast as part of the “social determinants” agenda. This may distort what gets counted as being aimed at reducing the social gradient. Although the provision of public health information, for example, may be laudable, reframing it as something that ostensibly reduces social determinants of health reinforces the impression that health is mainly a matter of chosen behaviour. However, the uptake of public health information is itself affected by social inequality, and messages are more likely to reach those who are already relatively well off, which exacerbates the social gradient. With its focus on local government and the turn towards a socialised account of health, it is not surprising that the report identifies little that clinicians or even those involved in public health can do directly. Nonetheless, we can extrapolate several important roles—particularly for public health professionals—from the shortcomings the report identified. Firstly, the report identified considerable uncertainties within local government regarding social determinants of health and the implementation of interventions aimed at tackling them. It is therefore clear that public health professionals have a role to educate and to guide. Secondly, and most importantly, an interventional evidence base on the social determinants of health must be built up. This will be a great challenge given the complex interactions that the social determinants of health hypothesis is based on and the difficulties inherent in measuring social changes. Public health professionals are well placed to understand and to meet these challenges.