A global framework for emerging research on the social determinants of health Sharon Friel Professor of Health Equity and Director, Regulatory Institutions Network, Director, Menzies Centre for Health Policy, The Australian National University

1.What are the questions? 2.What type of evidence is needed to answer the questions? 3.What architecture is needed?

Point 1. What’s the question?

Illuminating health inequities

Socio-economic gradient in health, Australia Data source: 45 and Up Study (Korda et al, under review)

Understanding the causes of health inequities

"why are the poor behaving this way?” "why are they poor?” Re-framing the question

Health inequities are socially produced

Living & Working Conditions e.g. Planning Housing Employment Health Care Systems e.g. Equitable access to care Health Promotion Power, Money & Resources e.g. Trade and investment Taxation Racism Health Equity Research Domains

Health equity Seven political domains that shape health and health inequity Intellectual property Trade and investment treaties Food Corporate activity Finance Migration Armed conflict Ottersen etal. The Lancet–University of Oslo Commission on Global Governance for Health The Lancet, 2014

Chief Investigators: Friel, Bammer, Gleeson, Kay, Thow Associate Investigators: Labonte, Snowdon, Stuckler Trade policy: Maximising benefits for nutrition, food security, human health, and the economy ARC Discovery Grant DP Friel et al. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement. Globalization and Health 2013, 9:46

Domain 1 aim develop a conceptual model of the system linkages between trade, food, the economy, society and health outcomes, investigate how systems science can be used to support integrated trade, food, and health policy-making Domain 2 aim produce quantitative evidence of diet related health effects of a trade agreement (the TPP) Domain 3 aim characterise the main stakeholder groups and institutions involved in the TPP negotiations, within Australia and at the international level assess the capacity of different modes of trade governance to achieve coherence between the goals of trade and health sectors (with respect to food and nutrition)

Does social spending save lives? Slide: David Stuckler

Greek Tragedy >200% rise in HIV infections 40% rise in homelessness 50% rise in people unable to access medical care 40% increase in infant mortality ~60% reported increase in suicides Kentikelenis et al. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2014

Economic growth in Iceland and Greece Slide: David Stuckler

What works to improve health equity and how

Evaluation of the impact of health-sector policy and programs on health equity; Applying a health equity lens to non-health sector policy and programs Understanding how SDH and health equity gets onto the agenda Understanding the barriers and opportunities: systems, processes and actors What does SDH policy and action look like Framing the question

Reflection from Health Ministers Baum Etal. Social Science and Medicine 2013

Social innovation

The art and science of advocacy and communication

1. Lack of public awareness about the SDH 2. Prominent ideology 3. Human attribution biases 4. Journalistic norms and practice … In two-thirds of the 50 stories [on television news], the main message was that individuals were personally responsible for their weight… Bonfiglioli 2007 Shaping the public discourse Hayes et al. Social Science & Medicine 64 (2007) 1842–1852

Point 2. What type of evidence/analysis is needed to answer the question

Evidence for policy Evidence of policy

Technical analysis Political analysis

Policy Market Social innovation

Different kinds of research to answer different questions Community trials Economic analysis Case studies Policy & regulatory analysis Epidemiology Natural experiments Natural sciences

 Discourse/framing analysis  Network analysis  Systems science  Realist evaluations Emerging theory-informed methods

Point 3. What architecture is needed

I.Knowledge II.Skills III. Funding and dissemination

Disciplinary diversity Epidemiology Health services Psychology Sociology Anthropology For example Law Economics Political science Public administration Systems science Questions of training

1. Disciplined mind 2. Synthesizing mind 3. Creative mind 4. Respectful mind 5. Ethical mind Minds for an equitable future

Flood the funders Be on grant selection committees Review every related article that you possibly can Shifting the paradigm with appropriate evidence