What Enables and Constrains the Inclusion of the Social Determinants of Health Inequities in Government Policy Agendas? A Narrative Review

Document Type : Review Article


1 Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia

2 School of Regulation and Global Governance (RegNet), College of Asia and the Pacific, Australian National University, Canberra, Australia

3 Institute of Policy Studies, University Brunei Darussalam, Gadong, Brunei Darussalam

4 Southgate Institute of Health, Society and Equity, Flinders University, Adelaide, SA, Australia

5 National Centre for Epidemiology and Population Health, College of Medicine, Biology & Environment, Australian National University, Canberra, Australia


Despite decades of evidence gathering and calls for action, few countries have systematically attenuated health inequities (HI) through action on the social determinants of health (SDH). This is at least partly because doing so presents a significant political and policy challenge. This paper explores this challenge through a review of the empirical literature, asking: what factors have enabled and constrained the inclusion of the social determinants of health inequities (SDHI) in government policy agendas?

A narrative review method was adopted involving three steps: first, drawing upon political science theories on agenda-setting, an integrated theoretical framework was developed to guide the review; second, a systematic search of scholarly databases for relevant literature; and third, qualitative analysis of the data and thematic synthesis of the results. Studies were included if they were empirical, met specified quality criteria, and identified factors that enabled or constrained the inclusion of the SDHI in government policy agendas.

A total of 48 studies were included in the final synthesis, with studies spanning a number of country-contexts and jurisdictional settings, and employing a diversity of theoretical frameworks. Influential factors included the ways in which the SDHI were framed in public, media and political discourse; emerging data and evidence describing health inequalities; limited supporting evidence and misalignment of proposed solutions with existing policy and institutional arrangements; institutionalised norms and ideologies (ie, belief systems) that are antithetical to a SDH approach including neoliberalism, the medicalisation of health and racism; civil society mobilization; leadership; and changes in government.

A complex set of interrelated, context-dependent and dynamic factors influence the inclusion or neglect of the SDHI in government policy agendas. It is better to think about these factors as increasing (or decreasing) the ‘probability’ of health equity reaching a government agenda, rather than in terms of ‘necessity’ or ‘sufficiency.’ Understanding these factors may help advocates develop strategies for generating political priority for attenuating HI in the future.


Main Subjects

  1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008.
  2. Lalonde M. A new perspective on the health of Canadians: a working document. Ottawa: Ministry of National Health and Welfare; 1974.
  3. Mackenbach JP. The persistence of health inequalities in modern welfare states: the explanation of a paradox. Soc Sci Med. 2012;75(4):761-769. doi:10.1016/j.socscimed.2012.02.031
  4. Exworthy M. Policy to tackle the social determinants of health: using conceptual models to understand the policy process. Health Policy Plan. 2008;23(5):318-327. doi:10.1093/heapol/czn022
  5. Embrett MG, Randall GE. Social determinants of health and health equity policy research: exploring the use, misuse, and nonuse of policy analysis theory. Soc Sci Med. 2014;108:147-155. doi:10.1016/j.socscimed.2014.03.004
  6. Farrer L, Marinetti C, Cavaco YK, Costongs C. Advocacy for health equity: a synthesis review. Milbank Q. 2015;93(2):392-437. doi:10.1111/1468-0009.12112
  7. Buse K, Mays N, Walt G. Making health policy. Open University Press; 2012.
  8. Parkhurst JO. The Politics Of Evidence: From Evidence-Based Policy to the Good Governance Of Evidence. Abingdon; New York: Routledge; 2017.
  9. Cairney P. The Politics of Evidence-Based Policy Making. London: Palgrave Pivot; 2016.
  10. Kingdon JW. Agendas, Alternatives, and Public Policies. London: Harper Collins; 1995.
  11. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370(9595):1370-1379. doi:10.1016/s0140-6736(07)61579-7
  12. World Health Organization. Closing the Gap: Policy Into Practice on Social Determinants of Health. Rio de Janeiro: WHO; 2011.
  13. Lasswell HD. Politics: Who Gets What, When, How. New York: P Smith; 1950.
  14. Graham H. Social determinants and their unequal distribution: clarifying policy understandings. Milbank Q. 2004;82(1):101-124.
  15. Parsons W. Public policy. Cheltenham, Northampton: Edward Elgar; 1995.
  16. Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009;87(8):608-613.
  17. Petticrew M, Roberts H. Systematic reviews in the social sciences: A practical guide. John Wiley Sons; 2008.
  18. Popay J, Roberts H, Sowden A, et al. Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC methods programme. Lancaster University; 2006. doi:10.13140/2.1.1018.4643
  19. Centre for Research Excellence in the Social Determinants of Health Equity.  http://www.flinders.edu.au/medicine/research/centres/centre-for-research-excellence-in-the-social-determinants-of-health-equity/.  Accessed  December 6, 2012.
  20. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study. Lancet. 2016;388(10040):131-157. doi:10.1016/s0140-6736(16)00345-7
  21. Sabatier P. The need for better theories. In: Sabatier P, Weible C, eds. Theories of the Policy Process. Boulder, CO: Westview Press; 2014.
  22. World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva; WHO; 2008.
  23. Krieger N. A glossary for social epidemiology. J Epidemiol Community Health. 2001;55(10):693-700.
  24. Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56(9):647-652.
  25. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: a framework for assessing research evidence. Government Chief Social Researcher’s Office; 2003.
  26. Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 4th ed. San Jose State University, USA: SAGE Publishing; 2008.
  27. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. doi:10.1186/1471-2288-8-45
  28. Aldrich R, Zwi AB, Short S. Advance Australia fair: social democratic and conservative politicians' discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 1972-2001. Soc Sci Med. 2007;64(1):125-137. doi:10.1016/j.socscimed.2006.08.034
  29. Came H. Sites of institutional racism in public health policy making in New Zealand. Soc Sci Med. 2014;106:214-220. doi:10.1016/j.socscimed.2014.01.055
  30. Gamble VN, Stone D. U.S. policy on health inequities: the interplay of politics and research. J Health Polit Policy Law. 2006;31(1):93-126. doi:10.1215/03616878-31-1-93
  31. Vallgårda S. Health inequalities: Political problematizations in Denmark and Sweden. Crit Public Health. 2007;17(1):45-56. doi:10.1080/09581590601071705
  32. Dahl E, Lie M. Policies to tackle health inequalities in Norway: from laggard to pioneer? Int J Health Serv. 2009;39(3):509-523. doi:10.2190/HS.39.3.e
  33. Vallgarda S. Social inequality in health: dichotomy or gradient? A comparative study of problematizations in national public health programmes. Health Policy. 2008;85(1):71-82. doi:10.1016/j.healthpol.2007.07.004
  34. Orton LC, Lloyd-Williams F, Taylor-Robinson DC, Moonan M, O'Flaherty M, Capewell S. Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health. 2011;11:821. doi:10.1186/1471-2458-11-821
  35. McCallum K. Distant and intimate conversations: media and indigenous health policy in Australia. Crit Arts. 2013;27(3):332-351. doi:10.1080/02560046.2013.800667
  36. de la Barra SL, Redman S, Eades S. Health research policy: a case study of policy change in Aboriginal and Torres Strait Islander health research. Aust New Zealand Health Policy. 2009;6:2. doi:10.1186/1743-8462-6-2
  37. Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom: the progress and pitfalls of policy. Health Serv Res. 2003;38(6 Pt 2):1905-1921.
  38. McGill E, Egan M, Petticrew M, et al. Trading quality for relevance: non-health decision-makers' use of evidence on the social determinants of health. BMJ Open. 2015;5(4):e007053. doi:10.1136/bmjopen-2014-007053
  39. Smith KE. The politics of ideas: The complex interplay of health inequalities research and policy. Sci Public Policy. 2014;41(5):561-574. doi:10.1093/scipol/sct085
  40. Gauld R, Bloomfield A, Kiro C, Lavis J, Ross S. Conceptions and uses of public health ideas by New Zealand government policymakers: report on a five-agency survey. Public Health. 2006;120(4):283-289. doi:10.1016/j.puhe.2005.10.008
  41. Exworthy M, Berney L, Powell M. 'How great expectations in Westminster may be dashed locally': the local implementation of national policy on health inequalities. Policy Polit. 2002;30(1):79-96. doi:10.1332/0305573022501584
  42. Carey G, Crammond B. Action on the social determinants of health: views from inside the policy process. Soc Sci Med. 2015;128:134-141. doi:10.1016/j.socscimed.2015.01.024
  43. Baum FE, Laris P, Fisher M, Newman L, Macdougall C. "Never mind the logic, give me the numbers": former Australian health ministers' perspectives on the social determinants of health. Soc Sci Med. 2013;87:138-146. doi:10.1016/j.socscimed.2013.03.033
  44. Smith KE. Understanding responses to the political context of health inequalities in research and policy: Can post-structural theories of power help? Soc Theory Health. 2015;13(3):355-376. doi:10.1057/sth.2015.24
  45. Browne J, de Leeuw E, Gleeson D, Adams K, Atkinson P, Hayes R. A network approach to policy framing: A case study of the National Aboriginal and Torres Strait Islander Health Plan. Soc Sci Med. 2017;172:10-18. doi:10.1016/j.socscimed.2016.11.011
  46. Klugman B. Effective social justice advocacy: a theory-of-change framework for assessing progress. Reprod Health Matters. 2011;19(38):146-162. doi:10.1016/s0968-8080(11)38582-5
  47. McIntyre D, Gilson L. Putting equity in health back onto the social policy agenda: experience from South Africa. Soc Sci Med. 2002;54(11):1637-1656.
  48. Nathan S, Rotem A, Ritchie J. Closing the gap: building the capacity of non-government organizations as advocates for health equity. Health Promot Int. 2002;17(1):69-78.
  49. Pittman PM. Beyond the sound of one hand clapping: Experience in six countries using health equity research in policy. J Health Polit Policy Law. 2006;31(1):33-50. doi:10.1215/03616878-31-1-33
  50. Collins PA, Abelson J, Eyles JD. Knowledge into action? understanding ideological barriers to addressing health inequalities at the local level. Health Policy. 2007;80(1):158-171. doi:10.1016/j.healthpol.2006.02.014
  51. Macnaughton E, Nelson G, Goering P. Bringing politics and evidence together: policy entrepreneurship and the conception of the At Home/Chez Soi Housing First Initiative for addressing homelessness and mental illness in Canada. Soc Sci Med. 2013;82:100-107. doi:10.1016/j.socscimed.2013.01.033
  52. Schmidt M, Joosen I, Kunst AE, Klazinga NS, Stronks K. Generating political priority to tackle health disparities: a case study in the Dutch city of The Hague. Am J Public Health. 2010;100 Suppl 1:S210-215. doi:10.2105/ajph.2009.168526
  53. Smith KE. Health inequalities in Scotland and England: the contrasting journeys of ideas from research into policy. Soc Sci Med. 2007;64(7):1438-1449. doi:10.1016/j.socscimed.2006.11.008
  54. McCallum K, Waller L. The Intervention of Media Power in Indigenous Policy-Making. Media International Australia. 2013;149(1):139-149. doi:10.1177/1329878x1314900115
  55. Strand M, Fosse E. Tackling health inequalities in Norway: applying linear and non-linear models in the policy-making process. Crit Public Health. 2011;21(3):373-381. doi:10.1080/09581596.2010.492210
  56. Smith K. Institutional filters: The translation and re-circulation of ideas about health inequalities within policy. Policy Polit. 2013;41(1):81-100. doi:10.1332/030557312X655413
  57. Lawless AP, Williams C, Hurley C, Wildgoose D, Sawford A, Kickbusch I. Health in All Policies: evaluating the South Australian approach to intersectoral action for health. Can J Public Health. 2012;103(7 Suppl 1):eS15-19.
  58. Delany T, Harris P, Williams C, et al. Health impact assessment in New South Wales & Health in All Policies in South Australia: differences, similarities and connections. BMC Public Health. 2014;14:699. doi:10.1186/1471-2458-14-699
  59. Qureshi K. It's not just pills and potions? depoliticising health inequalities policy in England. Anthropol Med. 2013;20(1):1-12. doi:10.1080/13648470.2012.747593
  60. Nutbeam D, Boxall AM. What influences the transfer of research into health policy and practice? Observations from England and Australia. Public Health. 2008;122(8):747-753. doi:10.1016/j.puhe.2008.04.020
  61. Bambra C, Smith KE, Garthwaite K, Joyce KE, Hunter DJ. A labour of Sisyphus? Public policy and health inequalities research from the Black and Acheson Reports to the Marmot Review. J Epidemiol Community Health. 2011;65(5):399-406. doi:10.1136/jech.2010.111195
  62. Fosse E. Norwegian public health policy: revitalization of the social democratic welfare state? Int J Health Serv. 2009;39(2):287-300. doi:10.2190/HS.39.2.d
  63. Davidson R, Hunt K, Kitzinger J. 'Radical blueprint for social change'? Media representations of New Labour's policies on public health. Sociol Health Illn. 2003;25(6):532-552.
  64. Cobb RW, Elder CD. Participation in American politics: The Dynamics of Agenda-Building. Johns Hopkins University Press; 1983.
  • Receive Date: 03 July 2017
  • Revise Date: 25 October 2017
  • Accept Date: 30 October 2017
  • First Publish Date: 01 February 2018