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The World Health Organization Health (WHO) defines health as “a state of complete physical, mental and social well-being; and not merely the absence of disease or infirmity.”[1] Health is influenced by medical and non-medical determinants which contribute to health inequities; the non-medical determinants of health are also referred to as the social determinants of health (SDH).

As per WHO, social determinants of health are ‘the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems that shape the conditions of daily life’. These forces include economic policies and systems, development agendas, social norms, social policies, and political systems.[2] The SDHs play a role in quality of life (QoL) and functioning at the individual level. They include classic non-medical factors such as gender, social class, income, socioeconomic status, education, ethnicity, culture, and neighbourhood. These days, SDHs also include other factors influencing education, employment, and the living environment, such as social safety, social capital, immigration, racism, religion, colonialism, legal status, addiction, unemployment, and legal status.[3] SDHs also include factors such as accessible healthcare and education, race and ethnicity, safe environmental conditions, and food insecurity, and intangible factors such as political, socioeconomic, and cultural beliefs. SDHs are shaped by the distribution of money, power and resources at global, national and local levels.[4]

It is well known that SDH contribute to many of the major health conditions including obesity, heart disease, diabetes, and depression.[5] It has also been realised that SDH are among the main factors resulting in avoidable health inequalities between different groups of people, within and between countries, by creating stratification in societies. In this context, the WHO established a commission on SDH in 2005 to support countries and global health partners in addressing the social factors that lead to poor health and health inequities. The aim of the commission was to draw attention of the governments and society towards the social determinants of health and create better conditions for health.[6]

Research on SDH is also essential to determine the value of healthcare delivery. It is increasingly realised that value-based models of healthcare systems impart positive results on the whole society rather than individuals. Holistic approach by healthcare providers to enhance patient care and to promote superior outcomes can increase the value of healthcare organizations. These are invariably tied to the complex circumstances in which people are born and live, which in turn determine the SDH.

Identifying SDH can help analyze the care to be provided to the people, and the care yet to be received by the people. In this context, electronic health records (EHRs) can be an invaluable source of information on SDH. EHRs have been mined for obtaining structured and unstructured data on type of care provided, clinical outcomes, survival, adverse effects, and factors determining the same. The social and demographic data about patients on the other hand is of great value in understanding the social angle of health, and helps deliver positive healthcare outcomes.[7]

Economists often justify SDH interventions based on ‘efficiency’ and ‘equity’ aspects. SDH interventions are needed for the efficient allocation of resources, and are also required for the equitable distribution of public policy pertaining to healthcare delivery. Recent economic thinking suggests that there should be a synergistic approach between efficiency and equity for the purpose of SDH interventions. The core concept is that a resource redistribution to achieve equity does have a price, but sometimes this price is worth paying. The role of economists is to find the least costly strategy to achieve equity and efficiency, ultimately resulting in social welfare, not just in the health aspect, but from a holistic viewpoint. In fact, there are many examples (such as SDH interventions for early child development) where efficiency and equity are shown to mutually enhance each other.[8]

SDH have considerable impact on the treatment outcomes as well: interventions that target SDH are often required in addition to therapy for improving the patient’s health. However, for mobilizing investment in SDH interventions, the value for money of those interventions should be firmly established. For any SDH intervention to have value for money, it is essential to assess whether the SDH intervention can bring about measurable changes in health outcomes. Any SDH intervention is likely to be multifaceted, and the outcomes need not be limited to the health sector alone. In this context, it is also essential to take into account all the potential benefits of the intervention. All these benefits must be incorporated when performing an economic evaluation of the SDH intervention.[8]

The economic argument surrounding the value for money of any SDH intervention depends on the evidence of effectiveness of the SDH intervention. In this context, it is necessary to examine the impact of the SDH intervention in the desired primary area, that is, to improve health. For example, the beneficial impact of SDH interventions targeting early childhood education should be evaluated in the context of improving health in terms of improved childhood vaccination, increased hygiene, reduced school absenteeism, and an overall reduced incidence of pediatric hospitalization due to avoidable diseases. Evaluation of SDH interventions that target economic welfare and social protection through targeted conditional cash transfers in middle-income and low-income countries should also include evaluation of the improvement in health of the beneficiaries as an outcome of the intervention. Interventions targeting urban development, such as affordable housing, assistance for improving internal conditions of houses, slum upgrading, traffic calming programmes, and developing public parks and swimming pools, also appear to have a positive impact on a number of health outcomes, and these need to be evaluated.[8]

In this context, there are multiple research gaps concerning the economics of SDH interventions:

• Most evidence originates from, and thus is biased towards, high-income countries.
• Evidence generation through randomization for SDH interventions is laden with a multitude of ethical, moral, social, and humanistic hurdles. Thus, causal impact of SDH interventions is often challenging to assess.
• It is challenging to accurately quantify the multifaceted benefits of the SDH interventions in monetary terms.

The SDH are thus an important concept that can alter the health of a large number of individuals, and are responsible for poor health outcomes despite the availability of well-designed health programmes. SDH interventions are essential not only to improve the efficiency and equity of health programmes, but also to enhance the living standards of people in a multifaceted way. Scientifically sound and robust methods are needed to be developed to accurately evaluate the value-for-money of different SDH interventions.

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References

1. https://www.who.int/about/governance/constitution
2. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
3. Islam MM. Social Determinants of Health and Related Inequalities: Confusion and Implications. Front Public Health. 2019 Feb 8;7:11.
4. https://www.medicalnewstoday.com/articles/social-determinants-of-health
5. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0312
6. https://www.who.int/teams/social-determinants-of-health/equity-and-health/commission-on-social-determinants-of-health
7. Gold R et al. Adoption of Social Determinants of Health EHR Tools by Community Health Centers. Ann Fam Med. 2018 Sep;16(5):399-407 https://apps.who.int/iris/bitstream/handle/10665/84213/9789241548625_eng.pdf