When I explain social determinants of health to people, the first reaction I get is ‘Okay, that is very intuitive.’ It makes sense if you are in poverty, your chances are that you will get sick more often than those who are not.
So, what to do about. When I try to offer a solution that requires changing the quality of social conditions, I get comments like ‘so why don’t such and such patient do not change his/her behaviour or go to a physician.’ Back to square one. Let me try to explain social determinants using health care system of Afghanistan as a real-life example.
This report by the World Health Organization measured differents outcomes over time to assess if countries had made progress towards the Millennium Development Goal in 2012. Take a look at Afghanistan’s under-five mortality rate in 2000 and 2010, and then at the maternal mortality rates in 2000 and 2010. Do you observe anything?
Now, social determinants of health are the conditions in which people are born, grow up, live, work and age. In other words, income, education, employment, working conditions, social status, physical environment, early childhood development, gender, culture, social systems (i.e. health care, education, transportation, housing), and many others are social determinants of health. They contribute to the health of populations at varying levels. Take life expectancy. Your life expectancy is an outcome to which all social determinants play a confounding part. Health care alone plays a minor part. Born in a country with the best health care system but with prevalent poverty, lack of employment, poor housing, and a violent environment, don’t expect to live long.
Like life expectancy, maternal mortality rate is sensitive to many social determinants such as education, income, sociocultural practices, transportation, and health system. Changes in any of them lead to improved maternal mortality. That’s the case in Afghanistan. From 2002 onward, the social conditions in Afghanistan have improved significantly. Specifically, education for women, road conditions, sociocultural practice, and basic health care services have increased and contributed to reduced maternal mortality.
Unlike life expectancy, infant and under-five mortality rates are less sensitive to some social determinants and more sensitive to quality health care services. That’s why, infant mortality rates are better predictors of improved health care services than other outcomes. Now, let’s look at the case of Afghanistan.
Afghanistan’s under-five mortality rate has remained almost the same between 2000 (151) and 2010 (149). What does it say? It means that some basic services of health care may have increased, as some official figures claim, up to 60% of the population, but the quality of services remain poor. It means there may be a community health worker but there is a shortage of pediatrician. Midwives may be available to help deliver the baby, but there is a lack of obstetric services or lack of incubators for newborns.
After almost a decade and a half of investment in Afghanistan’s health care system, it is time to put quality health care services at the heart of the interventions. The basis of accountability in the health care sector should be quality services, not a list of clinics or coverage rate.