Skip to content

Advertisement

  • Research
  • Open Access

Towards a global monitoring system for implementing the Rio Political Declaration on Social Determinants of Health: developing a core set of indicators for government action on the social determinants of health to improve health equity

  • 1Email author
International Journal for Equity in Health201817:136

https://doi.org/10.1186/s12939-018-0836-7

  • Received: 11 January 2018
  • Accepted: 6 August 2018
  • Published:

Abstract

Background

In the 2011 Rio Political Declaration on Social Determinants of Health, World Health Organization (WHO) Member States pledged action in five areas crucial for addressing health inequities. Their pledges referred to better governance for health and development, greater participation in policymaking and implementation, further reorientation of the health sector towards reducing health inequities, strengthening of global governance and collaboration, and monitoring progress and increasing accountability. WHO is developing a global system for monitoring governments’ and international organizations’ actions on the social determinants of health (SDH) to increase transparency and accountability, and to guide implementation, in alignment with broader health and development policy frameworks, including the universal health coverage and Sustainable Development Goals (SDG) agendas. We describe the selection of indicators proposed to be part of the initial WHO global system for monitoring action on the SDH.

Methods

An interdisciplinary working group was established by WHO, the Public Health Agency of Canada, and the Canadian Institutes of Health Research—Institute of Population and Public Health. We describe the processes and criteria used for selecting SDH action indicators that were of high quality and the described the challenges encountered in creating a set of metrics for capturing government action on addressing the Rio Political Declaration’s five Action Areas.

Results

We developed 19 measurement concepts, identified and screened 20 indicator databases and systems, including the 223 SDG indicators, and applied strong criteria for selecting indicators for the core indicator set. We identified 36 suitable existing indicators, which were often SDG indicators.

Conclusions

Lessons learnt included the importance of ensuring diversity of the working group and always focusing on health equity; challenges included the relative dearth of data and indicators on some key interventions and capturing the context and level of implementation of indicator interventions.

Keywords

  • Social determinants of health
  • Quality/process indicators, health care
  • Health status disparities
  • Equity
  • Rio declaration action areas
  • Policymaking

Background

In 2008, the World Health Organization’s (WHO) global Commission on Social Determinants of Health (CSDH) called for action on the social determinants of health (SDH), the conditions in which persons are born, grow, work, live, and age, to “close the gap in a generation” [1] (p1). Widespread recognition now exists that taking action on SDH is crucial for reducing and reversing the growing health inequities (i.e., unfair, remediable inequalities in health) [2] that exist within and between countries.

In 2011, a total of 125 countries developed and signed the Rio Political Declaration on Social Determinants of Health (hereafter Rio Political Declaration) [3]. The declaration recommended interventions from governments and international organizations in five Action Areas (Table 1). Building directly on and aligning closely with CSDH’s final recommendations [1], the declaration encompasses 50 pledges for implementing a minimum set of actions that address SDH for improving health equity across diverse sectors. The Rio Political Declaration’s vision of intersectoral and multisectoral action for health was endorsed by the 194 WHO Member States at the 65th World Health Assembly in 2012 (Resolution WHO65.8), and then echoed by 193 Member States of the United Nations (UN) in the 2015–2030 Sustainable Development Goals (SDGs) [4].
Table 1

Five Action Areas of the 2012 Rio Political Declaration on Social Determinants of Health

 

Action Area

1

Adopt better governance for health and development

2

Promote participation in policymaking and implementation

3

Further reorient the health sector towards promoting health and reducing health inequities

4

Strengthen global governance and collaboration

5

Monitor progress and increase accountability

Source: WHO, 2011

The interventions on the SDH, recommended in the pledges organized in the five Action Areas, are supported by an increasingly comprehensive body of evidence. For example, research findings continue to support the use of social protection floors and systems over the life course, including social protection benefits (e.g., cash transfers) for children, mothers, the unemployed, occupational injury victims, and older persons (e.g., [511]). Another example is evidence for the effectiveness of early childhood interventions in improving cognitive development, health service use, and health outcomes in both childhood and adulthood [1214]. Moreover, novel approaches in systems theory and causal inference used to evaluate social interventions continue to produce evidence of their beneficial effects on community and population health equity [15, 16].

Health sector monitoring of population health inequities within countries has improved at the global level, including WHO’s Health Equity Monitor [17], the Millennium Development Goals [18], and the progressive realization of the SDGs [19]. The importance of implementation of SDH interventions in the SDG era is gaining recognition [20]. However, specific efforts focused on monitoring SDH actions have only recently received attention, via individual national government commitments and of mandated intergovernmental organizations [16, 2124]. A need persists for monitoring SDH actions to align them with their actors, and not just the situation of SDH themselves (where these cannot be aligned with policy responsibilities) without overburdening existing monitoring systems.

Through the Rio Political Declaration and other WHO resolutions (e.g., WHA62.14), WHO has committed to developing a global monitoring system for action on SDH [25, 26]. The goals of the proposed WHO monitoring system are to (1) track the progressive realization of action on SDH through implementation of the Rio Political Declaration at national and international levels and (2) guide continuous improvement in SDH action by UN Member States and within the UN system by providing regular reports about the status of and trends in such action. The WHO global monitoring system for action on the SDH will complement WHO’s existing tracking of key social and environmental determinants of health. That system is analogous to other WHO monitoring systems focused on monitoring financing and implementation for water and sanitation [27] or implementation of the WHO Framework Convention on Tobacco Control [28].

The first step in establishing the SDH action monitoring system is identifying its domains, which are the five Action Areas of the Rio Political Declaration. SDH action is defined in this context as a human rights, governance, policy, or programmatic intervention that improves health. The second step is identifying relevant measurement concepts (i.e., actions that can be defined, conceptualized, and measured). Ideally, each measurement concept already has standard action indicators that are internationally harmonized, meet minimum quality standards, are based on data available for a majority of UN Member States, and are relevant for key stakeholders (e.g., national governments, international organizations, and civil society). SDH action indicators are performance indicators for inputs, outputs, and outcomes of relevant government interventions (e.g., existence of or coverage with laws, policies, or programs). These indicators may measure SDH action by (1) human rights frameworks; (2) governance structures and mechanisms; (3) social policies and programs; and (4) environmental policies and programs [29]. A recent global stocktake identified SDH-focused monitoring systems reporting action indicators in 16 countries and in five regional and global systems (mostly of WHO), although reporting of relevant indicators to the Rio Political Declaration is limited [29]. Canada was among the first countries to monitor SDH action and has qualitatively reported on national actions to advance the five Action Areas of the Rio Political Declaration [21, 22, 30].

We report in this paper on the process undertaken to (1) identify key measurement concepts for each of the five Action Areas of the Rio Political Declaration; (2) identify suitable candidate SDH action indicators and data sources; and (3) propose a core set of the 15–20 selected indicators, considering the needs of key indicator users, including national governments, international organizations, and civil society, which we propose form part of the initial WHO global system for monitoring action regarding SDH. These tasks were accomplished by an interdisciplinary working group (WG) established by WHO and its Canadian partners, the Public Health Agency of Canada (PHAC), and the Canadian Institutes of Health Research—Institute of Population and Public Health (CIHR–IPPH).

Methods

The WG implemented processes for identifying a set of indicators that were aligned with measurement concepts drawn from the Rio Political Declaration [3], had high content validity, and relied on available country-specific monitoring data. The Rio Political Declaration with 50 specific actions built directly on and aligned with the recommendations of the Commission on Social Determinants of Health [1]. Therefore, monitoring implementation of actions taken in response to the organizing policy framework of the Rio Political Declaration is in harmony with the long-term efforts on SDH that Member States have pursued.

Recruitment of WG members was a deliberate and extensive process that sought to bring together those with both technical and policy expertise, and with representation from all six WHO regions. This step was important for reflecting considerations for monitoring in the countries of their particular region. The WG comprised 18 experts, including academics, policy-makers from high-, middle-, and low-income Member States; and representatives from WHO. WG members represented Australia, Brazil, Canada, Chile, India, Italy, Kenya, Morocco, Norway, Rwanda, Switzerland, and the USA. The WG also included persons with expertise in indicator development. This broad representation enabled WG members to identify technically sound, feasible, and acceptable candidate indicators while considering the needs of key users of the indicators, including national governments, international organizations, and civil society. The WG was chaired by Patricia O’Campo PhD, University of Toronto, who is a world leader in the study of SDH. The WG was also supported by a secretariat of four graduate students who screened candidate indicators, drafted documents, and provided administrative support during WG meetings.

During a rapid 4-month period, the expert WG members:
  1. 1.

    identified and prioritized key measurement themes and specific measurement concepts related to action on the SDH in the Rio Political Declaration;

     
  2. 2.

    identified and selected an initial list of potentially suitable candidate indicators for each measurement concept from multiple databases and systems, including the SDG monitoring system; and

     
  3. 3.

    applied selection and quality criteria for prioritizing a core set of indicators.

     
A flow chart of the full process is depicted in Fig. 1. Key terms for the process were also defined early (Table 2).
Fig. 1
Fig. 1

Flow chart describing the expert working group process for arriving at a core set of proposed indicators for measuring social determinants of health (SDH) action

Table 2

Glossary of terms reflecting the components of the social determinants of health (SDH) action monitoring system and corresponding components of the Rio Political Declaration (from narrow to broad)

Component: SDH action monitoring system

Corresponding component: Rio Political Declaration

Term

Definition

Term

Definition

Domain

Set of measurement concepts that are heuristically related to one another. Five domains are included in the monitoring system that correspond to the five Action Areas of the Rio Political Declaration.

Action Area

A set of related actions in the Rio Political Declaration aimed at enhancing or reorienting capacities of governments or inter-governmental organizations to address the SDH. A total of five (1 to 5) Action Areas of the Rio Political Declaration addresses SDH.

Measurement concept

A defined, measurable aspect of an SDH intervention theme. Themes captured the intervention focus on a pledge or set of pledges, e.g., build social protection floors. A total of 23 measurement themes were proposed, which after debate and refinement, led to the proposal of a final list of 17 measurement concepts.

Pledge

An intended action on SDH belonging to one of five action areas pledged by United Nation Member States. Fifty pledges were included in the Rio Political Declaration. Pledges were enumerated by Roman numerals but several pledges could relate to a common SDH intervention theme.

SDH action indicator

A valid, reliable gauge of the measurement concept that describes the action on SDH.

Action on SDH (“SDH action”)

A determinants-oriented, non-medical governance, policy, or programmatic intervention that improves health equity.

Identification of measurement themes and measurement concepts derived from the Rio political declaration action areas and pledges

The WG members reviewed each pledge of the Rio Political Declaration to identify and record the frequency of occurrence of themes related to policy sectoral entry points (e.g., social service and protection policies, development strategies, policies, and rights) or such special population groups such as children; women; indigenous populations; informal workers; and lesbian, gay, bisexual, transgender, and intersex (LGBTI) populations. These entry points formed measurement themes, which were defined to ensure a common understanding of the theme across the WG. Broadly, measurement themes were general ideas that might have been reflected in more than one Rio Political Declaration Action Area or pledge (see glossary Table 2). For example, the measurement theme “build social protection floors” referred to “the extent to which governments provide essential health and economic security to populations in need” (see Table 4 in Appendix) and was linked to pledges in three of the Rio Action Areas: (1) to adopt better governance for health and development (pledge 1.x, promote and strengthen universal access to social services and social protection floors); (2) to further reorient the health sector towards reducing health inequities (pledge 3.iv, build, strengthen and maintain health financing and risk pooling systems and prevent persons from becoming impoverished when they seek medical treatment); and (3) to strengthen global governance and collaboration (pledge 4.ii. support social protection floors as defined by countries to address their specific needs and the ongoing work on social protection within the UN systems, including the work of the International Labour Organization, see Table 4 in Appendix for a list and description of measurement themes by Rio Action Area).

These measurement themes, either in isolation or coupled with back-reference to Rio Political Declaration pledges, guided the formation of the more actionable measurement concepts to facilitate the proposal of suitable indicators of SDH action. Building on the measurement theme related to social protection discussed in an earlier section of the paper, the measurement concept of level of public social protection was identified. Other examples of measurement concepts included level of implementation of mechanisms for participation of civil society; provision of public laws guaranteeing workers human rights for informal workers; level of implementation of mechanisms for ensuring integration of equity into health systems, policies and programs; and North–South, South–South sharing to develop holistic policies addressing inequalities and sustainable development.

The WG members engaged in an iterative process for refining and prioritizing relevant measurement concepts for action on SDH, as follows. Measurement concepts that were mentioned more frequently within or across domains were prioritized over those mentioned less frequently. Preference was given to measurement concepts unique to action regarding SDH and well supported by evidence as recommended by the WG members. Measurement concepts were developed with attention paid to their relevance/applicability across different country contexts. Prioritized measurement concepts also aimed to reflect a balance of indicators for SDH-focused human rights or governance structures or mechanisms and policies or programs on specific determinants of health. Furnishing these discussions with information on data availability by country as described in the next section also shaped the finalization and definition of measurement concepts.

Identification and selection of the most suitable indicators for each measurement concept from multiple databases or systems

We screened existing reports and international databases proposed by WG members and external academic experts that are used for monitoring by international organizations or academic institutions. A prioritized source for indicators was the monitoring system of the SDGs with its 261 indicators [31] because using SDG indicators was regarded as crucial for ensuring alignment of the SDH action monitoring system with the 2015–2030 SDG agenda [32]. Indicators proposed by WHO and the World Bank for universal health coverage were also prioritized to ensure alignment with the universal health coverage agenda [3335]. In total, we screened 21 data sources and references produced by the International Labour Organization, the World Bank, the Pan American Health Organization, and others (see Table 5 in Appendix for a list of sources consulted).

To ensure consistency with best practices of indicator selection, we reviewed existing relevant reports of international monitoring efforts as well as the indicator development literature [21, 3641]. This process guided criteria development for arriving at the core set of proposed indicators, including inclusion or exclusion criteria of screened indicators for an initial list of candidate indicators, and a set of quality criteria for evaluating candidate indicators to form the core set of proposed indicators (described in the next section).

Inclusion and exclusion criteria

To be eligible for inclusion in the initial list, indicators were required to
  1. 1.

    capture a key measurement concept;

     
  2. 2.
    measure an action (or intervention) regarding SDH, defined as
    1. (a)

      a governance intervention focused on SDH or health equity;

       
    2. (b)

      a social intervention that improves health or health equity; or

       
    3. (c)

      an environmental intervention that improves SDH or health equity [29];

       
     
  3. 3.

    measure a modifiable action [29, 40];

     
  4. 4.

    measure a national-level government action (Rio Political Declaration Action Areas 1, 2, 3 and 5) or a global-level action from the countries’ government or international governmental organizations (Rio Political Declaration Action Area 4); and

     
  5. 5.

    be a quantitative or, if qualitative, at a minimum be a categorical indicator (i.e., existence of laws) [21, 40].

     
An indicator was excluded from the initial list if it:
  1. 1.

    does not measure an action regarding SDH (i.e., measures an intention as opposed to an action);

     
  2. 2.

    has no data available or has data becoming available only over the long term (> 3 years);

     
  3. 3.

    measures an action that cannot be modified; or

     
  4. 4.

    measures an action taken at the local level only.

     

The WG debated whether to include only continuous quantitative indicators focusing on the effectiveness of interventions (e.g., coverage), but this criterion was relaxed slightly on the basis of the nature of the measurement concepts as well as data availability constraints.

To further reduce the list of candidate indicators that met the inclusion criteria, we assessed the level of alignment with the measurement concepts. WG members scored each indicator on the measurement concept match criteria, where a score of 1 was assigned when the indicator was not at all in accordance with the corresponding measurement concept, and a score of 7 was assigned when it was completely in accordance with the corresponding measurement concept. A rationale for the score was also provided. Table 6 in Appendix provides detailed examples of candidate indicators that met inclusion criteria for measurement concepts as well as measurement concept alignment scores for domains 1–3.

Application of quality assessment criteria to arrive at a core set of indicators

The initial list of indicators was put forward on the basis of face validity and technical quality. In the process of finalizing the proposal for the monitoring framework the WG members developed and applied a broad set of technical criteria to apply to the indicators. Several of the criteria could be operationalized and formed part of formal documented assessments as described in Table 6 in Appendix. The technical quality assessment criteria were defined and applied as follows:
  1. 1.

    For harmonization purposes, preference was given to indicators from the SDG indicator system and concepts covered in SDG targets [42].

     
  2. 2.

    Indicators that could demonstrate change over time and were feasible were preferred. This meant preference was given to indicators with regular reporting of at least 5-year intervals, but greater preference was given to indicators with 2–3-year reporting intervals.

     
  3. 3.

    Indicators should demonstrate benefits for SDH, health service use, health outcomes, or health equity. Although no extensive or formal assessment of studies on the effectiveness of government actions was conducted, where WG members had knowledge of studies describing the links between social determinants and the indicators, the information was noted. Consequently, preference was also given to indicators measuring actions with a stronger evidence base over those with a weaker evidence base [21].

     
  4. 4.

    Expected acceptability (i.e., user-inspired, responding to data needs, and acceptable to such key stakeholders as national governments or civil society) [38, 41]. The assessment of these criteria was based on the knowledge and background of the WG members, who had been nominated by the WHO regional offices to represent the experiences of the countries of their particular region.

     
  5. 5.

    Feasibility and cost-effectiveness of providing the information—whether easy to obtain without additional burden for the producer or guardian of the data [38, 41]. Preference was given to official data over other sources because this would enable WHO and other countries to gather data more cost-effectively.

     
  6. 6.

    Type—preference was given to continuous indicators (e.g., the proportion of a population covered by a social protection floor) over ordinal indicators (e.g., provision of social protection floors was complete versus medium versus low) over binary indicators (e.g., social protection floor was provided versus not provided).

     
  7. 7.

    Applicability across diverse country contexts and global harmonization [38].

     
  8. 8.

    SMART criteria [39], as follows:

    Specificity—targets a specific area for improvement; Measurability—is easy to measure, interpret, and communicate with straightforward policy implications (avoid composite indices); Assignability—clearly specifies who will take the action; Realistic—an action that realistically can be taken, given available resources; and Time-relatedness—an action that can be changed over time (e.g., annual changes are feasible). The SMART criteria overlap with some of the criteria described previously, but the WG members believed that making explicit reference to them was important because they are commonly used in indicator development work.

     

On the basis of the number of technical quality assessment criteria met, the indicator was given a rating on a scale of 1–8 and a rationale for the score.

This quality review also included an assessment of the indicator’s methodologic development and data availability as follows:
  • Tier 1—Represented an indicator that is conceptually clear with established methodology and standards to generate the indicator and data regularly produced by countries.

  • Tier 2—Indicators were conceptually clear on the basis of established methodology and standards but where data were not regularly available across countries.

  • Tier 3—Indicators were not based on established methodology or standards.

Table 6 in Appendix provides detailed examples of candidate indicators and the quality and technical ratings and overall assessment of the availability of indicators by domain.

Results

The WG members developed and prioritized 23 measurement themes, and 19 measurement concepts. Following the iterative process of evaluation, we identified a core set of 36 candidate indicators for the monitoring system on SDH action.

The core set of indicators proposed by the WG is presented in Table 3. Each indicator was uniquely named, with the nomenclature reflecting the indictor’s domain, measurement concept (that at times included an indication of being an equity measure), and the individual indicator. For example, Indicator 3.1I.1 Parity index (by wealth quintile) in coverage with safely managed drinking water is:
  • an indicator from domain 3 (i.e., 3.1I.1)

  • the measurement concept 1I (i.e., 3.1I.1), where the “I” indicates that inequality in an intervention is measured; and

  • the first indicator for this measurement concept (i.e., 3.1I.1).

Table 3

Final core set of 36 indicators and sources of data proposed by the working group to consider for the monitoring system on taking action regarding social determinants of health (SDH)

Domain/Measurement concept

Indicator

Domain 1: National governance

 1.1 Level of public social protection

1.1.1 Percentage of the population covered by social protection floors/systems below the poverty line

[SDG Indicator 1.3.1]

 1.1I Gender inequities in the level of public social protection

1.1I.1 Parity index (female/male) for the percentage of the population covered by social protection floors/systems below the poverty line

[SDG Indicator 1.3.1, disaggregated data]

 1.2 Level of public provision of early childhood education

1.2.1 Participation rate in organized learning (one year before the official primary entry age)

[SDG Indicator 4.2.2]

 1.2I Gender inequities in the level of public social protection

1.2I.1 Parity index (female/male) for participation rate in organized learning (one year before the official primary entry age)

[SDG Indicator 4.2.2, disaggregated data]

 1.2II Income inequities in the level of public social protection

1.2II.1 Parity index (bottom/top wealth quintile) for participation rate in organized learning (one year before the official primary entry age)

[SDG Indicator 4.2.2, disaggregated data]

 1.a Provision of the rights and public laws guaranteeing self-determination of indigenous peoples

[no indicator yet identified]

 1.b Provision of public laws guaranteeing human rights for transgender populations

1.b.1 Presence or lack of laws that criminalize transgender identity and expression, protect against discrimination on the basis of gender identity/gender expression as a category, and determine the legal right for individuals to determine their legal gender and namea,*

[United Nations Development Programme]

 1.c Provision of public laws guaranteeing human rights for sex workers

1.c.1 Presence or lack of laws that criminalize sex work and protect the public health of sex workers*

[Review of national legislation]

 1.d Provision of public laws guaranteeing workers human rights for informal work

1.d.1 Increase in national compliance of labor rights (freedom of association and collective bargaining) based on International Labour Organization textual sources and national legislation

[SDG Indicator 8.8.2]

 1.e Level of intersectoral action for health and health equity

1.e.1 Whether a national policy exists that addresses at least two priority determinants of health amongst target populationsb*

[Pan American Health Organization (PAHO)]

Domain 2: Participation

 2.a Mechanisms for guaranteeing transparency in policymaking

2.a.1 Whether country has adopted and implemented constitutional, statutory, or policy guarantees for public access to information

[SDG Indicator 16.10.2]

 2.b Level of implementation of mechanisms for participation of civil society

2.b.1 Whether the country has accountability mechanisms that support civil society engagement in health impact decisions*

[PAHO]

2.b.2 Whether mechanisms exist to engage communities and civil society in the policy development process across all sectors*

[PAHO]

 2.c Level of implementation of mechanisms for participation of civil society in policymaking for indigenous peoples

2.c.1 Number of policies that recognize the duty to consult and cooperate in good faith with indigenous peoples to obtain their free, prior and informed consent before adopting and implementing legislative or administrative measures that may affect them

[World Conference on Indigenous Peoples commitment, paragraph 3*]

2.c.2 (1) Existence of special measures to strengthen capacity of indigenous peoples’ representative institutions; (2) existence and capacity of national human rights institutions to reach out to vulnerable groups such as indigenous peoples; (3) institutional mechanisms and procedures for consultation with indigenous peoples, in accordance with international standards*

[UN Declaration on the Rights of Indigenous Peoples]

2.c.3 (1) Provisions for direct participation of indigenous peoples’ elected representatives in legislative and elected bodies; (2) recognition in the national legal framework of the duty to consult with indigenous peoples before adopting or implementing legislative or administrative measures that may affect them*

[United Nations (UN) Declaration on the Rights of Indigenous Peoples]

 2.d Level of implementation of mechanisms for participation of civil society in policymaking for transgender populations

2.d.1 Presence/lack of laws that prohibit lesbian, gay, bisexual, transgender, and intersex persons from forming organizations and participating in political parties and social movements*

[United Nations Development Programme]

Domain 3: Health sector reorientation

 3.1 The level of comprehensive, equitable basic service coverage by health systems (including primary health care and the right to health)

3.1.1 Percentage of population using safely managed drinking-water services

[SDG Indicator 6.1.1]

3.1.2 General government expenditure on primary health care and health promotion as a proportion of general government expenditure

(proxy, if data are unavailable: 3.1.2 General government expenditure on health as a proportion of general government expenditure)

[WHO]

 3.1I Inequities in the level of comprehensive, equitable basic service coverage by health systems (including primary health care and the right to health)

3.1I.1 Parity index (by wealth quintile) in coverage with safely managed drinking water

[SDG Indicator 6.1.1, disaggregated data]

 3.2 Level of financial health protection

3.2.1 Percentage of population with catastrophic health expenditure (universal health coverage)

[WHO]

 3.2I Inequities in level of financial health protection

3.2I.1 Out-of-pocket (OOP) payments as % of income amongst lowest wealth quintile or OOP as % of income amongst highest wealth quintile

[WHO, disaggregated data]

 3.3 Level of integration of equity into health systems, policies and programmes

3.3.1 Percentage of total government health expenditure on prevention and public health services

[Organization for Economic Co-operation and Development health accounts; WHO national health accounts]

3.3.2. Equity-adjusted universal health service coverage index*

[WHO]

 3.a Mechanisms for ensuring integration of equity into health systems, policies and programmes

3.a.1 Existence of policies and strategies to address health inequalities and social determinants of health

(Existence of a national policy that supports routine consideration of health equity in health promotion and disease prevention programs)

[World Health Organization European Region (EURO)]

3.a.2 Elements in national policies to address health inequities and social determinants of health

(Existence of a national policy that supports routine consideration of health equity in health promotion and disease prevention programs)

[EURO]

Domain 4: Global governance

 4.1 Level of international funding for comprehensive, equitable basic service coverage by health systems (including primary health care and the right to health)

4.1.1 Amount of water- and sanitation-related official development assistance that is part of a government coordinated spending plan

[SDG Indicator 6.a.1]

 4.a Level of implementation of international agreements that improve the SDH

4.a.1 The country’s performance on the International Health Regulations capacity and health emergency preparedness index

[SDG Indicator 3.d.1]

4.a.2 Number of countries with tax policies that have been implemented to reduce tobacco demand

[World Health Organization Framework Convention on Tobacco Control]

 4.b Participation of developing countries in international policymaking

4.b.1 Percentage of members or voting rights of developing countries in international organizations

[SDG Indicator 10.6.1/16.8.1]

 4.c North-South, South-South sharing to develop holistic policies addressing inequities and sustainable development

4.c.1 US dollar value of financial and technical assistance (including through North-South, South-South and triangular cooperation) committed to developing countries

[SDG 17.9.1]

Domain 5: Monitoring and accountability

 5.1 Disaggregation of health data according to SDH

5.1.1 Percentage of indicators in the Global Health Observatory that are provided and disaggregated by a social characteristic

[WHO]

 5.a. Level of implementation of SDH-focused monitoring systems

5.a.1 Country has dedicated SDH action monitoring system (as per WHO definition to be developed)*

[WHO/PAHO]

5.a.2 Country has dedicated monitoring system for health inequalities

[WHO]

 5.b. Financial investment in research and evaluations of SDH interventions to promote equity

5.b.1 Proportion of national health research spending related to actions on SDH*

[Canadian Institutes of Health Research—Institute of Population and Public Health]

 5.c. Mechanism for guaranteeing access to information as a key component of research, monitoring and evaluations to ensure accountability and justice

5.c.1 Whether country has adopted and implemented constitutional, statutory or policy guarantees for public access to information

[SDG Indicator 16.10.2]

Key: Governance interventions (or processes) are indicated with a lowercase letter (e.g., 3.a.1 measurement). A capital Roman numeral I or II refers to indicators measuring inequities in the population coverage with an intervention (e.g., 3.1I.1) (mainly parity indices [ratio of disadvantaged to advantaged population in intervention coverage])

*Indicator does not have comprehensive data availability (i.e., does not have all of: established methods, international standards, and data available across many countries)

aComposite index composed from three individual binary indicators

bA composite index could be composed of this indicator and additional binary indicators from the Pan American Health Organization’s Health in All Policies regional monitoring system

Five indicators of the core set expressly deal with inequities in intervention coverage, 21 cover governance interventions, and the remaining 10 address social and environmental interventions to improve the SDH.

Tables in the appendices provide information about the results of the development of measurement themes and concepts (Table 4 in Appendix) as well as information about the sources of data consulted to identify the candidate indicators (Table 5 in Appendix). An example of candidate indicators for consideration for the measurement concepts and their levels of alignment, face validity, and technical quality are presented in Table 6 in Appendix. What is not shown in Table 6 in Appendix are measurement concepts for which we could not find relevant indicators. For example, for the following measurement concepts, we were unable to locate candidate indicators: measure extent to which equity impacts of all government policies assessed routinely in decision making (governance); provision public laws guaranteeing self-determination of Indigenous peoples (governance); promote platforms for knowledge exchange of equity-oriented good practices and successful experiences (health sector reorientation); represent level of implementation of international agreements that improve the SDH (global governance); and ensure that justice and accountability are key components of research and evaluations (monitoring and accountability).

Discussion

Summary of findings

We present the methodology used to identify and prioritize key measurement concepts from the Rio Political Declaration and to select relevant, high quality indicators with real-life restrictions on data availability to form the first proposed core set of indicators to guide global monitoring for action on SDH. This set of indicators was presented to a large group of UN Member States and global technical experts at the International Technical Meeting on Measuring and Monitoring Action on the Social Determinants of Health, which took place in Ottawa, Canada, in June 2016 [43] to further guide a broader SDH Action Monitoring System for Member Countries. This is an innovative initiative as previous literature focused explicitly on indicators of determinant vs policy outcomes [34, 44]. Ultimately, this set of indicators will enable policy-makers to track progress in addressing SDH and to build the evidence base of effective actions for reducing health inequities (e.g., [59, 23, 45]). Recent evidence emphasizes the importance of cross-government commitment to addressing the root of SDH inequities [33]. Principles guiding identification of the indicator set included input from a diverse working group, attention to equity in the concepts and indicators, and reliance on existing indicators.

Lessons learnt for global monitoring system development

We identified several strengths of our methods for developing a proposed core set of indicators. First, our WG members included diverse technical and policy experts from all six WHO regions. This broad representation enabled the WG to identify technically sound, feasible, and acceptable candidate indicators while considering the needs of key users of the indicators. Second, we drew on best practices for indicator selection [21, 3841] in developing the inclusion or exclusion and quality assessment criteria applied to candidate indicators during the screening process. We also adopted an iterative approach that involved consideration of data availability to refine and prioritize measurement concepts.

A guiding principle for the indicator set development was a strong focus on equity. First, some disaggregated indicators (i.e., by sex, age, income, etc.) were included where the concept and data permitted. As is becoming the reference standard in the SDG era with its commitment of leaving no one behind [32], disaggregated indicators better capture how action on the SDH works or does not work to reduce health inequities. To further incorporate inequity measurement into the monitoring system, the WG sought to incorporate indicators that would focus specifically on actions directly affecting the most vulnerable groups, thereby ensuring that no one is left behind. This included indicators that measure inequities experienced by indigenous peoples, children, women, persons living in poverty, LGBTI populations, and informal workers.

We identified six key challenges in the development of the core set of indicators. First, we discovered that indicators monitoring SDH-focused interventions are still not routinely collected for certain areas. For example, indicators for intersectoral actions (e.g., Health in All Policies) have only recently been assessed qualitatively by PAHO [34]. Indicators related to the health expenditures on health promotion are focused only in Organization for Economic Cooperation and Development countries. The WG members therefore relied heavily on the SDG indicator system, which presents a number of novel SDH action indicators.

Second, indicators that are explicitly focused on equity are limited. An equity orientation to monitoring health determinants is a new area of focus for health surveillance and monitoring systems [46], although examples such as indicators for measuring actions related to multisectoral governance and participation are starting to emerge [40]. Moreover, although many populations deserving additional attention (e.g., indigenous peoples, children) during monitoring efforts were considered, our final indicators were limited in number so some such as migrants or persons with disabilities were not reflected in our final set. Similarly, another example of a trade-off was around exclusion of informal payments (tipping or bribes) in health systems from the final set limiting the representation of the domain measurement concept “mechanisms for ensuring integration of equity into health systems, policies and progammes” (Table 3, item 3.a).

Third, although we sought to apply the quality assessment criteria with care, time constraints and limited resources presented some challenges. For example, one criterion required that we give priority to indicators with stronger existing evidence about the benefits of that particular SDH. The application of the criterion relied on the expert panel’s knowledge base; neither time nor resources allowed more extensive literature reviews of this particular topic. Another area affected by our short time frame, and will have to be examined in future work in this area, was our inability to examine and identify process indicators that reflect the dynamic nature of and interaction between two or more measurement concepts or domains.

A fourth challenge identified was identifying how to capture the way interventions are implemented and in what types of contexts including such questions as those pertaining to Indigenous populations, that in some countries are regional concerns and not applicable to the country as a whole. Multiple SDH indicators measure actions taken to improve SDH, but they are not designed to capture the degree of implementation or coverage or whether the action was successful. The political, social, cultural, or community contexts in which the interventions are implemented are not always clear from the indicators. This is important information for determining if or how an intervention works or does not work.

Fifth, assessing the effectiveness and cost-effectiveness of SDH-focused interventions is difficult on the basis of indicators alone. The range of information on cost-effectiveness is limited by the extent of effectiveness studies, which are inherently challenged by the complexity of the SDH interventions [47]. Consolidating the evidence base of countries’ implementations of complex policy-level interventions will be necessary for ensuring that the monitoring system is able to capture SDH actions that are considered best practices. Although systematic reviews are useful for building the evidence base for a single sector, especially health sector initiatives, other methods of summarizing the effective implementation and impacts of complex cross-sectoral policies will likely be required [48, 49].

Finally, the WG also experienced limitations in the available data sources. For instance, the domains of the monitoring system capture all Rio Political Declaration Action Areas, but the scan of globally available indicators revealed a disproportionate number of existing indicators for each Action Area. Action Area 4 strengthen global governance and collaboration for addressing the SDH (domain 4) and Action Area 5 monitor progress and increase accountability (domain 5) had only six and five candidate indicators, respectively. And while data availability was a criterion, conceptual fit and feasibility for data collection were also important considerations. For example, indicator 5.b.1 was only available for Canada but this was an indication of the feasibility of developing and reporting a standard metric. Additional work is needed to develop more suitable indicators to capture action to strengthen global governance and collaboration, and action for monitoring progress and increasing accountability.

Implications for research and practice

More work will be needed as the monitoring system continues to develop. Where data gaps have been identified, further exploration of existing data sources and potential new sources will be necessary. A need also exists for evaluating the monitoring system for relevance, accuracy, and validity, and potentially for adapting indicators as new data sources become available or data quality improves. More research on under-studied but crucial interventions on SDH is needed (e.g., mechanisms and structures for intersectoral action for health and global health governance interventions that protect health and health equity from international trade agreements) to further strengthen the evidence base for SDH action indicators, which might necessitate developing novel research methods.

Conclusions

Because of the pervasive and growing inequalities worldwide, there is an emerging trend towards promoting and monitoring government action on SDH. Yet few existing indicators adequately capture a government’s intent to and implementation of policies and programs to address SDH. Many challenges exist to developing such indicators, some of which have been described here (e.g., those related to data availability). While the methods presented in this paper extend the state of the art in measuring government action on SDH, future efforts should attend to the existing gaps to create a strong set of indicators for monitoring SDH in high- and low-income countries alike.

Abbreviations

CSDH: 

Commission on Social Determinants of Health

PAHO: 

Pan American Health Organization

PHAC: 

Public Health Agency of Canada

SDG: 

Sustainable Development Goals

SDH: 

Social determinants of health

SMART: 

Specificity, measurability, assignability, realistic, and time-related

WG: 

Working Group

WHO: 

World Health Organization

Declarations

Acknowledgements

The following individuals were members of the Working Group and writing team and were authors on this paper.

Working Group for Monitoring Action on the Social Determinants of Health (alphabetical order):

Aluisio Barros2, Abdesslam Boutayeb3, Christine Brown4, Hazel D. Dean5, Erica Di Ruggiero6, Rita M. Ferrelli7, Patricia Frenz8, John Glover9, Mana Herel10, James Humuza11, Doris Kirigia12, Patricia O’Campo1 (Working Group Chair), Frank Pega13, Srinath Reddy14, Agata Stankiewicz20, Tone Torgesen15, Nicole B. Valentine18, Eugenio Villar19

Non-Working Group contributors (alphabetical order):

Philip Baden16, Marie DesMeules21, Michelle Dimitris17 Ariel Pulver16, Kandace Ryckman23

1 pat.ocampo@utoronto.ca; University of Toronto and Chair of the Working Group for Monitoring Action on the Social Determinants of Health (Canada)

2 abarros.epo@gmail.com Universidade Federal de Pelotas (Brazil)

3 x.boutayeb@menara.ma; University Mohammed Premier (Morocco)

4 brownch@who.int; WHO regional Office for Europe, Office for Investment for Health and Development (Italy)

5 hdd0@cdc.gov; U.S. Department of Health and Human Services/Centers for Disease Control and Prevention (USA)

6 e.diruggiero@utoronto.ca; Canadian Institutes of Health Research - Institute of Population and Public Health (Canada)

7 rita.ferrelli@iss.it; istituto Superiore di Sanità (Italy)

8 pfrenz@med.uchile.cl; Escuela de Salud Pública, Facultad de Medicina, Universidad de Chile (Chile)

9 john.glover@utoronto.ca; Torrens University Australia (Australia)

10 mana.herel@cfc-swc.gc.ca; Public Health Agency of Canada (Canada)

11 jhumuza@nursph.org; School of Public Health National University of Rwanda (Rwanda)

12kirigiadoris@yahoo.com.au; KEMRI-Wellcome Trust Research Programme (Kenya)

13 pegaf@who.int; World Health Organization – headquarters (Switzerland)

14 ksrinathreddy@phfi.org; Public Health Foundation of India (India)

15 tpt@shdir.no; The National Institute for Public Health (Norway)

16 philip.baiden@uta.edu; The University of Texas at Arlington (USA)

17 michelle.dimitris@mail.mcgill.ca; McGill University (Canada)

18valentinen@who.int; World Health Organization – headquarters (Switzerland)

19 villare@who.int; World Health Organization – headquarters (Switzerland)

20agata.stankiewicz@phac-aspc.gc.ca; Public Health Agency of Canada (Canada)

21Marie.DesMeules@phac-aspc.gc.ca; Public Health Agency of Canada (Canada)

22 ariel.pulver@mail.utoronto.ca; University of Toronto (Canada)

23 k.ryckman@mail.utoronto.ca; McGill University (Canada)

Funding

The workgroup activities were funded by the World Health Organization, Public Health Agency of Canada, and the Canadian Institutes for Health Research.

Availability of data and materials

We did not analyze any primary or secondary quantitative data, and therefore, the concern of data availability is not relevant.

Authors’ contributions

The working group and non-working group members contributed to the conceptualization of the paper, developed and executed the methods. PO, PB, MD, AP and KR drafted the paper and all remaining working group members provided extensive comments and improvements to the drafts. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study did not involve human subjects and was therefore exempt from Research Ethics Board review.

Consent for publication

Our manuscript does not contain any individual person’s data and therefore consent for publication is not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
University of Toronto and Chair of the Working Group for Monitoring Action on the Social Determinants of Health, Toronto, Canada

References

  1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.Google Scholar
  2. Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167–94.View ArticlePubMedGoogle Scholar
  3. World Health Organization. Rio Political Declaration on Social Determinants of Health. Rio de Janeiro: World Health Organization; 2011.Google Scholar
  4. UN General Assembly, Transforming our world: the 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/post2015/transformingourworld/publication. Accessed 21 Oct 2015.
  5. Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews. 2011, Issue 12. Art. No.: CD001871. https://doi.org/10.1002/14651858.
  6. Pega F, Carter K, Blakely T, Lucas PJ. In-work tax credits for families and their impact on health status in adults. Cochrane Database Syst Rev. 2013;8:CD009963.Google Scholar
  7. Borrell C, Palencia L, Muntaner C, Urquia M, Malmusi D, O'Campo P. Influence of macrosocial policies on women's health and gender inequalities in health. Epidemiol Rev. 2014;36:31–48.View ArticlePubMedGoogle Scholar
  8. O'Campo P, Molnar A, Ng E, Renahy E, Mitchell C, Shankardass K, et al. Social welfare matters: a realist review of when, how, and why unemployment insurance impacts poverty and health. Soc Sci Med. 2015;132:88–94.View ArticlePubMedGoogle Scholar
  9. The Cochrane Collaboration. Cochrane Public Health. 2016; Available from: http://ph.cochrane.org/. Cited 19 Feb 2016
  10. Pega F, Liu SY, Walter S, Lhachimi SK. Unconditional cash transfers for assistance in humanitarian disasters: effect on use of health services and health outcomes in low- and middle-income countries. Cochrane Database Syst Rev. 2015;9:CD011247.Google Scholar
  11. Marmot M, Wilkinson R. Social determinants of health: the solid facts. 2nd ed: World Health Organization; 2003.Google Scholar
  12. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. Lancet. 2017;389(10064):91–102.View ArticlePubMedGoogle Scholar
  13. Engle PL, Fernald LC, Alderman H, Behrman J, O'Gara C, Yousafzai A, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet. 2011;378(9799):1339–53.View ArticlePubMedGoogle Scholar
  14. Marmot, M., J. Allen, R. Bell, E. Bloomer, P. Goldblatt, H. Consortium for the European review of social determinants of, et al., WHO European review of social determinants of health and the health divide. Lancet, 2012.380(9846): p. 1011–1029.Google Scholar
  15. Hawe P. Lessons from complex interventions to improve health. Annu Rev Public Health. 2015;36:307–23.View ArticlePubMedGoogle Scholar
  16. Carey G, Crammond B. Systems change for the social determinants of health. BMC Public Health. 2015;15(1):1.View ArticleGoogle Scholar
  17. Hosseinpoor AR, Bergen N, Schlotheuber A, Victora C, Boerma T, Barros AD. Data Resource Profile: WHO Health Equity Monitor (HEM). Int J Epidemiol. 2016;45(5):1404–1405e.View ArticlePubMedPubMed CentralGoogle Scholar
  18. United Nations Statistics Division. Millennium Development Goal Indicators Database. 2006 18 January 2006; Available from: http://millenniumindicators.un.org/unsd/mi/mi_goals.asp.
  19. Becerra-Posada F. Taking health into account in all policies--Author's reply. Lancet Glob Health. 2015;3(10):e595.View ArticlePubMedGoogle Scholar
  20. Rasanathan K, Diaz T. Research on health equity in the SDG era: the urgent need for greater focus on implementation. Int J Equity Health. 2016;15(1):202.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Public Health Agency of Canada. Rio Political Declaration on Social Determinants of Health: A Snapshot of Canadian Actions 2015. Ottawa: Public Health Agency of Canada; 2015.Google Scholar
  22. Public Health Agency of Canada. Rio Political Declaration on Social Determinants of Health: A Selection of Canadian Actions 2013. Ottawa; 2013.Google Scholar
  23. Ospina M, Huertas JA, Montaño JI, Rivillas JC. Observatorio Nacional de Cáncer Colombia. Facultad Nacional de Salud Pública. 2016;33(2):262–76.Google Scholar
  24. Ospina, M.L., J.C. Rivillas, J.I. Montaño, and Colonia F., Experiencias de países hacia la equidad en salud: Colombia., in Equidad en salud desde un enfoque de determinantes sociales. Documento de trabajo n°39. EUROsociAL, R.M.E. Ferrelli, Editor. 2015: http://sia.eurosocial-ii.eu/files/docs/1457517999-DT_39-EQUIDAD%20OK2b.pdf. Accessed 16 Jan 2017.
  25. 62nd World Health Assembly. Resolution WHA62.14: reducing health inequities through action on the social determinants of health. Geneva: World Health Organization; 2009.Google Scholar
  26. 68th World Health Assembly. Resolution WHA68.17: contributing to social and economic development: sustainable action across sectors to improve health and health equity (follow-up of the 8th Global Conference on Health Promotion). Geneva: World Health Organization; 2015.Google Scholar
  27. UN-Water and World Health Organization. UN-water global analysis and assessment of sanitation and drinking-water (GLAAS) 2014 report: investing in water and sanitation: increasing access, reducing inequalities. Geneva: World Health Organization; 2016.Google Scholar
  28. World Health Organization. 2014 Global Progress Report on Implementation of the WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2014.Google Scholar
  29. Pega F, Valentine NB, Rasanathan K, Hosseinpoor AR, Torgersen TP, Ramanathan V, et al. The need to monitor actions on the social determinants of health. Bull World Health Organ. 2017;95(11):784–7.View ArticlePubMedPubMed CentralGoogle Scholar
  30. Stankiewicz A, Herel M, DesMeules M. Report summary--Rio political declaration on social determinants of health: a snapshot of Canadian actions 2015. Health Promot Chronic Dis Prev Can. 2015;35(7):113–4.View ArticlePubMedPubMed CentralGoogle Scholar
  31. United Nations Economic and Social Council, Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators. United Nations Economic and Social Council. New York (https://unstats.un.org/unsd/statcom/47th-session/documents/2016-2-IAEG-SDGs-E.pdf). December 17, 2015, United Nations Economic and Social Council: New York.
  32. United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development (Resolution 70/1). New York: United Nations; 2015.Google Scholar
  33. Marmot M, Goldblatt P. Importance of monitoring health inequalities. BMJ. 2013;347:f6576.View ArticlePubMedGoogle Scholar
  34. Vega J, Frenz P. Integrating social determinants of health in the universal health coverage monitoring framework. Rev Panam Salud Publica. 2013;34(6):468–72.PubMedGoogle Scholar
  35. World Health Organization. Measuring and monitoring intersectoral factors influencing equity in universal health coverage (UHC) and health: Summary report of a meeting in Bellagio, 6–8 May 2014. Geneva: World Health Organization; 2014.Google Scholar
  36. United National Development Programme, Data for Implementation and Monitoring of the 2030 Agenda for Sustainable Development. Guidance Note. https://www.undp.org/content/dam/undp/library/Sustainable%20Development/Guidance_Note_Data%20for%20SDGs.pdf. 2017.Google Scholar
  37. Braveman PA. Monitoring equity in health and healthcare: a conceptual framework. J Health Popul Nutr. 2003;21:181–92.PubMedGoogle Scholar
  38. Church, C. and M.M. Rogers, Designing for results: integrating monitoring and evaluation in conflict transformation programs (Washington, DC: Search for Common Ground), available at https://www.sfcg.org/Documents/manualpart1.pdf. Accessed 26 Mar 2016. 2006.
  39. Shahin A, Mahbod MA. Prioritization of key performance indicators. Int J Product Perform Manag. 2007;56(3):226–40.View ArticleGoogle Scholar
  40. Pan American Health Organization, Validation of the indicators of implementation of the Action Plan on Health in All Policies: proposal for implementation in countries [Validación de los indicadores de implementación del Plan de Acción sobre la Salud en Todas las Políticas: Propuesta para su aplicación en los países]. 2016, Pan American Health Organization: Washington, DC.Google Scholar
  41. UNICEF, Monitoring and Evaluation Training Resource. Selecting indicators; 2015. http://www.ceecis.org/remf/Service3/unicef_eng/module2/index.html.
  42. Leadership Council of the Sustainable Development Solutions Network, Indicators and a Monitoring Framework for the Sustainable Development Goals. Available from: http://unsdsn.org/resources/publications/indicators/ . 2015.Google Scholar
  43. World Health Organization. in Technical meeting on measuring and monitoring action on the social determinants of health 2016. Ottawa, Canada.Google Scholar
  44. Marmot M. Universal health coverage and social determinants of health. Lancet. 2013;382(9900):1227–8.View ArticlePubMedGoogle Scholar
  45. Montano D, Hoven H, Siegrist J. A meta-analysis of health effects of randomized controlled worksite interventions: does social stratification matter? Scand J Work Environ Health. 2014;40(3):230–4.View ArticlePubMedGoogle Scholar
  46. Valentine NB, Swift T, Hosseinpour AR. Monitoring health determinants with an equity focus: a key role in addressing social determinants, universal health coverage, and advancing the 2030 sustainable development agenda. Glob Health Action. 2016;9:1–10. https://doi.org/10.3402/gha.v9.34247.
  47. World Health Organization. Review of social determinants and the health divide in the WHO European Region: final report. In: Regional Office for Europe. Kopenhagen: World Health Organization; 2013.Google Scholar
  48. Petticrew M. Time to rethink the systematic review catechism? Moving from ‘what works’ to ‘what happens’. Syst Rev. 2015;4(1):36.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. Bmj. 2015;350:h1258.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

Advertisement