The Initiative was formed between 2019 and 2020. It was launched by WHO in 2021. A partnership agreement was established between WHO (at headquarters, regional and country level), the Swiss Agency for Development and Cooperation (SDC) (a development agency), University College London, Institute of Health Equity (UCL/IHE) (an academic think-tank), and the University of Lausanne (UNISANTE (UNIL/UNISANTE) (a clinical leader working to integrate the social determinants of health into clinical teaching and health services practice). These partners form the Initiative “core team” at present. Elsewhere, we describe the innovations associated with the initial configuration of this partnership (see Additional file 1).
The Initiative applies a multi-level approach (global, regional, national, local) to knowledge sharing, capacity building, and advocacy with the aim of supporting action in countries and of learning about action on the social determinants of health. Geographically, the Initiative is working through WHO regional and country offices in countries with largely low- and middle-income status. Pathfinder countries and territories include Chile, Colombia, Costa Rica, El Salvador, Lao People’s Democratic Republic (PDR), Morocco, Occupied Palestinian Territory (oPt), Peru and the Philippines. In most cases, the Initiative work in countries has begun through WHO outreach to public health agencies, but there has been increasing effective engagement of other key stakeholders beyond the health sector and it is anticipated that the final collaborations formed at country level will involve many other key stakeholders beyond the health sector.
Theory of change
One of the first activities of the Initiative’s core team was to evolve a theory of change.
This began with a review and discussion of the literature and reflection on the lived experiences of public health officers working across WHO, shared through virtual meetings and correspondence, owing to COVID-19 travel restrictions.
These discussions acknowledged that the literature reflected that action was not yet wide-reaching [7], and generally, literature showed that addressing structural determinants was particularly difficult because it involved multisectoral action [17, 19, 26,27,28]. Experience and calls from Member States through WHO resolutions highlighted that a key difficulty is for the health sector to implement multisectoral action [23, 24]. Important themes that emerged from these discussions were: the importance of social mobilisation, the alignment of windows of opportunity, and equipping health policy-makers to be better advocates and partners for health, not solely for health care [27, 28]. As the Initiative’s core team discussed the problem of action further, they noted several perceived obstacles to progress on this agenda in countries. These discussions generated two key points that are central to the Initiative’s theory of change. First, the importance of theory was noted (“less rhetoric and more theory is needed”). Without theory it is not possible to improve the design and implementation of interventions and policies. It is also not possible to convince others of the validity of approach.
Second, the discussions showed that common ideological, technical and operational barriers to addressing the social determinants of health for advancing health equity operate across different countries (see Fig. 2, left). Ideological barriers to action relate to a perception of striving for health equity as being associated with a left-leaning agenda [29]. However, there are examples where this is not the case. For example, the UN Sustainable Development Goals (SDGs) are a non-partisan development platform for governments from different political persuasions and they promote the reduction of social inequalities. There are also technical barriers. For example, there is limited evidence available on the co-benefits across different policy goals such as: how do policies taxing fossil fuels affect other social determinants of health equity, while addressing climate change in a positive manner; or how do social protection floors reduce transmission of COVID-19, while reducing violence [29, 30]. Finally, operational barriers include: (i) a lack of understanding of what the social determinants of health equity are [31, 32]; (ii) limited integration of the social determinants of health equity within the routine functions of health systems [33, 34]; (iii) limited focus on interventions that address the structural determinants of health inequities [7, 28, 35]; (iv) under-representation of community voices in the health sector and in its multi/intersectoral work [17, 36]; and (v) limited forums and incentives for policy integration and for multi/intersectoral collaboration across government authorities [30, 37, 38].
Based on these considerations, the Initiative theory of change sought to introduce ‘interventions’ associated with change, in three areas (see Fig. 2).
First, strengthening knowledge and narratives for scale-up related to health equity would be emphasized. Updated knowledge that resonates with the current world crises experienced in many countries, including COVID-19 and conflict, and healthy societies and the well-being economy, contextualises the information on the social determinants of health for different change agents desiring to advocate for action. Knowledge on co-benefits between health and other policy sectors enables better collaboration.
Second, focused work in Pathfinder countries with demonstration sites would promote action to address structural determinants of health equity and allow for the development and testing of models. Models provide useful tools for discussion between ministries of health and central government to promote action and for UN, WHO and donor technical and financial assistance to countries. Third, the Initiative would enhance intra and inter-country networks of policy champions (and change-agents), academics, health workers and communities. Networks provide sustenance to change agents that are addressing governance changes, for example, seeking to influence institutional processes.
The core outcome of the Initiative, by 2024, is that: “health, social and economic COVID-19 recovery policies are informed by and act on equity impact assessments of social determinants, with policies for reduced inequities implemented in at least 6 countries”.
Strategic actions
In pursuing the logic of this theory of change, the Pathfinder countries follow a set of strategic actions on the ground: (1) strengthening knowledge on structural determinants of health equity and increasing local assessment capacity; (2) supporting community participation in co-identifying social determinants of health; and (3) promoting collaboration for addressing structural determinants of health equity in all policies and actions, with a social policies emphasis. (Details of the sequences of changes associated with these actions is included in Additional file 2) In undertaking strategic actions, Pathfinder countries engage nationally and sub-nationally.
Strategic, ‘initial’ themes
Based on the WHO COVID-19 review of social determinants of health [3], as well as the concomitant social crisis reported by the UN [21] and discussed by the Initiative core team, an initial set of structural determinants of health themes were prioritised (while others may yet be identified). The themes were tested in discussions with prospective country Pathfinder policy-makers, and confirmed as offering promising entry-points for action, in particular as they aligned with broader social policy goals. These themes are:
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Reducing precariousness, in particular in informal economy employment;
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Improving income and food security;
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Ensuring adequate housing and social services;
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Guaranteeing employment (sick leave, business closures).
Cutting across these themes, there were additional health equity concerns for a number of population groups who experience compounded disadvantage for intersecting identities: workers in the informal economy who are also migrants; women and girls suffering from gender inequality and violence; and ethnic groups facing social stigmatisation or exclusion owing to racism [3]. For example, a large-scale investigation of SARS-CoV-2 infection rates covering 2 135 190 people in communities and 100 000 health-care workers in the United Kingdom and the USA between March and April 2020 found that health-care workers for people with COVID-19 had at least a three times greater risk of a positive COVID-19 test and predicted infection than the general community. Yet ethnic minority health-care workers were at especially high risk, with a risk of COVID-19 at least five times that of the non-minority general community [39].