The political determinants of health—10 years onBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h81 (Published 08 January 2015) Cite this as: BMJ 2015;350:h81
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Ilona Kickbusch in her Editorial on the political determinants of health makes a number of important points vital to the success of modern public health practice. These need careful consideration by the public health community to ensure it is ‘fit for purpose’. For example, at a recent “Governance for Health” Summit hosted by the Centre for Public Policy and Health at Durham University a number of contemporary challenges facing a more complex international order were reviewed: including the burden of non-communicable disease, emerging communicable diseases such as Ebola, and the focus on social determinants and inequities.
The Summit began with a review of the findings of the Lancet/University of Oslo Commission on Global Governance for Health, establishing the theme that health and health policy are political entities. Kickbusch, who was also a keynote speaker at the Summit, quotes the final report of the Commission on Social Determinants of Health: “that health is shaped by factors such as the distribution of money, power and resources at global, national and local levels”. It’s hard to think of anything more political! Accordingly, dealing with the social determinants of health will be similarly political.
Kickbusch rightly emphasizes the present-day primacy of economic over social policies, citing the increasingly understood adverse health effects of current austerity policies. She quotes Mackenbach’s warning of “romantic illusions” . Amartya Sen made the linked point in a recent article on universal health care in which he emphasized that its ethics should: “be distinguished from the value of eliminating inequalities in general, which would demand much more radical economic and social changes”.
It is increasingly understood that the health policy process is not linear and rational but complex and messy. Kickbusch refers to De Leeuw, Clavier and Breton’s all too true quotation of John Maynard Keynes to the effect that: “There is nothing a Government hates more than to be well informed: for it makes the process of arriving at decisions much more complicated and difficult”. They speak of “the best visual metaphor for this reality of the policy making process [as] that of juggling”. Just occasionally those in public health will have the chance to catch a ball and run with it.
There are profound implications here, particularly for public health practitioners. Kickbusch is surely right that they are not presently equipped “to analyse political context and understand complexities, and to frame arguments and act effectively in the political arena”. Amidst complexities concerning the determinants of disease they must be capable of initiating and informing the policy debate at the political, professional and public levels to advocate for policies and actions to improve health. This will require analysing broader strategies for health, creating innovative networks and partnerships for action across many different sectors and actors, and acting as a catalyst for change. Today, however, the linear-rationalist paradigm remains far too strong in UK public health training and practice.
One point is clear, and emerged strongly at the Durham Summit. Health is a form of “soft power” and a “political tool” which is why Kickbusch is so right to focus on the political determinants of health. A new political economy is indeed needed, and much more impressive political and public health policy leadership to counter the sense of inevitability of inequity. The need is to speak not just to health but all the other sectors that influence it in today’s world of multiple determinants: education, environment, transport, agriculture amongst others. Such leaders need to be value based and evidence informed, yet avoid being “blown off course” by overly complicating academics. As Kickbusch indicates, it will be a challenge!
Competing interests: No competing interests