The Determinants of Health - moving description into solutions

The Determinants of Health were covered in drphealth Sept 16 DofH. The nagging question that all of public health should ask, is so what?   We are familiar with the relationship between income, education etc. but not that knowledgeable with the technologies on how to modify or mitigate the impacts caused by disparities in the determinants.  Ontario brings to the table an intriguing review of practices amongst health units Ontario action on determinants of health . Jointly produced by OPHA and ALPHA , mostly notable not a government based initiative, the survey of the 36 Ontario health units is informative for the country. 

Ontario’s relatively unique structure autonomous health unit governance bodies, aligned to some extent with local government, reflects the more traditional delivery structure for public health.  Perhaps ironically, it is the structure that now allows for greater freedom to innovative that the remaining provinces where health regions now dominate. 

The gist of the report comes down to the health units being partners, stimulating change through information (surveillance, evaluation, research, dissemination), targeting services to reduce inequities within the public health scope, advocating for policy change, and supporting planning.  The barriers were found in workforce skills, knowledge gaps, leadership, and lack of planning.  The supporting needs were mostly in information (best practices, evidence reviews, network).   While the report is entitled Activities to Address the Social Determinants, it speaks to the broader Determinants of health in its analysis. OPHA/alPHA survey report

In 2008 the WHO  completed and released its report on the social determinants of health http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf , which more than previous works speaks to potential actions to address and mitigate the impacts of the social determinants (noting that WHO does acknowledge the difference between the determinants and social determinants in its publications).   The committee was chaired by Sir Michael Marmot, who was the CPHA 2008 keynote speaker and spoke to the effectiveness of interventions in a presentation that regrettable is still not posted to the CPHA archives.  The main components of his thesis, but not the details, were published in Lancet 372 (9650) 1661-1669, Marmot Health inequities action 2008 Lancet and talks to closing the gap in a generation.  The detailed analysis looked at policy difference by country and the impact on reducing inequities.   A similar analysis looked at states in the US (and including Canadian provinces) and can demonstrate not just the inequities, but the ability to use macro level policy intervention to modify their impact.

Now, for the health leaders in the country who say that poverty and other determinants have an impact on health, but it is not the health sectors responsibility to address those factors, given that 20-25% of health care costs in Canada are directly attributable to the disparity caused by income inequalities – perhaps its finally time to come to the finance table and not only put cash on the table, but require public health and other health sector groups to integrate determinants work in what they do routinely.

Thank you to the OPHA/alPHa for demonstrating that even in the absence of a requirement, that public health bodies are willing to do what is the right thing to do.  Subtly hidden in the report is that the lack of leadership is one of the key obstacles in moving forward, and these organizations are showing some leadership that is desperately needed.