[afro-nets] The Commission on Social Determinants of Health (2)

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

The Commission on Social Determinants of Health (2)
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Part 2 of 4

2.2.2 Anticipating potential resistance to CSDH messages -- and
preparing strategically

On the question of why policy action on SDH has lagged in most
settings, the existing literature presents two main explanatory
strands. The first sees the blockage as a problem of knowledge,
the second as a question of power. According to the first ac-
count, action to address SDH has been weak because the evidence
base on which to build such action is inadequate, or existing
evidence has not been effectively communicated to those in a po-
sition to effect change.

The second account emphasizes the political economic dimension
of power and profit, and suggests that the most important barri-
ers to action on SDH lie in this area. It sees policy failure on
SDH not primarily as a symptom of ignorance, but as the logical
consequence of existing power relations. Notably the fact that
certain influential constituencies derive benefit from a status
quo in which SDH are not addressed, and believe their interests
would be compromised if policies were enacted to tackle social
determinants aggressively.

The key objectives of the CSDH clearly include filling gaps in
the scientific evidence base relative to social determinants and
effective policies and interventions to address them. The very
existence of the Commission reflects the conviction that effec-
tive communication of SDH messages to policymakers, health and
development actors and the broader public can help catalyse ac-
tion that will significantly improve vulnerable people's chances
for health. However, the CSDH must also take seriously the sec-
ond explanatory strand just evoked, centred on political-
economic power relations.

Our historical survey has suggested that it is not primarily the
lack of knowledge that has thus far hampered action on SDH. Over
the past quarter century, the evidence available has been suffi-
cient for most countries to acknowledge in principle (via numer-
ous declarations and official statements) the urgent need for
such action. However, between that acknowledgement and the ac-
tual implementation of meaningful policies, political barriers
have often emerged. It is particularly important that the CSDH
focus on these issues at the very outset of its activities. De-
signing and carrying through a process to collect scientific
evidence will in a sense be obvious and "natural" to many Com-
missioners and their support staff; addressing the political
barriers may be less so. Yet if the political strategy is not
well developed, the evidence collection, however scientifically
sound, may fail to generate the concrete change the Commission
seeks. Scholars have begun to analyse the political/structural
aspect of resistance to SDH approaches, but much work remains to
be done.

This paper cannot map the relevant power relationships in ex-
haustive detail, since the particularities of national and local
contexts will once again be crucial, and relevant constituencies
will vary across the range of thematic areas the Commission will
address (e.g., food security, housing, social exclusion, etc.).
This detailed political mapping will be a primary responsibility
for the Commission's Knowledge Networks and for the co-
ordinating groups in each partner country. What the present pa-
per can do is identify several broad constituencies likely to
feel their interests are threatened by SDH policy approaches. By
focusing clearly on these constituencies and understanding their
respective stakes in processes related to SDH, the Commission
can develop strategies to draw them into the CSDH process
through dialogue or, failing that, to minimize the damage caused
by their resistance.

The medical establishment SDH agendas, including efforts to ad-
vance health promotion and intersectoral action, have in the
past encountered active or passive resistance on the part of
many medical professionals and institutions. It is reasonable to
suppose that this pattern will continue under the CSDH. A sig-
nificant challenge for SDH and health equity agendas will be
bringing the medical establishment on board as a constructive
partner. Health care providers, especially physicians, are gen-
erally part of the social elite, and share its values and class
interests. Like other members of privileged social categories,
they will resent and often resist government policies that re-
distribute resources from the more advantaged to the less well-
off in society.

Furthermore, and more importantly, physicians have a strong
group interest in maintaining their monopoly over authoritative
discourse and practice around health. Medical professionals are
reluctant to see control of health issues slip away from them to
other sectors and professional constituencies, or to cede to
communities the power to set health agendas. The atrophy of in-
tersectoral action and the widespread discrediting of community
participation under Health for All partly reflected this persis-
tent dynamic, although other causal factors were also relevant.
The reasons for this pattern have to do in part with doctors'
desire to maintain their social prestige, but the more fundamen-
tal issue is economic. Individual physicians and the medical es-
tablishment as a whole make money by providing curative inter-
ventions. They will not make money from the introduction of a
school feeding programme or improvements to the housing stock in
a slum neighbourhood.

McGinnis et al. have underscored the inherent structural asymme-
try between public health and the provision of curative medical
care, when it comes to political clout and the competition for
resources. This issue must be of concern to the Commission as it
develops its approach to policy dialogue. In many settings the
structural configuration of health governance institutions has
combined with "interest group dynamics" to result in a "vacuum
of political accountability for maintaining population health".
In contrast, "a well defined set of actors--physicians and other
health care providers--has responsibility for medical care". In
addition to their ethical commitment to deliver medical services
to those who need them, "providers have a strong financial in-
centive to provide medical care, as well as an interest-group
incentives to lobby for increasingly more medical care re-
sources". To the extent that SDH programmes are seen as compet-
ing for these scarce resources that might otherwise be invested
in medical care, health care providers and other constituencies
that derive profit from patient care and related services may
resist them. Within national governments SDH interventions rep-
resent major opportunities to improve the health status of popu-
lations, particularly vulnerable groups, at relatively low cost.
National governments should be eager to pursue these policies.
However, the desire and/or the technical capacity of governments
to implement such approaches can by no means be taken for
granted.

The Ministry of Health may be wary of social determinants ap-
proaches, because these may be seen both as channelling health
funds away from the MoH towards other government departments,
and as loosening the MoH's scientific and political authority
over health. Making health "everybody's business" should regis-
ter as a highly constructive development, but it could also be
seen as a diminishment of the power and prerogatives of the MoH
and health sector specialists. At the same time, earlier experi-
ences in IAH suggest that non-health ministries and government
officials may (at least initially) also be reluctant to commit
time, energy and resources to work oriented towards health
goals.

In general, many elected officials must of course make their own
tacit cost-benefit calculations in terms of election cycles and
the need to quickly deliver tangible benefits to electors. They
operate on a compressed time-frame and seek opportunities for
"quick wins", with a preference moreover for policy options
where the causal link between intervention and outcome is obvi-
ous. In contrast, some SDH programmes might require years or
decades to really begin generating major measurable effects.
Such efforts will do little to advance decision-makers' immedi-
ate electoral interests. Furthermore, the lines of causality in
intersectoral action are notoriously complex, making it diffi-
cult in many instances to prove that a particular programme was
the source of a given health improvement. Added to this is the
consideration that the prime beneficiaries of many SDH interven-
tions would be poor and marginalized constituencies who are of-
ten less likely to participate in the political process and thus
to "pay off" in terms of votes for politicians. As McGinnis et
al. argue: "It takes more than just evidence that social change
would improve health to convince the general public [or a forti-
ori policymakers] that such redistributive investments should be
undertaken. These choices are very much about ideology and so-
cial values". Some government leaders will be opposed to many
aspects of an SDH programme on ideological grounds, because they
will see SDH interventions as largely constituting unnecessary
government interference in processes better left to market
forces and individual choice/responsibility. The resistance to
the introduction of new, government-led redistributive policies
will be encountered among leaders of some wealthy countries ea-
ger to secure global dominance for the neoliberal "free market"
model; it can also be expected among officials in some develop-
ing countries who are strongly lobbied and influenced either by
private sector interests or by major global institutions closely
aligned with the neoliberal agenda. Moreover, even in countries
interested in adopting redistributive mechanisms to address SDH,
governments may be unable to implement such programmes: because
of lack of resources; as the result of social sector spending
ceilings and other constraints imposed by IFIs and donors; or
because of the shortfalls they face in terms of human and other
resources for planning, implementing and managing complicated
social programmes. At the same time, many developing country
policymakers and programme implementers exhibit an (understand-
able) level of "initiative fatigue", scepticism and resistance
to priorities seen as imposed from outside. Such resistance is
an inherent obstacle to the introduction of any major new pro-
gramme initiative in some developing countries. Thus it will be
crucial for the CSDH to co-ordinate its policy recommendations
with the existing structures and policy frameworks through which
countries operate, and which govern relationships between devel-
oping countries and donors (e.g., PRSPs). The CSDH must not be
seen as piling on yet another set of "global priorities" and
recommended actions with no clear relationship to the structures
and processes currently in use.

The corporate sector Resistance to certain CSDH policy recommen-
dations -- as to previous attempts to catalyse action on health
risk factors such as smoking and diet -- is likely to come from
some corporate and commercial interests. Homedes and Ugalde have
shown that neoliberal health sector reforms in Latin America
have primarily benefited large corporations. They argue that un-
der these reforms: "Excluded health policies are those that have
a negative impact on corporate profits such as safety programs
in factories and agriculture, accident reduction in vehicle
transportation, tobacco reduction, the promotion of generic
drugs, and the promotion of essential drug lists". If the corpo-
rate sector and its allies have opposed such components within
health sector programming, it is reasonable to assume they will
resist similar strategies proposed under the banner of SDH.

The most obvious tensions for an SDH agenda may arise with those
corporations that profit directly from the marketing of poten-
tially health-damaging products and lifestyles: e.g., manufac-
turers of tobacco products; sugar; fast food and junk foods; al-
cohol; automobiles; and weapons. As McGinnis et al. note for the
US context: "The behavioural issues that together account for so
many deaths -- tobacco, alcohol, dietary excess and sedentary
lifestyles -- are all products in part of strong commercial
forces. Tobacco and alcohol represent US industries with annual
sales of well over $100 billion. The food industry spends bil-
lions just on advertising and promotion". In this sense, the
sustained effort to confront the tobacco industry and to estab-
lish the Framework Convention on Tobacco Control may provide
lessons for the work of the CSDH.

Yet the situation of an SDH agenda with respect to corporate in-
terests is more complex that in the case of tobacco. Rather than
a single industry (and one moreover with a largely negative pub-
lic profile), SDH interventions may be seen as potentially
threatening the interests of national and transnational compa-
nies in a variety of different sectors, including some of the
world's most powerful and beloved consumer product brands. The
recommendations that will emerge from the Commission's Knowledge
Networks on employment/working conditions and globaliza-
tion/trade are particularly sensitive in this regard. Numerous
transnational corporations are strongly inclined to fight gov-
ernment regulation and controls over questions such as labour
practices, workplace safety and the impact of corporate activi-
ties on the environment. Companies' profitability often depends
on eluding such unwelcome constraints. This is in addition to
companies' perpetual motivation to minimize the sums they must
pay in taxes. It is to be anticipated that many transnational
corporations may perceive policies addressing social and envi-
ronmental determinants of health as a threat, insofar as such
policies might raise companies' production costs and impose ad-
ditional regulations on their behaviour with regard to produc-
tion processes, labour relations, environmental impacts and mar-
keting practices. Corporate interests likely to be made uncom-
fortable by an SDH agenda include powerful companies in the for-
profit medical sector and the pharmaceutical industry. The phar-
maceutical industry may regard the CSDH as threatening for two
reasons: first, because an "upstream" preventive-promotive ap-
proach to health will not generate profits for the industry (and
might indeed in the long run actually reduce demand for some of
its products); second because of worries that the globalization
and trade Knowledge Network or other organs of the Commission
might publicly criticize the industry and/or generate policy
recommendations seen as contrary to its interests.

Within international organizations and the development community
Institutions such as the World Bank and IMF have immense power
to influence health and social policy in developing countries.
The struggles of the Alma-Ata agenda in the 1980s offer, among
other things, a lesson about what is likely to happen when
health leaders recommend policies that are significantly out of
step with the frameworks being promoted by the international fi-
nancial institutions. To avoid a repetition of this scenario,
the CSDH will need to manage its relationship with the IFIs and
other major development institutions strategically. This may be
a difficult challenge. While the IFIs' policy approaches have
evolved since the 1980s, some analysts caution that the changes
have been more on the level of rhetoric than of substance. The
World Bank's acknowledgement of the importance of a strong, ca-
pable state and the presence of new frameworks such as PRSPs do
not necessarily signify changes in the underlying assumptions
and imperatives of the neoliberal model. Critics argue that the
asymmetrical power relationships between the IFIs and countries
and the sorts of policy approaches recommended by the World Bank
and IMF remain as before in many instances. The IFIs continue to
advocate market liberalization and privatization, a "leaner"
state and strict ceilings on public spending, including for
health and social services. Their advice to countries may thus
in many cases run counter to the policy approaches the CSDH will
promote.

Moreover, both the IFIs and the bilateral development agencies
of powerful countries are strongly influenced by corporate agen-
das. IFIs often act to advance the interests of corporations
with close ties to their major shareholder governments. Thus to
the extent the Commission's messages and policy advice are per-
ceived as threatening to influential corporate constituencies,
the IFIs and bilaterals may seek to discredit the Commission and
its recommendations, either through public critiques or behind
the scenes advice to national policymakers and other interlocu-
tors. The CSDH may thus wish to consider advance outreach to key
constituencies within the IFIs, bilaterals and other donor agen-
cies as a special priority, developing and implementing targeted
outreach strategies in the early phase of its operations. Main
strategic questions:
To interest political leaders, a SDH policy agenda will have to
offer opportunities for some "quick wins". This principle ap-
plies to country-level political processes and at the global
level to the Commission itself. What might "quick wins" look
like, for countries tackling social determinants and for the
CSDH? How will the Commission develop its relationship with the
major international financial institutions, in particular the
World Bank?