It will be myopic to view health as a rendition of service or a basket of behaviours only. The word health encompasses much more; more importantly, it is influenced by several other factors that may not relate to medical science but have an inevitable influence on health outcomes. These are known as the Social Determinants of Health (SDH), a host of non-medical factors with a make-or-break effect on the health of a person, a community, or a country. The term social determinants of health refer to the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems, including development agendas, economic policies and systems, social policies and norms, and political systems, shaping the conditions of their daily lives. The social determinants of health are important indicators of the unfair and avoidable differences in health status within and between countries. In all countries at all levels of income, health and illness follow the same social gradient: the lower the socioeconomic position, the worse the health and access to care. The World Health organisation (WHO), finds that incidence and mortality rates of Covid-19 in deprived areas are double the rates of the least deprived areas. Even otherwise, people in countries with Human Development (HD) have 19 years higher life expectancy than people in low HD countries. Besides, low educated subgroups report "poor health" 100 per cent more often than tertiary educated.

SDH in the Indian Context

As per the WHO, the social determinants of health, which can influence health equity include a) income and social protection; b) education; c) unemployment and job insecurity; d) working life conditions; e) food insecurity; f) housing, basic amenities, and the environment; g) early childhood development; i) non-discrimination and social inclusion; j) structural conflict, and k) access to affordable health services of decent quality. It states that SDH accounts for between 30-55 per cent of health outcomes and as an example cites that mortality reduction in the under-five age group is attributed to 50 per cent of investments outside the health sector. Understanding the non-medical factors of health is a recent phenomenon in India that started gaining ground after 2005 with an increase in studies on health inequalities. This was a marked shift from the 1980s when the focus was on family planning, reproductive health, and child survival. The health priorities may be attributed to India’s focus on increasing the coverage of health services since the discussion on health inequalities in the policy sphere was also missing.

Improving SDH Important to Meet SDGs

The importance of social determinants of health can be fathomed from the fact that they comprise some of the key Sustainable Development Goals (SDGs) – SGDs 1 to 6 (no poverty; zero hunger; good health and well-being; quality education; gender equality; clean water and sanitation), 8 (decent work and economic growth), 11 (sustainable cities and communities), 13 (climate action) and 16 (peace, justice, and strong institutions) specifically refer to aspects that have an impact on the social determinants of health. Careful consideration of SDH is also critical to assess the Covid-19 situation in India and whether the response to it has been adequate. A case in point can be the comorbidity factor of Covid-19 that increases mortality significantly. One can think that smoking, largely considered a ‘male’ attribute and restricted to the middle and upper classes, damages the lungs, and hence, these are the people who are more likely to contract the infection due to the comorbidity due to weak lungs. However, people of New Delhi, one of the most polluted cities in the world, who cannot afford an air purifier, can also have weak lungs due to sustained exposure to vehicular pollution, known to emit the most carcinogenic content as well as industrial and indoor pollution. Besides cancer, it can also cause a wide range of noncancerous diseases including allergy, asthma, and other respiratory problems. Owing to their socio-economic conditions, these people are more likely to be deprived of treatment as compared to their middle- and upper-class compatriots.

Improving social determinants of health will require a dedicated “health in all policies” approach. Living amid Covid-19, people, policymakers, and politicians have realised the value of health as the mainstay of a happy and productive life. A “health in all policies” approach incorporates health considerations into decision-making across sectors and policy areas. It will also require a focus on policies and practices in non-health sectors that impact health and health equity. This will include ensuring access to care where needed such as ensuring mid-day meals despite lockdown to avoid malnutrition, and access to information at the right time mobilising community healthcare workers, to mention a few. In view of the long-term effects of the Covid-19 scenario in India and the large-scale job cuts, the highest priority must be given to restoring people’s livelihood as lack of steady income results in poverty that affects access to education and care. Improving on the SDHs and SDGs will certainly make a smaller number of people seek health care for avoidable/preventable causes.

The author is CEO, Integrated Health and Wellbeing (IHW) Council

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