Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health
This classic paper was written by the pre-eminent Australian health equity scholar, Fran Baum (Professor of Public Health, and Director of both the Southgate Institute of Health, Society and Equity; and the South Australian Community Health Research Unit, Flinders University). At the time of writing, she was a member of the World Health Organization’s (WHO) Commission on the Social Determinants of Health.
Baum says that to bring about greater health equity we need the “nutcracker” effect: both top-down political commitment and bottom-up action from civil society groups. She notes that evidence on health inequities has existed for some time, but few governments have institutionalized remedial action. This is because governments have been more committed to individualism, and minimal government intervention, than to health equity, and because pressure from the better off in society has not been sufficient to “influence government’s desire to be socially just.” (p. 92)
Change requires political leaders who are committed to social justice values (a favouring of collective well-being over individual well-being), and who can lead people through complexity. Baum argues that many leaders still believe that treating high risk or diseased individuals improves population health, despite evidence to the contrary. Almost two decades ago, Geoffrey Rose (1985) showed that changing a health risk factor by a small amount has a greater impact than individual intervention on the incidence of a disease in a community.
Baum explains that public and institutional engagement on behalf of greater equity is called “linking social capital.” Societies high in “linking social capital” have high levels of trust in formal institutions and transparent government processes, characteristics that are declining in many Western countries. If we are to change this, civil society’s strategies for change must go beyond blaming individuals to creating health and equity-promoting environments.
Use this resource to
- Foster discussion among colleagues about the factors required for governments to take concrete action for greater health equity
- Learn more about the history of health equity and health promotion thinking
- Reconnect with the centrality of social justice values in health equity work
Baum, F. (2007) Cracking the nut of health equity: Top down and bottom up pressure for action on the social determinants of health. Promotion & Education, 14(2), 90-95.