Title: NIHR Global Health Research Unit on Social and Environmental Determinants of Health Inequalities
Funder: Department of Health and Social Care

Abstract: Brazil and Ecuador manifest stark inequalities, including inequalities in health. These inequalities arise from the social determinants of health – the conditions in which people are born, grow, work, live, age and die. Many environmental factors, including urbanisation and the climate emergency, are increasing priorities for individual and population health. These tend to have the most harmful impacts on the most deprived in society. The health system needs to respond to such social and environmental threats, but its organisation may mean that it is not protecting the most vulnerable in society._x000D_ To try to reduce the impact of social conditions such as poverty, governments have introduced policies such as conditional cash transfers or housing programmes for the very poor. Similarly, governments may introduce environmental policies to protect the environment and mitigate any harmful effects on living conditions. While such policies may not be primarily aimed at improving health, they may still have large impacts on health and health inequalities, with much of the historical improvement in life expectancy attributable to them. Our Unit will focus on discovering which policies impact health, whether they had a bigger impact on disadvantaged groups (defined by axes such as income, ethnicity, race, sex, geography, migration, urbanicity and deprivation), and how the organisation and provision of the health system (particularly regarding coverage, access and quality) could optimise any positive health impacts. _x000D_ We will build on our existing GHR Group on Social Policy and Health Inequalities and the experiences and relationships that have been moulded by that Group. Over the next five years, we plan to be global leaders, focused on Latin America, in harnessing existing databases by integrating them to evaluate the impact of social and environmental policies on health and health inequalities, and the extent to which these can be affected by the health system. We will develop research capacity in data linkage and policy evaluation as a legacy for Brazil and Ecuador. We will achieve this by:_x000D_ 1. Building and developing high quality data resources in Brazil and Ecuador;_x000D_ 2. Conducting rigorous evaluations of the impacts of social and environmental policies, and the effects of large-scale population migration, on health and health inequalities;_x000D_ 3. Updating or creating small area deprivation indices for Brazil and Ecuador;_x000D_ 4. Determining how health systems are best organised to improve health for all social groups and interact with social and environmental policies;_x000D_ 5. Focusing on priority health outcomes with relevance to Brazil, Ecuador and Latin America, in which the research team have expertise: non-communicable diseases including mental health and asthma; maternal and child health; reproductive and sexual health; COVID-19 and emerging health threats; infectious diseases; and violence;_x000D_ 6. Monitoring progress towards the 2030 Agenda for Sustainable Development (particularly Goal 3, but also any impacting on health equity);_x000D_ 7. Working with stakeholders, communities and the public to develop our research agenda, set priorities, disseminate results targeted to specific audiences and in so doing influence regional and national policy; and_x000D_ 8. Building capacity in the relevant disciplines in global health research in Brazil, Ecuador, the UK and globally through the development of training programmes and the promotion of south-south learning.

Lay abstract: Brazil and Ecuador are Latin American countries that show marked inequalities in health. Although there are many potential causes of health differences between different social groups, it is reasonable to assume that these are largely due to the social determinants of health – the conditions in which people are born, grow, work, live, age and die. At the same time, there are many environmental factors that can impact individual and population health, including the built environment and climate change. These tend to have the most harmful impacts on the most deprived in society._x000D_ In an attempt to reduce the impact of social conditions such as poverty, governments sometimes have introduced policies such as providing small cash payments to or building houses for the very poor. Similarly, in an attempt to protect the environment and to mitigate their harmful effects on the conditions in which people live, governments may introduce environmental policies. While such policies may not target an individual’s or a population’s health, they may still have a notable influence on health. Our Unit will focus on discovering whether these policies, when implemented, had any impact on health, whether they had a bigger impact on disadvantaged groups (defined by income, ethnicity, sex, geography, migrant status and deprivation), and the extent to which the health impacts have been modified by how health services are provided, particularly regarding coverage, access and quality._x000D_ Over the next five years, we plan to lead globally, with particular reference to Latin America, in terms of using the full potential of existing databases by integrating them to find out whether social and environmental policies have had an impact on health and health inequalities, and the extent to which these can be affected by health service provision. We will achieve this by:_x000D_ 1. Building, developing and linking national databases covering health, social (e.g. welfare) and environmental registers in Brazil and Ecuador;_x000D_ 2. Studying the impacts of social and environmental policies, and the effects of large scale population movement on health and health inequalities;_x000D_ 3. Creating indicators of deprivation covering small areas for the whole of Brazil and Ecuador;_x000D_ 4. Determining how best to organise health services to improve health for all social groups and to respond to social and environmental threats in a way that minimises the damage they do to health;_x000D_ 5. Focusing on health outcomes that are considered priorities in Brazil, Ecuador and the Latin American region, in which the research team have expertise: non-communicable diseases including mental health and asthma; maternal and child health; reproductive and sexual health; COVID-19, infectious diseases and emerging health threats; neglected tropical diseases; and violence;_x000D_ 6. Monitoring progress towards the United Nations’ 2030 Agenda for Sustainable Development (particularly Goal 3: Ensure healthy lives and promote well-being for all at all ages);_x000D_ 7. Working with stakeholders, communities and the public to decide which policies we should evaluate, set priorities for our research, and tell different audiences about our results, particularly those who are making policies; and_x000D_ 8. Training researchers from Brazil, Ecuador and other low and middle-income countries in global health research methods by developing a research hub in Ecuador, and providing training programmes and mechanisms to share researchers’ experiences.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;2.6 RESOURCES AND INFRASTRUCTURE (AETIOLOGY);8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: GENERIC HEALTH RELEVANCE