Changes Not for the Fainthearted: Reorienting Health Care Systems Toward Health Equity Through Action on the Social Determinants of Health

Entrenched poor health and health inequity are important public health problems. Conventionally, solutions to such problems originate from the health care sector, a conception reinforced by the dominant biomedical imagination of health. By contrast, attention to the social determinants of health has recently been given new force in the fight against health inequity. The health care sector is a vital determinant of health in itself and a key resource in improving health in an equitable manner. Actors in the health care sector must recognize and reverse the sector''s propensity to generate health inequity. The sector must also strengthen its role in working with other sectors of government to act collectively on the deep-rooted causes of poor and inequitable health.The production of better population health outcomes is usually equated with improvements in health care. But this is a somewhat crude equation. All too often, health care sectors, firmly rooted in medicine, do not demonstrate active engagement with the wide determinants of patients'' health; do not ensure, through a nuanced understanding of social determinants, that care services are made available and accessible to all social groups equitably; and have not been as proactive as one might expect, given the evidence on social determinants of health, in engaging and working with other government sectors (as a kind of steward in support of those sectors'' own activities) to ensure that all government entities appreciate their potential to affect health and health equity.This situation must change. As a first step toward change, some questions need to be answered. How are we as a global community performing with respect to health and health equity, both within countries and between them? What are key obstacles to improving integrated action by health care sectors on the social determinants of health? And what might a reoriented health care sector—one that takes health equity as a central goal and, in so doing, engages with the entire range of social determinants of health—look like? We first offer some definitions of key terms to clarify our discussion.We follow the lead of the Commission on Social Determinants of Health (CSDH) in viewing social determinants as the social, political, economic, and cultural conditions in which people live and work and the structural drivers of these conditions. We define the health care sector as the sector typically responsible for hospital- and community-based health services, public health surveillance, health promotion and workforce planning, standard setting, and regulation of public and private health care services.We use the term stewardship to describe the various roles that can be taken by actors in the health care sector in collaboration with their counterparts in other government sectors. We selected this term deliberately to recognize and minimize the risk of health imperialism (the domination of the health care sector over agendas shared with other sectors). Stewardship implies the general duty of care for a population''s health borne by government as a whole; it involves a nuanced balance of leadership and facilitation in the relationship between the health care sector and other government sectors, ranging from education through infrastructure and urban planning to trade. We define inequity as unjust and avoidable inequalities.