The need to monitor actions on the social determinants of health

Intersectoral actions, defined as the alignment of strategies and resources between actors from two or more policy sectors to achieve complementary objectives,1 are central to the health-related sustainable development goals (SDGs). 2 The World Health Organization’s (WHO) Commission on Social Determinants of Health recommended a subset of intersectoral actions to improve health equity in 2008.3 Intersectoral actions address the social, commercial, cultural, economic, environmental and political determinants of health. Without intersectoral actions, the health sector will probably not achieve SDG 3, that is, ensuring healthy lives and promoting well-being for all at all ages.4 National governments have committed to and implemented several of these intersectoral actions through multisectoral development and health policy frameworks, including the 2030 agenda for sustainable development,4 the Rio Political Declaration on Social Determinants of Health,5 the New Urban Agenda6 and the Marrakech Ministerial Declaration on Health, Environment and Climate Change.7 We argue for monitoring intersectoral actions because such assessment draws attention to those government interventions that improve living conditions, but are outside the immediate control of the health sector. These interventions often have established co-benefits across multiple policy sectors (for instance, emission-free public transport systems improve air quality, transport and health). Action monitoring can also strengthen coherence and efficiency across sectors. The SDGs’ extensive multisectoral indicator framework8 offers health policy-makers the opportunity to link action monitoring to the SDGs, as national governments begin their SDG implementation.4 In particular, actions taken in the context of policy frameworks that address the social determinants of health, such as those in the five action areas of the Rio Political Declaration,5 need to be monitored. Therefore, we define and categorize indicators for intersectoral actions on social determinants of health that improve health equity. If these indicators are drawn from the SDG indicator system,8 they will enable policy-makers to link intersectoral actions to sustainable development.9 For social determinants of health, we use WHO commission’s definitions,3 which refer to the wider set of social, commercial, cultural, economic, environmental and political determinants that drive patterns of health inequalities. These determinants are the daily conditions in which people grow, live, work and age; they are the forces and systems shaping living conditions. Determinants include population exposure to the physical environment; occupational hazards, housing, chemicals, air and water quality, sanitation and hygiene, and climate change. The determinants converge and accumulate over time to shape the health of population groups according to their social status. This is defined by, for example, education, ethnicity including indigeneity and migrant status, gender, gender identity, income, occupation and sexual orientation. Hence, changes in health equity that result from specific interventions or policy frameworks aimed to improve social determinants of health may take time to show. Using the commission’s evidencebased recommendations for intersectoral action,3 we offer a classification of three groups of intersectoral interventions that focus on the determinants and are relevant to the SDGs’ equity and sustainable development foci.4 The first group includes governance interventions, defined as political and decisionmaking structures and processes that improve health equity, such as wholeof-government or multisectoral committees, funds or plans, or human rights legislation. The second group consists of socioeconomic interventions, defined as those policies and programmes that allocate social and or financial resources to improve health equity. Such interventions could improve early child development, education, living wage, pay equity and social protection. The third group includes environmental interventions, defined as policies or programmes for the built or natural environment that improve health equity. Examples of such interventions are slum upgrading, air and drinking water quality improvement, sanitation and hygiene improvement and climate change mitigations and adaptations. Of the commission’s 39 intersectoral action recommendations,3 17 are for governance interventions, 16 for socioeconomic interventions and 6 for environmental interventions (Box 1). Effective action monitoring requires valid, sensitive and reliable indicators drawn from a solid evidence base on intervention effectiveness. Theoretical evidence suggests that interventions focussed on social determinants of health could be used as action indicators, since they are theorized to improve these determinants, health service use, health The need to monitor actions on the social determinants of health Frank Pega, Nicole B Valentine, Kumanan Rasanathan, Ahmad Reza Hosseinpoor, Tone P Torgersen, Veerabhadran Ramanathan, Tipicha Posayanonda, Nathalie Röbbel, Yassine Kalboussi, David H Rehkopf, Carlos Dora, Eugenio R Villar Montesinos & Maria P Neira