A global framework for emerging research on the social determinants of health

Sharon FrielProfessor of Health Equity and Director, Regulatory Institutions Network,

Director, Menzies Centre for Health Policy, The Australian National University

1. What are the questions?

2. What type of evidence is needed to answer the questions?

3. What architecture is needed?

Point 1.

What’s the question?

Illuminating health inequities

Socio-economic gradient in health, Australia

0

2

4

6

8

10

12

14

$5-<10K $10-<20K $20-<30K $30-<40K $40-<50K $50-<70K >=$70K

Perce

ntage

Household income

Diabetes

0

5

10

15

20

25

30

35

$5-<10K $10-<20K $20-<30K $30-<40K $40-<50K $50-<70K >=$70K

Perce

ntage

Household income

Depression

Data source: 45 and Up Study (Korda et al, under review)

Understanding the causes of health inequities

"why are the poor behaving this way?”

"why are they poor?”

Re-framing the question

Health inequities are socially produced

Living & Working Conditions

e.g.PlanningHousing

Employment

Health Care Systemse.g.

Equitable access to careHealth Promotion

Power, Money & Resourcese.g.

Trade and investmentTaxationRacism

Health Equity

Research Domains

Health equity

Seven political domains that shape health and health inequity

Intellectual property

Trade and investment treaties

Food

Corporate activity

FinanceMigration

Armed conflict

Ottersen etal. The Lancet–University of Oslo Commission on Global Governance for Health The Lancet, 2014

Chief Investigators: Friel, Bammer, Gleeson, Kay, ThowAssociate Investigators: Labonte, Snowdon, Stuckler

Trade policy: Maximising benefits for nutrition, food security, human

health, and the economy

ARC Discovery Grant DP130101478

2013-2015

Friel et al. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement. Globalization and Health 2013, 9:46

Domain 1 aim• develop a conceptual model of the system linkages between trade,

food, the economy, society and health outcomes, • investigate how systems science can be used to support integrated

trade, food, and health policy-making

Domain 2 aim• produce quantitative evidence of diet related health effects of a

trade agreement (the TPP)

Domain 3 aim• characterise the main stakeholder groups and institutions involved

in the TPP negotiations, within Australia and at the international level

• assess the capacity of different modes of trade governance to achieve coherence between the goals of trade and health sectors (with respect to food and nutrition)

Does social spending save lives?

Slide: David Stuckler

Greek Tragedy

• >200% rise in HIV infections

• 40% rise in homelessness

• 50% rise in people unable to access medical care

• 40% increase in infant mortality

• ~60% reported increase in suicides

Kentikelenis et al. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2014

Economic growth in Iceland and Greece

Slide: David Stuckler

What works to improve health equity and how

Evaluation of the impact of health-sector policy and

programs on health equity;Applying a health equity lens to non-health sector

policy and programsUnderstanding how SDH

and health equity gets onto the agenda

Understanding the barriers and opportunities:

systems, processes and actors

What does SDH policy and action look like

Framing the question

Reflection from Health Ministers

Baum Etal. Social Science and Medicine 2013

Social innovation

The art and science of advocacy and communication

1. Lack of public awareness about the SDH2. Prominent ideology3. Human attribution biases4. Journalistic norms and practice

…In two-thirds of the 50 stories [on television news], the main message was that individuals were

personally responsible for their weight…Bonfiglioli 2007

Shaping the public discourse

Hayes et al. Social Science & Medicine 64 (2007) 1842–1852

Point 2. What type of evidence/analysis

is needed to answer the question

Evidence for policy

Evidence of policy

Technical analysis

Political analysis

Policy

Market

Social innovation

Different kinds of research to answer different questions

Community trialsEconomic analysis

Case studies

Policy & regulatory analysis

Epidemiology

Natural experiments

Natural sciences

Discourse/framing analysis Network analysis Systems science Realist evaluations

Emerging theory-informed methods

Point 3.

What architecture is needed

I. Knowledge

II. Skills

III. Funding and dissemination

Disciplinary diversity

• Epidemiology• Health services• Psychology• Sociology• Anthropology

For example

• Law• Economics• Political science• Public administration• Systems science

Questions of training

1. Disciplined mind

2. Synthesizing mind

3. Creative mind

4. Respectful mind

5. Ethical mind

Minds for an equitable future

• Flood the funders

• Be on grant selection committees

• Review every related article that you possibly can

Shifting the paradigm with appropriate evidence