Intended for healthcare professionals


Social determinants of health and the design of health programmes for the poor

BMJ 2008; 337 doi: (Published 09 July 2008) Cite this as: BMJ 2008;337:a290
  1. Sebastian Taylor, senior research fellow1,
  2. Alireza Marandi, professor of paediatrics2
  1. 1Social Determinants of Health, Department of Epidemiology and Public Health, University College London, London WC1E 6BT
  2. 2Shaheed Beheshti University, Evin, Tehran, Islamic Republic of Iran
  1. Correspondence to: S Taylor sebastian.taylor{at}
  • Accepted 5 May 2008

Sebastian Taylor and Alireza Marandi provide examples of how health programme designs that take social, economic, political, cultural, and environmental factors into account can improve health equity, especially among the poor

Socioeconomic development has brought major improvements in global health. Advances in health care have played an important role. However, social determinants—social, economic, political, cultural, and environmental factors—heavily influence people’s demand for, access to, and use of health services. As a reflection of wider social inequalities, health systems tend to favour the better off, sustaining and sometimes amplifying health inequity (box 1).1

Box 1 China: growth and inequity2

  • Between 1978 and 1998 the number of people below the poverty line in China fell from 250 million to 42 million

  • As per capita income has risen, so too has inequality—not only in economic terms—but also in social terms that affect access to health services

  • Changing patterns of income and employment have produced a “floating population” of 100-200 million migrant workers, who move from rural to urban areas

  • Often on short term contracts, and without urban residency status, these people cannot access health care and other statutory benefits, including reproductive and sexual health services

  • In 2005, around 80% of new HIV infections in Beijing were in migrant workers

This is not inevitable. Healthcare systems and services can promote health equity if they are designed to maximise the “fit” between patients and providers.3 We use examples of health programmes taken from low, middle, and high income countries (Cambodia, Iran, Mexico, and the United States) to show how designing health services to take account of and work with wider socioeconomic determinants can improve health equity by enhancing service delivery and promoting uptake, particularly among the poor. Limited availability of data and limited attention to equity when evaluating health programmes make it difficult to reach definite conclusions, but in …

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