Tackling the socio-economic gradient has a moral dimension; namely that “the highest attainable standards of health should be within the reach of all without distinction for race, religion, political belief, economic or social condition” (WHO, 1948).
KCC is uniquely positioned to co-ordinate efforts but must do so in a way that includes other partners and communities. Operating within an agreed framework there must be an understanding of the nature and scope of health inequalities within the county, a choice of priority interventions and a commitment to monitor and evaluate their effects over time.
The starting point is a clear picture of the health issues and of their determinants. Disaggregated data should be used and then organized to identify the population sub-groups and health issues that reveal the greatest health inequalities.
Armed with this information partner organizations can take co-ordinated action in the complex web of relevant health determinants. There should be a shared vision that is supported by everyone involved in the process and partnership arrangements to support on-going inter-sectoral communication and collaboration. It is particularly important that the engagement and commitment of professionals and community leaders is engaged so that people with the relevant skills can provide expertise and practical experience in support of the effort. Following implementation, close monitoring and evaluation are required to understand whether the activities related to the intervention have been completed within the required time frame. Also to see whether inputs and outputs and activity have been delivered and whether targets have been reached and outcomes achieved.
A results sharing mechanism that includes multi-sectoral partners and the community helps reinforce collaboration and maintain focus on the desired equity outcomes. Available and emerging results must be communicated in ways that are understandable and useful to end users.
The leadership for reducing health inequalities must in particular take full account of the evidence base (of which the UK is a world leader – see Marmot Review post) and have a positive appreciation of the conundrum of the limitations of individual responsibility for poor health.
Social or individual responsibilities and inequalities in health
Much inequality health policy focuses on structural explanations of social change emphasizing the influence of past and present social relations over future developments. “The social structures we inherit, in particular our social class, gender and family births, determine our social relationships and our life courses”. The kinds of intervention design in this regard include Sure Start Children’s Centres.
More recently health policy has turned towards to what social scientists refer to as “agency”. The concern with agency focuses attention … upon the role of individuals in negotiating or responding to social relationships. After all we are all individuals with a power to make choices about the relations we have. The choices we have in our relations with others determine how these develop and how our life chances are played out. Indeed social structures are constructed by the aggregation of individual actions; we create our social world; so our individual decisions matter.
Since 2004 much national health inequalities policy has focused upon individuals; thus agency approaches.
The key challenge to all who are engaged in addressing this agenda, whilst stressing the potential that many individuals have to look after themselves better and reduce their risk of developing chronic disease, is to appreciate individual circumstances; and thus refrain from blaming equally all individuals, regardless of social circumstance who suffer ill health. The dialogue that should address in particular the needs of the disadvantaged should avoid pre-occupation with dependency and the attribution of blame.
Instead recognition should be given to the expertise with which people and parents successfully negotiate their lives despite inadequate resources. The typology set out in figure 17 below emphasizes the capacity of people to be creative and reflexive agents, whilst locating their agency within social stratification and thus their power relationships. This capacity for agency is constrained as well as enabled by lack of material resources and power.
Forms of agency exercised by people in poverty
Recognition of these dynamics should be used by professionals and organizations in mobilizing support and appropriate interventions. This is particularly important in community development.
The horizontal axis represents the continuum from the personal to the political and the vertical axis represents the continuum from the everyday living to the strategic. Thus ‘Getting by’ refers to ways in which people manage to live on a limited income. Professionals should maintain and further develop their understanding of the reality of people’s lives when addressing the needs of people challenged by the prospects of healthy living with limited resources.
‘Getting out’ refers to the activities and routes by which people escape from poverty and the barriers necessary to overcome. Partnerships responsible for educational opportunity, community development and training should work to optimize such opportunities as skills leading to better employment prospects that represent the best opportunities to escape poverty and aspire towards healthier living.
‘Getting (back) at’ refers to activities such as the ‘black economy’ which whilst not condoned, should be regarded as a reflection of community dysfunction, indeed a sense of community and of social solidarity. Partnerships concerned with the safety and effectiveness of local communities should continue to be mindful of the complexities of lives led by people with inadequate resources.
‘Getting organised’ refers to collective forms of action. The consequence of this is that more than lip service has to be paid to notions of equality of respect and of common citizenship. “People in poverty do not want to be treated as different. Instead their struggle is for recognition of their humanity and citizenship and the equal worth that flows from that” (Lister 2004 p188). Thus the biggest challenge is to the community at large.