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Wednesday, December 15, 2010

Social Determinants of Health - National Collaborating Centre for Healthy Public Policy Responds

Michael Keeling, English Writer and Editor, National Collaborating Centre for Healthy Public Policy and François Benoit, Lead, National Collaborating Centre for Healthy Public Policy

“Why do we have to structure our society in such a way as to create ill health?”

In the May/June edition of the Canadian Journal of Public Health (25 years ago) Dr. Trevor Hancock’s Beyond Health Care: From Public Health Policy to Healthy Public Policy contrasted public health policy, which “accepts the givens of our present socio-cultural system and within those givens plans an illness care system” to healthy public policy, which questions those givens by asking: “Why do we have to structure our society in such a way as to create ill health?” (1)

Responses to this and similar questions have produced a convincing body of literature calling for collective action to influence the economic, social, cultural and environmental landscapes that determine health. This includes acting on the policies informing them.

The Health Council of Canada’s Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada draws on this literature to show that policies which nominally have nothing to do with health can have profound, inequitable effects on the health of populations and different sub-groups. Stepping It Up engagingly summarizes and contributes to the story of making the case for acting structurally.

Despite the convincing arguments for the why of acting on the social determinants of health, we continue to confront the how. Among other things, this paper contributes to the how by asking us to observe:

  • That “health is everybody’s business” (pp. 7, 20, 33). This expands the circle of responsibility to learn about and act upon health outcomes.
  • That we must leave our silos in order to act. Intersectoral action is the way to address “complex, long-term and intertwined” issues (pp. 20, 23).
  • That structural prevention influences behaviours. Healthy living strategies have limitations, and to advance further we need to act on determinants. (pp. 17, 32).

This critical perspective contributes to shifting thinking from the simple dossier (linear, unisectoral, clear cause-effect) towards the complex dossier (nonlinear, multisectoral, less-predictable). These latter features are the domain of the study of wicked problems, wherein interventions demand a “seismic shift” in our understanding.

In our role as a centre for expertise in healthy public policy, we are seeing promising trends.  First, there are tools emerging for tackling these issues. Health impact assessment uses a social determinants of health framework with an equity focus embedded in the process. Other promising tools include policy analysis methods which incorporate equity and applicability, and integrated approaches to guide issue mapping on wicked problems.

Another trend is that we are seeing more and more public health practitioners, community organizations, not-for-profits and members of communities working collaboratively across sectors to make a difference, whether in Sudbury, Saskatoon, Vancouver, Montréal, Toronto or Natuashish.

This paper will be a stimulating tonic to foster all of these efforts, adding to the pan-Canadian movement to prevent or relieve the “hardening of the categories.”

Note 1. Trevor Hancock (1985) “Beyond Health Care: From Public Health Policy to Healthy Public Policy” Canadian Journal of Public Health (76, Supplement 1, 1985)


Michael Keeling is the English Writer and Editor and François Benoit is the Lead at the National Collaborating Centre for Healthy Public PolicyThe NCCHPP seeks to increase the expertise of public health actors across Canada in healthy public policy through the development, sharing and use of knowledge. The NCCHPP is one of six centres financed by the Public Health Agency of Canada. The six centres form a network across Canada, each hosted by a different institution and each focusing on a specific topic linked to public health.  More details are available from their website at

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