The Report of the Commission on the Social Determinants of Health

A SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis

Susan B. Rifkin
Department of Social Policy
London School of Economics
Introduction
For this presentation, I need to explain the position from which I come. I have
been involved both as an academic and activist in the promotion of the Primary
Health Care vision for over 35 years. My experience precedes the Alma Ata
Declaration in 1978. In 1973 I was living and working in Asia where I spent the
next 10 years. I was involved in creating a network of community based health
care practitioners throughout the region. Originally the network was based in
Christian institutions but gradually expanded to other indigenous NGOs. This
network became institutionalized as the Asian Community Health Action Network
(ACHAN) which was a founding member and main contributor to the Peoples
Health Movement. I was ACHANs first coordinator. Returning to Europe in
1983 I worked as a consultant for WHO involved with the leadership trying to
translate PHC into implementable programmes. My one of my major areas of
interest was community participation and I published work in this area both for
WHO and peer reviewed journals. I also became involved with academia based
for many years at the London School of Hygiene and Tropical medicine but also
doing consultancy work in Asia and Africa and helping to establish two Masters
programmes in Heidelberg, Germany and in Kisumu Kenya. Most recently I have
been a co organizer of a PHC study unit at the London School of Hygiene and
Tropical Medicine.
The reason I am describing this experience is because it is the basis of my
presentation. Confronted with a document that presented strong evidence for the

necessity for adopting a PHC approach to health improvements, evidence that

was not available in 1978, I was challenged to see what I could add to the
dialogue around this ground breaking work. What seem to me to be important
was to take an overview of the document. For this reason I decided to do a
SWOT analysis pulling examples from my own experiences around people and
participation. I have not attempted to take on the more technical issues of
service delivery or financing. The purpose of this paper is to highlight some of
the most critical Strengths, Weaknesses, Opportunities and Threats the Report
presents to policy makers, programme managers and civil society as a document
to shape the way in which we view and act upon health improvements in the 21st
century.
Strengths
As I implied above the most important strength of the Report is that it provides
evidence for the assumptions that formed the basis for the Alma Ata Declaration.
The Declaration, one might say, was more an act of faith built on the necessity of
addressing issues around social justice. The Report gives data that shows that
Social injustice is killing people on a grand scale. (back page CSDH ,2008) In a
period where policy makers and academics call for evidence based decisions, we
now have a document that responds to this call. Lacking evidence is no longer an
excuse for evading public health responsibilities and providing health care in the
business as usual approach.
Some of the evidence presented is quite compelling. Chapters 2 and 3 bring out
rather starling comparisons both between countries and within countries. There is
the graph comparing the differences in infant mortality rates and mothers
education among a range of low income countries and death rates and areas of
depravation in England and Wales. Chapter 4 reviews the evidence and presents
an analysis leading to recommendations. This makes the document a call for
action. It is not merely a review and critique of challenges and possible solutions.

In addition, the document clearly articulates the concepts of social justice and
human rights. Part 1 sets the context of the agenda and makes clear what are
the priorities based on the Commissions findings. The Report slowly brings
together data and arguments to show why health improvements must be based
on these two principles. The first concept is the main argument establishing the
necessity and actions to achieve health equity. The second concept is addressed
more concretely in part 4 in the discussion on the structural drivers of inequity:
power, money and resources. The report links these two concepts in the
following argument. Health is a moral obligation (a human right, a demand for
social justice). Governments must insure this right rather than treating health as a
commodity. In addition governments must exercise control over this right and
provide resources. But there is also a critical role for civil society (people) who
through empowering experiences can exercise this right and ensure social justice
is carried out.
The Report is a major contribution to mainstreaming the social, economic and
political arguments put forward to counter the view health is merely about
controlling diseases. Much of the published work in the area of medicine and
health is an examination of specific disease causes and outcomes. It does not go
beyond the rigid scientific analysis to deal with the context in which disease
develops. While the scientific presentations are critical they also limit
understanding of how health improves. In addition, they define how most people
perceive health. Ask anyone on the street how to define health and they will
equate the definition with a hospital. The report asks and even demands a much
larger context for defining and acting upon health matters.
Emerging from the expansion of health beyond disease control, the Report
highlights both intersectoral collaboration and the use of both quantitative and
qualitative data to act upon poor health. In doing so it recognizes the complexity
of factors that affect the health both of individuals and communities and
highlights how peoples perceptions of health affect attitudes and behaviours.

The chapter on gender equality brings together more concretely the need to
address these issues. The chapter on monitoring, research and training
highlights the need for qualitative evidence and for research the addresses both
outcome and process.
Finally, for the purposes of the presentation, a strength of this report is that it
begins to identify actions and alternatives to address challenges it has examined.
It suggests in Chapter 15 on global governance ways in which existing
institutions can be developed to support the reduction of health inequalities. It
particularly targets the UN institutions and points to how WHO can take a leading
role. In Chapter 16 it looks how research, monitoring and training can support
this interpretation of how health improves and in Chapter 17 it clearly links the
suggestions to the MDGs and shows how progress can be monitored using both
frameworks. Its call for change is underpinned with positive suggestions and
identification of ways in which the recommendations can be moved forward.
Weaknesses
However, the Report has some weaknesses that need to be addressed if the
recommendations are to be taken forward.
Most critical, and perhaps a threat as well as a weakness, is the assumptions
that the ethical imperatives of social justice and health as a human right are
values shared by all cultures and societies. While in the Judeo Christian tradition
this is a fair assumption it is not true in all countries or societies. For example,
the Indian traditions of Hindu and Buddhist belief do not attribute the resolution of
poor health (suffering) as a problem of the state. Rather they see it as a
reflection of individual choice or results of choices in previous lives. The
government has no obligation to reduce such results. Another example is the
Confucian belief of the role of the state as the mother-father of the people.
Individuals do not make demands but trust the state to perform according to the
Confucian ethic which would ensure good health. The cultural orientation of the

Report appears to be absolute without opportunities for dialogue. At best this

failure could be considered nave; at worst ,colonialist.
Following this concern, there is also a concern about how the evidence is
presented. It could be argued, as human rights activists have done in contexts
where social justice and human rights have been ignored, that the evidence
provides a specific point of view. It chooses its evidence and arguments to
support this view. It is very clear about its orientation. However it could be
strengthened by engaging with those who take alternative positions. This is not a
criticism. It is only to suggest without taking on the critics, the report is in danger
of being rejected by those who have argued contrary points of view. A critical
point of view is that of people who still see that good health is a result of biomedical interventions rather than also dependent on other determinants. As this
view is dominating paradigm that influences policy and practice, it could be
argued evidence that meets their concerns should be presented. A major
challenge for moving the Reports recommendations forward will be to engage
the opposition.
There are also weaknesses in the technical presentation that could be improved
to strengthen the Reports arguments. The evidence in the early chapters
concerning equity, environment, employment, social protection, universal health
care and financing is rather robust and presents strong data. Later chapters are
not so strong. It is understandable in that concerns about gender, social
participation and voice are relatively new to the health agenda. It is more difficult
to record more wide spread results. However it does mean that the earlier
chapters appear to be stronger. This weakness is not helped by the fact that the
boxes in the text often give only rudimentary information and also refer back to
analysis presented by the knowledge networks. As a result, it is difficult to get a
full understanding of the material presented and it is not possible to go back to
the original source to examine the example in detail and form ones own
conclusions.

More specifically, in the area of human rights and the role of civil society I wish to
make three comments. The first is that human rights is presented more in the
context of a demand and not equally as a responsibility. While examples of
expansion of empowerment give illustrations about how this responsibility can be
exercised (Participatory budgeting in Brazil p. 162; SEWA p. 163) the
descriptions are in the context of responses to rights abuses than to creating
structures for responsible, accountable responses to unfair situations. A
discussion of responsibilities along the lines presented by Ruger (2006) seems to
be a necessary contribution to the human rights discussions.
The second is a concern about the use of the term civil society. The term
appears to have been used more universally with the development of the neoliberal approach to health improvements and implies advocacy of issues from
those without power. Civil society is a term describing organizations and/or
institutions comprised of groups of people advocating and working for changes
around specific shared problems. It excludes those who share the problems but
do not belong to any organization or institution. These people are those who
circumstances due to lack of capacity, energy and/or motivation prevent them
from joining such groups. By definition, these people are most often the poorest
members of society who have no opportunities to express their concerns. Civil
society therefore cannot been seen as reflecting the views of the very poor for
whom it often pretends to represent.
The third is the use of the word empowerment. The discussion of p.158 about
the creation of a legal civic identity implies that empowerment can be given to
people. However, it can be argued that empowerment is gained through the act
of creating that identify as it is the act not the creation a law that empowers
people. (Rifkin and Pridmore, 2001)

Although the recommendation on 14.2

does recognise a situation needs to be created to allow people to exercise their

rights, it does not examine to process by which these situations allow
empowerment to take place.

Opportunities
It may be that in the present financial environment when the assumptions upon
which neo-liberal ideas and action were based are now being seriously
undermined, the opportunity for a totally different approach to health care is
possible. The Report provides the basis for re-evaluating health care value and
objectives and brings forth institutions and structures that are built on social
justice and equity. Taking up this challenge, a most recent example is An initial
response from individuals, social movements and non-governmental
Organisations in support of a transitional programme for radical economic
transformation presented in Beijing, 15 October 2008 by the the Asia-Europe
People's Forum, the Transnational Institute and Focus on the Global South.
These groups took the opportunity of a meeting to put forward concrete steps for
restructuring the global financial structures. These recommendations had social
justice and human rights as their basis. They support frameworks for acting on
the Reports recommendations. However, history suggests that such calls do not
change structures in the immediate future.
Thus more realistically, the immediate opportunity presented by the report is that
of renewing the focus on social justice and health development that is driven by
energy and commitment. The provision of evidence that shows the results for
health improvement based solely on a bio-medical view of health and/or a neo
liberal economic agenda have failed to address health needs of the majority of
the worlds population. Alma Ata 30 years ago mobilized people and
governments to confront this challenge. Now once again provided with much
stronger ammunition there is the possibility of a consensus to define health as a
human condition and health improvements as a means to improve this condition
through attacking a range of factors by which this condition can be improved.
More concretely the report has the opportunity to influence medical education
bringing it beyond its present bio-medical boundaries. The report discusses this

opportunity and suggests training for students in the social determinants of

health. It seems a way forward would be for new students of medicine and other
health professions the first week of training to focus on examining the Report in
detail and reflecting upon of its influences on their own choice of careers.
The Report also provides the opportunity to harness money and effort on a
common research agenda. Looking in more detail about both the process and
outcome of health improvements will identify and suggest research gaps that
need to be addressed. The wider view of health again shows how little we know
about peoples attitudes and behaviours and why health choices are made. Using
mixed methods of qualitative and quantitative research and viewing peoples
choices as not simply an intervention but a process of change can strengthen
opportunities to address and improve health for all groups of people.
The opportunities suggested for research and for analysis for interventions are
also critical. By linking health improvement to concerns about climate change
moves the health agenda into the most important concern of the future.
Confronting climate change means that it is necessary to think outside the box
by identifying a range of interventions to address a very complex challenge.
(Calvin, 2008) By presenting a way of regarding health improvements outside the
bio-medical box, there is a precedent to look at climate change and to see clear
ways in which health and climate change might work together.
Finally, the opportunity in the global health policy agenda to link SDH with the
MDGs highlights weaknesses in the MDGs and suggests how they can be
strengthened. The Report points out that the lack of an equity focus weakens the
goals. (p.196-7) (Although the same can be said about the lack of a role for civil
society, the Report does not mention this.) However by suggesting the
modification of the MDGs to reflect equity, it supports the strength of target
oriented policies and uses them to address the main concerns of the report for
equity and social justice. Using the SDH framework for the MDGs provides an

opportunity to support countries and areas where the MDG targets are not being
met. Including a role for civil society might also strengthen actions to reach the
MDG targets.
Threats
The major threat to the Report of the Commission is that, like the Alma Ata
Declaration, it will be hailed and celebrated as a new way forward in health but
for the next 30 years will become a focus of disagreements and disparities
undermining decisive and necessary action. In the case of Alma Ata policy and
action become grounded in a debate over selective vs. comprehensive PHC.
Essentially this debate saw proponents of selective PHC, praising the idea of
PHC but promoting piece meal approaches focusing on disease control as
preliminary step to implementation. As a result, focus shifted money and
commitment from a holistic health approach to a disease oriented vertical
programme approach. (Rifkin and Walt, 1986) The greater challenges to
confront health barriers such as the lack of social justice were sidelined and only
pushed back onto the health agenda much later by civil action groups such as
the Peoples Health Movement. (Peoples Health Assembly, 2000)
There are a series of reasons to suggest that this sidelining of a still revolutionary
approach to health improvements is the most serious threat to action on
recommendations of the report. Firstly, like Alma Ata, the CSDH report
challenges the biomedical and predominant view of how health improves. This
view is the framework of allopathic medical education. Those who do not see
health and medicine in a social framework will continue to resist a new paradigm
and continue to argue and capture resources for their science without
considering consequences beyond their narrow scientific concerns. Until there
are concerted efforts to change medical education, as noted above, key actors in
health policy and programmes are likely to ignore or resist new ways of providing
health care and accepting equity as a key for this provision. While Professor
Marmot in his talk to the Pan American Health Organization on October 1, 2008

resisted The Economists view the Report was quixotic, there is evidence from
the PHC experience that the adjective may not be so easily dismissed.
As second reason for this threat is that present uncertainties in financial markets
and in the anxiety over possible repercussions of climate change may push the
SDH agenda to the sidelines. As governments begin to create structures for
global action on money markets and climate change, health and health concerns
may move further down the agenda. Rather than looking at a restructuring of
health provision, governments could return to emergency health care allowing
financing and regulation spin out of control. The result could see an increasingly
difficult challenge over provision of care to the poor and a continuing flow of
human resources from poor to more wealthy areas.
The financial crisis links to the provision of resources to the low income countries
by donor agencies from the richer countries. Although recent years has seen
increasing calls for and action on donor co-ordination, there is a growing view
that donors are making decisions about health aid that are seriously undermining
recipient governments health choices and health systems. (Lancet/LSHTM
conference September 11-12, 2008) While donors, both bi-lateral and large
private foundations such as Gates and alliances such as GAVI, spend money on
their own and often competing agendas the issue of equity often gets lost. The
Report calls for much wider commitment in funding and co-ordination among
donors. However, there is not so much evidence this call is being heeded. With
other domestic and global priorities and shrinking domestic budgets, donors
make continue to ignore the evidence the Report provides.
Finally, as referred to in the discussion of Threats, there is the question of how
the Report will be seen by those who culture and history do not see social justice
and human rights as a basis for the relationship between government and
citizens. There certainly is little evidence to show that these principles are
universally accepted by all people and governments A dialogue will be

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necessary to find common ground. Such dialogue will need to take place where
the environment is not judgemental and all views are equally able to be
presented.. In a polarized world where daily fundamentalists threat turns into
violence and death this is probably the great challenge of all.
Conclusion
The Report raises great hopes and great challenges. It points a way forward to
enable all people to gain improved health and life. Whether and how rapid steps
are implemented depends most of all on leadership with vision and commitment.
This leadership must be global and must be willing to seek compromise and
consensus to gain the overall goal. Role models are necessary--role models
who are willing to sacrifice personal gain for the greater good. It is not possible
to predict the future. We can only say with certainty that change is inevitable. We
now have a tool to shape the future for the better; do we have the courage and
conviction to use the tool for the purposes for which it was fashioned?

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References
Calvin, W.(2008) Global Fever: How to treat climate change Chicago: University
of Chicago Press.
Commission on the Social Determinants of Health. (2008) Closing the gap in a
generation Geneva: World Health Organization
Lancet/ London School of Hygiene and Tropical Medicine (2008) Celebrating
Alma Ata 30 Years On Conference at the London School of Hygiene and Tropical
Medicine September 11-12, 2008.
People's Health Assembly (2000). People's Charter for Health.

Rifkin, S.B. and Walt, G. (1986) "How health improves : defining the issues
concerning "comprehensive primary health care" and "selective primary health
care". Social Science and Medicine Vol 23, No 6,: 559-566.
Rifkin. S.B. and Pridmore, P. (2001) Partners in Planning London: Macmillan.
Ruger, J. R. (2006) Toward a theory of a right to health: capability and
incompletely theorized agreements Yale Journal of Law and Humanities Vol.18:
273-326.

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