Introduction and background

In 2008, the World Health Organization’s (WHO) Commission on Social Determinants of Health (the Commission) report synthesized evidence on the causes of health inequities, focussing on the non-medical factors that influence health outcomes (the ‘social’ determinants of health) [1]. The work of the Commission set in motion new knowledge generation and theorization around the social determinants of health. Since the Commission’s time, there has been significant growth in the social determinants of health and health equity literature. A recent bibliometric analysis of publications from 1966 to 2018 found that output of health equity publications grew from 1000 papers per annum in 2004, prior to the Commission, to approximately 8000 per annum by 2019 [2]. Also during the COVID-19 pandemic, there has been a surge of new studies documenting inequities in COVID-19 infection, morbidity and mortality [3].

The growing body of publications focuses on describing and quantifying the association between health inequities and the social determinants of health [4, 5]. While there are still important knowledge gaps regarding the extent of health inequities, there are more important knowledge gaps in understanding and documenting the actual actions taken by countries [6,7,8]. The mixed or negative trends in health inequities suggest that actions have been absent or not yielded the desired results [4, 7]. WHO has regularly called for more implementation and evaluation research to address this gap, including in 2005 [9], 2007 [10] and 2010–11 [11,12,13,14], as has UNICEF [15].

Furthermore, actions on the aspect of social determinants referred to as “structural determinants of health equity” are less well documented [16]. Structural determinants can be characterised as the formal and informal rules of institutions, policies, culture and values, which include structural discrimination such as classism, racism, sexism, able-ism, xenophobia, and homophobia (see Table 1 and Fig. 1) [17,18,19,20]. Structural determinants impact social patterns of “intermediate determinants”—exposures, behaviours and health service access that are important for health. Health equity and health inequities are the outcomes − the unfair and avoidable, or remedial, differences or inequalities in health outcomes between groups in society. Evidence states that on balance addressing structural determinants (acting on institutions, policy, culture and values) yields greater, long lasting positive impacts on health equity, when compared with addressing intermediate determinants alone (i.e. acting on individuals) [1].

Table 1 Social determinants of health definitions and concepts
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Fig. 1
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Conceptual framework of the social determinants of health and health equity. Source: Adapted from Solar, Irwin, 2007, 2010 [17]

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The ongoing COVID-19 pandemic has exemplified how structural (social) determinants of health equity (e.g., sick leave benefits) have real impacts − demonstrated by inequities in COVID-19 infection rates, access to treatment and increased mortality [3]. In light of this, the United Nations have called for a renewed social contract with health and well-being at the heart of all government policies [21]. Among key processes that can be used by governments to address structural determinants of health are Health in All Policies [22]. Health in All Policies approaches aim for all sectors to contribute to better public policies, by considering the health implications of decisions, seeking synergies, and avoiding harmful health impacts.

In summary, there are compelling arguments for more action on the social determinants of health. Even though national governments pledged their commitment through the Rio Political Declaration on Social Determinants of Health in 2011, action has been slow [23]. Taking cognizance of this, the 74th World Health Assembly in 2021 adopted a new resolution on the social determinants of health [24]. These developments have informed the launch of an eight-year WHO Special Initiative for Action on the Social Determinants of Health for Advancing Health Equity (‘the Initiative’), which is the focus of this note from the field [25]. The Initiative has the goal of ensuring that health equity is integrated into social and economic policies. The following sections describe the Initiative, report on regional and country-level activities that have been undertaken by the Initiative in the first year-and-a-half of its existence, and summarises lessons learnt.

The Initiative: key stakeholders, structure, and theory of change

The Initiative was formed between 2019 and 2020. It was launched by WHO in 2021. A partnership agreement was established between WHO (at headquarters, regional and country level), the Swiss Agency for Development and Cooperation (SDC) (a development agency), University College London, Institute of Health Equity (UCL/IHE) (an academic think-tank), and the University of Lausanne (UNISANTE (UNIL/UNISANTE) (a clinical leader working to integrate the social determinants of health into clinical teaching and health services practice). These partners form the Initiative “core team” at present. Elsewhere, we describe the innovations associated with the initial configuration of this partnership (see Additional file 1).

The Initiative applies a multi-level approach (global, regional, national, local) to knowledge sharing, capacity building, and advocacy with the aim of supporting action in countries and of learning about action on the social determinants of health. Geographically, the Initiative is working through WHO regional and country offices in countries with largely low- and middle-income status. Pathfinder countries and territories include Chile, Colombia, Costa Rica, El Salvador, Lao People’s Democratic Republic (PDR), Morocco, Occupied Palestinian Territory (oPt), Peru and the Philippines. In most cases, the Initiative work in countries has begun through WHO outreach to public health agencies, but there has been increasing effective engagement of other key stakeholders beyond the health sector and it is anticipated that the final collaborations formed at country level will involve many other key stakeholders beyond the health sector.

Theory of change

One of the first activities of the Initiative’s core team was to evolve a theory of change.

This began with a review and discussion of the literature and reflection on the lived experiences of public health officers working across WHO, shared through virtual meetings and correspondence, owing to COVID-19 travel restrictions.

These discussions acknowledged that the literature reflected that action was not yet wide-reaching [7], and generally, literature showed that addressing structural determinants was particularly difficult because it involved multisectoral action [17, 19, 26,27,28]. Experience and calls from Member States through WHO resolutions highlighted that a key difficulty is for the health sector to implement multisectoral action [23, 24]. Important themes that emerged from these discussions were: the importance of social mobilisation, the alignment of windows of opportunity, and equip** health policy-makers to be better advocates and partners for health, not solely for health care [27, 28]. As the Initiative’s core team discussed the problem of action further, they noted several perceived obstacles to progress on this agenda in countries. These discussions generated two key points that are central to the Initiative’s theory of change. First, the importance of theory was noted (“less rhetoric and more theory is needed”). Without theory it is not possible to improve the design and implementation of interventions and policies. It is also not possible to convince others of the validity of approach.

Second, the discussions showed that common ideological, technical and operational barriers to addressing the social determinants of health for advancing health equity operate across different countries (see Fig. 2, left). Ideological barriers to action relate to a perception of striving for health equity as being associated with a left-leaning agenda [29]. However, there are examples where this is not the case. For example, the UN Sustainable Development Goals (SDGs) are a non-partisan development platform for governments from different political persuasions and they promote the reduction of social inequalities. There are also technical barriers. For example, there is limited evidence available on the co-benefits across different policy goals such as: how do policies taxing fossil fuels affect other social determinants of health equity, while addressing climate change in a positive manner; or how do social protection floors reduce transmission of COVID-19, while reducing violence [29, 30]. Finally, operational barriers include: (i) a lack of understanding of what the social determinants of health equity are [31, 32]; (ii) limited integration of the social determinants of health equity within the routine functions of health systems [33, 34]; (iii) limited focus on interventions that address the structural determinants of health inequities [7, 28, 35]; (iv) under-representation of community voices in the health sector and in its multi/intersectoral work [17, 36]; and (v) limited forums and incentives for policy integration and for multi/intersectoral collaboration across government authorities [30, 37, 38].

Fig. 2
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The Initiative’s theory of change

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Based on these considerations, the Initiative theory of change sought to introduce ‘interventions’ associated with change, in three areas (see Fig. 2).

First, strengthening knowledge and narratives for scale-up related to health equity would be emphasized. Updated knowledge that resonates with the current world crises experienced in many countries, including COVID-19 and conflict, and healthy societies and the well-being economy, contextualises the information on the social determinants of health for different change agents desiring to advocate for action. Knowledge on co-benefits between health and other policy sectors enables better collaboration.

Second, focused work in Pathfinder countries with demonstration sites would promote action to address structural determinants of health equity and allow for the development and testing of models. Models provide useful tools for discussion between ministries of health and central government to promote action and for UN, WHO and donor technical and financial assistance to countries. Third, the Initiative would enhance intra and inter-country networks of policy champions (and change-agents), academics, health workers and communities. Networks provide sustenance to change agents that are addressing governance changes, for example, seeking to influence institutional processes.

The core outcome of the Initiative, by 2024, is that: “health, social and economic COVID-19 recovery policies are informed by and act on equity impact assessments of social determinants, with policies for reduced inequities implemented in at least 6 countries”.

Strategic actions

In pursuing the logic of this theory of change, the Pathfinder countries follow a set of strategic actions on the ground: (1) strengthening knowledge on structural determinants of health equity and increasing local assessment capacity; (2) supporting community participation in co-identifying social determinants of health; and (3) promoting collaboration for addressing structural determinants of health equity in all policies and actions, with a social policies emphasis. (Details of the sequences of changes associated with these actions is included in Additional file 2) In undertaking strategic actions, Pathfinder countries engage nationally and sub-nationally.

Strategic, ‘initial’ themes

Based on the WHO COVID-19 review of social determinants of health [3], as well as the concomitant social crisis reported by the UN [21] and discussed by the Initiative core team, an initial set of structural determinants of health themes were prioritised (while others may yet be identified). The themes were tested in discussions with prospective country Pathfinder policy-makers, and confirmed as offering promising entry-points for action, in particular as they aligned with broader social policy goals. These themes are:

  • Reducing precariousness, in particular in informal economy employment;

  • Improving income and food security;

  • Ensuring adequate housing and social services;

  • Guaranteeing employment (sick leave, business closures).

Cutting across these themes, there were additional health equity concerns for a number of population groups who experience compounded disadvantage for intersecting identities: workers in the informal economy who are also migrants; women and girls suffering from gender inequality and violence; and ethnic groups facing social stigmatisation or exclusion owing to racism [3]. For example, a large-scale investigation of SARS-CoV-2 infection rates covering 2 135 190 people in communities and 100 000 health-care workers in the United Kingdom and the USA between March and April 2020 found that health-care workers for people with COVID-19 had at least a three times greater risk of a positive COVID-19 test and predicted infection than the general community. Yet ethnic minority health-care workers were at especially high risk, with a risk of COVID-19 at least five times that of the non-minority general community [39].

Activities of the Initiative in its first year-and-a-half

This overview of the first year-and-a-half of the Initiative focuses on: (1) regional strengthening to create enabling environments for country action; and (2) a programme of work started in six Pathfinder countries. Related to both of these areas, the Initiative, through UNIL/UNISANTE, launched an annual global one-week virtual summer school that ran in 2021, to which country policy makers and WHO staff were invited and several attended.

Regional strengthening to create enabling environments for country action

Three WHO regional offices undertook activities to strengthen country action as part of the Initiative: the Americas (AMRO/Pan American Health Organization (PAHO)), the Eastern Mediterranean, and the Western Pacific regions. Alongside the various activities reported below, these regional offices also supported policy dialogues regarding opportunities and priorities for country Pathfinders.

The region of the Americas

Systematic reviews were completed to assess regional evidence on the state of the social determinants of health, and on interventions and policies to address them. Core review themes, based on relevance to the countries in the region were: informal work, unemployment and migration. Preliminary analysis, still underway, mapped health equity impacts of policies under thematic areas. For example, in the case of unemployment, the five main domains of health impact were: physical health; mental health; health systems; HIV and unemployment; or the impact of parents’ unemployment status on children’s health. The regional office also reviewed the extent of country policies, plans and programmes being used to address structural determinants of health equity in response to COVID-19 and beyond. They conducted perception studies of policymakers and health care services providers in Pathfinder countries. They developed “Voices for health equity” video case studies to raise awareness of the experiences of disadvantaged populations. They also created a partnership with the regional domestic workers association, CONLACTRAHO.

The Eastern Mediterranean region

The regional office convened a regional Commission on Social Determinants of Health, comprising academic experts as well as political and bureaucratic leaders who worked together on a report [40]. This report assembled regional evidence on the social determinants of health, including in the context of COVID-19, and set an agenda for regional action, research and advocacy. The regional office ran workshops to disseminate the recommendations of the Commission and commissioned work for a tool to assist country work across the region, including in Pathfinder countries.

The Western Pacific region

The regional office undertook a sco** review of population groups most affected during COVID-19. They produced a regional guidance-note on equity considerations for COVID-19 surveillance and a video series on the People of the Western Pacific. These videos help policy-makers to reflect on the predicament of different populations groups in the Western Pacific Region as regards health equity. Examples of topics covered include vaccination against measles in the Philippines, preventing and responding to gender-based violence in Papua New Guinea, and providing tailored care to refugees in the COVID-19 response in Malaysia. The highlighting of vaccine inequity was also applied to the situation of COVID-19 and played an important role in supporting the Philippines work.

Country work and entry points: six Pathfinder countries

Six Pathfinder countries contributed actively to the Initiative in its first year-and-a-half: for the Americas, (1) Costa Rica, (2) Chile, (3) Colombia; for the Eastern Mediterranean, (4) Morocco; for the Western Pacific, (5) Lao PDR, (6) the Philippines. Country work reported below relates to: (i) the initial formation of teams; (ii) the identification of possible entry points and partners; (iii) the plan or vision put forward for taking action on structural determinants; and (iv) some early activities (facilitating stakeholder meetings to identify priorities and form partnerships/networks; measurement and surveillance; and training and advocacy).

Costa Rica has identified the opportunity for supporting action on the structural determinants of health equity through expansion of universal and targeted policies covering informal work, social protection and for migrants. There has also been a national drive to scale-up community participation at all local levels. Efforts underway are part of a “3Rs” plan for “Recovery, social reconstruction and resilience” of the central Americas region post-COVID-19, supported by the European Union. The 3Rs places emphasis on interventions for women, migrants, children, youth, border territories, Indigenous and Afro-descendant populations. A regional office project, “Community Participation for People-Centered Health in the Framework of the COVID-19 Pandemic”, has facilitated spaces for dialogue in Costa Rica between institutions and communities in order to identify health problems and needs in response to the COVID-19 pandemic. People-centeredness in this instance is tied to Primary Health Care, where the actions of the health sector link up to those of other sectors, and are buttressed by community/social participation.

In Chile, action on the social determinants of health is connected to universalization of social policies, alongside setting-up a more integrated health and social care system as part of health reforms. New “care systems” are being conceived that address gender, income and class inequities, among others. The COVID-19 pandemic revealed the many weaknesses and disjunctions in the care system for those in informal settlements or work, for migrants, as well as for other population groups already facing social exclusion. The country team identified intersectoral mechanisms to support the health and social development ministries to work together in the context of the Initiative.

Colombia has launched its observatory for equity in health which has been under development for some time [41]. Supported by the Initiative, the observatory will use evaluations of the health equity impacts of social policies to promote changes for immigrant policies. The observatory has already highlighted the plight of migrants during the COVID-19 pandemic, as Colombia is a migrant “receiving” country (see: Colombian congress live video; Minister of Health and Social Protection’s news feature).

In Morocco, the Ministry of Health, supported by the Moroccan National Social Determinants of Health Commission, WHO and the regional Commission on Social Determinants of Health, undertook a national study on the social determinants of health and health inequities. The results of this study were discussed in a workshop in which a research network was established and key themes to explore further were also identified. The research network will develop a training programme on the social determinants of health and Health in All Policies. This programme will serve as a basis for building capacities of multisectoral actors to understand and act on the social determinants of health, but the exact focus of actions on structural determinants still needs definition.

Lao PDR saw heightened attention placed on community health during the COVID-19 pandemic, which it will use to leverage action on the social determinants of health under the Initiative. The Ministry of Home Affairs has developed a Memorandum of Understanding with the Ministry of Health to develop a Community Network Engagement for Essential Healthcare and COVID-19 responses through Trust (CONNECT). This intersectoral collaboration aims to strengthen local health governance under the nation’s “three builds” decentralization policy. Shifting towards comprehensive Primary Health Care approaches, a three-layer intervention to strengthen local governance and community engagement for health equity has been developed, field tested and endorsed for nation-wide rollout. The most disadvantaged districts have been identified, baseline surveys are being conducted and methods to assess the impact of CONNECT on structural determinants of health are being designed.

In the Philippines, roll-out for the COVID-19 vaccine prioritized equity through reaching the most disadvantaged constituencies. Assessments of local data and evidence was key to identifying that individuals experiencing homelessness were disproportionately impacted by COVID-19. In response the WHO country office partnered with the national government, the United Nations Population Fund and local civil society to reach COVID-19 vaccines to populations experiencing homelessness (see news feature). This work has had the knock-on effect of loosening registration requirements (for both populations experiencing homelessness and survivors of gender-based violence), and increasing vaccination coverage in the whole capital, Manila. This work is serving as a launchpad for the Initiative. Expanding beyond vaccination programmes for these populations is the next step for this Pathfinder country.

Lessons and future directions

The Initiative has, during its first year-and-a-half, contributed to the evolving narrative on the social determinants of health in Pathfinder countries through forming core teams, involving the WHO country office and at least one or more civil servants that have progressed visions for change: facilitating stakeholder meetings; and advancing measurement, training and advocacy. Pathfinder countries have committed to an action-learning process around a common theory-of-change, and are working to identify structural determinants, several across the ‘initial’ themes and population groups identified but in other cases prioritisation and adaptation to national priorities is still underway. Not all countries have undertaken all strategic actions of the Initiative yet owing to changes in leadership, priorities in relation to the COVID-19 pandemic, and changes in WHO support staffing for the Initiative. Nonetheless, in all cases they are seeking for policy opportunities, and their activities in the first year-and-a-half have set the basis for progressing strategic actions. Joint reflection and writing in the course of meetings and monitoring processes revealed lessons on particular factors enabling action in the Initiative. These are presented below.

Develo** models for action on structural determinants

The ability to work on structural determinants has varied across Pathfinder countries. Yet even in contexts unfamiliar with addressing social determinants of health, country teams are finding innovative ways to broaden concerns with equity in access to health care to question broader structural determinants of health equity. Approaching the work in the form of a model has been a useful heuristic device for learning and practice in a non-judgemental way. Emerging models have different granularity of details; and may be adapted in the coming year. For example, in Colombia, it seems feasible to use health impact evaluations to develop inputs to migration policies but exactly what this entails in terms of governance structure for multisectoral collaboration is not yet defined. In other cases, such as Costa Rica and Lao PDR improving governance through engagement with affected communities in social dialogue platforms, may evolve as another model aligned with Primary Health Care. The case of Costa Rica, with social development mechanisms proposed by a ‘non-health’ ministry (the ministry of social development), most clearly presents immediate engagement with multisectoral stakeholders to support action on structural determinants of health equity. Exactly how each of these models will go on to influence formal and informal rules of institutions, policies, culture and values to improve the structural determinants of health is an area that needs greater focus and clarity going forward.

Leveraging and broadening networks, including with communities

Network-building for action on the structural determinants of health equity has been critical across all regions and Pathfinder countries. For example, the regional office for the Americas has engaged a regional association of domestic workers and this collaboration has raised the visibility of social policies for workers in the informal economy in several Pathfinder countries. In the Eastern Mediterranean, in Morocco, creating a network of academics has been a first step. The Philippines has worked with the UNFPA. Including partners in networks from beyond the health sector has started slowly but more needs to be done in the coming year. The fact that some countries are placing a specific emphasis on community participation mechanisms as entry points for change to structural determinants of health equity will be instructive. Develo** a deeper understanding of the role of communities as participants in policy networks will be key to develop further [42].

Integrating existing knowledge resources and develo** new ones to build capacity

Literature on Health in All Policies efforts in countries discusses the importance of strengthening the capabilities of the health sector staff and allowing time for them to work with other sectors [42, 43]. In Pathfinder countries, a similar demand for strengthening capabilities of individual actors and capacities of institutions is being observed. Reviews of knowledge from the academic literature and develo** human interest stories have been conducted in all regions. Strengthening knowledge on social policies to address them has been more gradual. In the case of the Americas, they recognised the need to assess capabilities and capacities for intersectoral action and community engagement. The theme of capacity building has become a central focus in Morocco as well. The one-week summer schools offered through the UNIL/UNISANTE partner goes some way to addressing the need for training but further work is needed to enhance capacity building more generally. Resources available to support capacity building need to be mapped. For example, in 2021, a WHO resource on community engagement approaches and experiences was launched [44]. Beyond WHO, resources such as Making change visible: evaluation to advance social participation in health [45], need to be reviewed. Training for data collection and multi/intersectoral action is needed, for which certain WHO resources currently exist [46, 47]. Within the data area, approaches for assessing the reach of the Initiative as regards its impact on the lives of beneficiaries is a measurement challenge requiring practical guidance. Next steps thus involve considering how to meet the training and capacity building needs more centrally in the Initiative – both with respect to internal WHO and UN processes, and for actors in government bureaucracies [48].

Conclusion

The Initiative has produced a common theory of change to support action on the social determinants of health for advancing health equity on the ground. WHO and core partners have reenforced evidence and assessments under the ongoing COVID-19 pandemic; promoted dialogue on the structural determinants of health equity; and supported country-level engagement for action. Steps taken by countries themselves during the first year-and-a-half of the Initiative have shown the feasibility and importance of building models, leveraging networks, and enhancing capacity building. Notwithstanding early successes, implementation challenges remain. Political change and financial uncertainy may limit general investments in the civil services and in the specific human resources needed to realise the policy commitments to address the social determinants of health.