Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks
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Artículo de revisión / Review
Health systems in context: a systematic
review of the integration of the social
determinants of health within health systems
frameworks
Evan Russell,1 Bryce Johnson,2 Heidi Larsen,2 M. Lelinneth B. Novilla,2
Josefien van Olmen,3 and R. Chad Swanson 2
Suggested citation Russell E, Johnson B, Larsen H, Novilla MLB, van Olmen J, Swanson RC. Health systems in context: a
systematic review of the integration of the social determinants of health within health systems frame-
works. Rev Panam Salud Publica. 2013;34(6):461–7.
abstract Objective. To systematically review and analyze various ways that health systems frame-
works interact with the social determinants of health (SDH), as well as the implications of
these interactions.
Methods. This was a review of the literature conducted in 2012 using predetermined crite-
ria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic
Reviews, and the World Bank E-Library) and grey literature for articles with any consider-
ation of the SDH within health systems frameworks. Snowball sampling and expert opinion
were used to include any potentially relevant articles not identified by the initial search. In
total, 4 152 documents were found; of these, 27 were included in the analyses.
Results. Five main categories of interaction between health systems and SDH emerged:
Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded
and Production models, which conceive the SDH to be outside the health system; at the other
end, the Joint and Systems models, which visualize a continuous and dynamic interaction.
Conclusions. Considering the complex and dynamic interactions among different kinds of
organizations involved in and with the health system, the Joint and Systems models seem to
best reflect these interactions, and should thereby guide stakeholders in planning for change.
Key words Social policy; equity in health; health systems, trends; guidelines as topic; Americas.
Calls for action on the social deter- The SDH, or the “conditions in which ica and the Caribbean (7). Collectively,
minants of health (SDH) as an integral people are born, grow, live, work, and the SDH present a critical challenge to
component of the post-2015 Millennium age,” (3) are factors in the “social envi- health systems, national governments,
Development Goals (MDGs) agenda in- ronment” that impact health. Factors and the international community (8).
dicate the urgent need for intersectoral including poverty, stress, working con- Despite acknowledgement that there
alignment and cross-cutting action (1, 2). ditions, unemployment, social support, are multiple sectors that contribute to
food, transportation, early life devel- the social determinants, many actions
1 Johns Hopkins Bloomberg School of Public Health–
International Health, Baltimore, Maryland, United
opment, and addiction (4) have been to address these factors have tradition-
States of America. Send correspondence to Evan implicated as contributors to marked ally been embedded within, or were
Russell, erussell@jhsph.edu differences (of a decade or more) in life closely related to, the health system
2 Brigham Young University, Provo, Utah, United
States of America. expectancies between and within coun- (HS). Although some recent multisector
3 Institute of Tropical Medicine, Antwerp, Belgium. tries (5, 6), particularly in Latin Amer- approaches to reducing the SDH impact
Rev Panam Salud Publica 34(6), 2013 461Review Russell et al. • Systematic review of the social determinants of health within health systems have been employed (9), historically the MATERIALS AND METHODS the titles of articles were screened to HS has been assigned the resources and eliminate those irrelevant to the main mandate to address health and disease in Data collection topic. Then, to reduce variability be- most settings, even when the multisec- tween reviewers, both reviewers to- tor etiology of health is acknowledged The basis for this study’s data col- gether screened 100 articles based on the (10). Given this widespread expecta- lection methodology was a systematic inclusion criteria to establish procedural tion, a clear framework that details the review that followed the Cochrane coherence. Subsequently, each reviewer constituents and the interactions among Systematic Review protocol (23) and scanned at least 20% of the other re- them (11) is critical for understanding, took place over the course of 2012. The viewer’s screening decisions. Abstracts evaluating, and strengthening the HS strategy was employed initially to iden- were evaluated by the reviewers inde- (12–14). Although there is no consensus tify English language HS articles from pendently and eliminated if both agreed as to the definition of an HS, several any part of the world that discussed a they were obviously irrelevant. In the proposed definitions allude to the pro- framework or an equivalent structure, case of a disagreement, the full-text was tective, restorative, and responsive roles and then to narrow the selection to screened, and a third reviewer was con- that it plays in relation to health (15–19). those especially relevant for the review sulted when necessary. While offering a general vision of the (23). For the initial, broad selection, any HS as a set of components with actions article describing or discussing health Data analysis leading toward health, many of the pro- frameworks with terms such as, “health posed frameworks differ as to structure, system,” “framework,” “model,” “com- In conducting a qualitative analysis, composition, and relationships of the ponent,” “definition,” or “indicator” was the first author, with the assistance of various parts. included. Articles were considered rel- other co-authors, reviewed the final 27 As the international community broad- evant to the review if they discussed a articles with the following questions in ens its attention from health (care) to specific HS definition and framework mind: How does the framework con- the SDH, it will need practical guid- and were published after 1980. A “defi- sider the relationship between SDH and ance on how it can best use the array of nition” referred to a broad description health? How does it frame the impact knowledge on both SDH and HS in an of the overall functions and purposes of that HS components may have on SDH? integrated way to address the disparities a HS. A “framework” was considered Does the particular framework consider in health within and between societies relevant if it included components, such the impact SDH may have on HS com- and countries (10). Sustaining any prog- as organizations, networks, or individu- ponents? If yes, how? The key results of ress beyond the MDGs will require ad- als, and any relationship between or this analysis were included along with a dressing the “causes of the causes” (10) among its components, with the explicit short description of each study. by strengthening country-level systems. or implied purpose of improving health. Such a task necessitates an understand- As the inclusion or lack thereof of SDH RESULTS ing of HS structures, operations, their with the HS was a central question in perceived and explicit boundaries, and this review, the “social determinants of A total of 4 138 English language re- their interactions with various determi- health” was not included as a search cords were initially identified, plus an nants at local, national, and even global term in order to see how different frame- additional 14 were included via snow- levels. While analyses of HS frameworks works considered this relationship, if at ball sampling and expert opinion. A have been carried out from a strengthen- all, and to avoid selecting only articles title or title and abstract screening of ing (11), historical (20), and an invest- that explicitly acknowledge and discuss the initial 4 152 articles narrowed these ment (21) perspective, there has been no this interaction. down to 35 articles for full text review; widely available analysis of HS frame- Databases searched for this review finally, 27 articles remained that met the works in relation to social determinants were selected based on their level of eligibility criteria by including both an and vice versa. The boundaries, interac- comprehensiveness and coverage of HS definition and framework, as well as tions, and overall relationships between the topic; they included PubMed, the some mention of the SDH for analysis the SDH and HS may shape the structure, Cochrane Database for Systematic Re- (7, 9, 12, 13, 16–18, 24–43). These articles financing, activities, and evaluation of the views, and the World Bank E-Library. were included in the final qualitative HS. Given the impact of the MDGs on A number of grey literature sources analysis (Figure 1). the structure and organization of health were also considered. Expert opinion The degree of integration of SDH around the world (22), understanding and a snowball sampling technique were within HS frameworks varied from little the different HS-SDH conceptualizations then employed to identify other relevant or no integration, where the SDH and may lead to better development action in frameworks that may have been omitted HS are considered completely outside 2015 and beyond. from the initial search. the HS or not addressed at all in the The present study offers a systematic Two independent researchers partici- HS framework, to a significant integra- review of HS frameworks in relation pated in the article selection process. tion of SDH in which interactions were to the SDH. It analyzes: (a) how frame- Articles excluded were those without explicitly discussed. Based on the study works consider the relationship between references, those that did not present a questions, five categories emerged from SDH and health; (b) how the HS impacts coherent framework, and those that dis- the analysis: (a) frameworks that sepa- the SDH; and (c) how SDH, in turn, im- cussed a framework covered in another rated the SDH from the HS completely pact the HS. article. In the first stage of the review, or only included minimal interaction 462 Rev Panam Salud Publica 34(6), 2013
Russell et al. • Systematic review of the social determinants of health within health systems Review
FIGURE 1. Inclusion diagram for a systematic review of the integration of the social determinants model suggested that more inclusive
of health within health systems frameworks, 2012 SDH frameworks may not be practical
if the state can only control HS funding
and administration (24).
Identification
4 138 records identified 14 records identified
through database search through other sources
Production model
Moving beyond the “primary pur-
pose” definition, Production models
Screening
(Table 2) have a defined relationship
4 117 articles excluded via title or title and with the SDH (34). These frameworks
4 152 records screened
abstract screen due to obvious irrelevancy
postulate a casual relationship between
the SDH and the HS whereby determi-
nants such as the Physical and Social En-
8 full text articles excluded vironment (16) feed into and affect (13)
Eligibility
• 2 describe dynamics but not HS structure
the mix of interventions for health (33,
• 2 only compared HS reform efforts, not HS
35 full text articles 36, 44). The resulting services can then
• 1 describes only sub-section of HS
assessed fpr eligibility produce health, yet if they are poorly
• 1 describes only financing of HS
• 1 presentation of framework already analysed designed, these services can also impact
• 1 framework not adequately described SDH, e.g., economic vulnerability (32).
Included
27 studies included in Reciprocal model
qualitative analysis
Reciprocal models (Table 3) combine
these unidirectional Production models
and suggest that while the SDH are ex-
were categorized as using a “Bounded” dress the non-linear dynamics of this ternal to the HS, the HS must strive to
model (four articles); (b) frameworks SDH-HS relationship were categorized improve “broader social, political, and
that focused on the SDH as either an in- as “Systems” model (six articles). A brief institutional factors” as they act in tan-
put or output of the HS were categorized analysis of articles from each category is dem with environmental factors as HS
as using a “Production” model (seven presented along with their accompany- inputs and outcomes (37–40). Under-
articles); (c) the “Reciprocal” model ing tables: standing this input-output interaction
maintains the separation described in between the SDH and HS is particularly
the Production model, but considered Bounded model critical in evaluation, as the HS itself
the SDH to be simultaneous inputs and may lead to improvements on some
outputs (five articles); (d) articles that Bounded HS frameworks have rigid SDH, but may also exacerbate others
characterized the relationship between borders between the internal functions (7, 37).
the SDH and HS as fluid and interac- and organization of the HS and the ex-
tive were classified as using the “Joint” ternal milieu, such as the SDH (Table 1). Joint model
model (five articles); and (e) articles These frameworks tended to exclude
that acknowledged the Joint model, but activities that were considered outside Some of the literature presented a
moved beyond its components to ad- government control (26). The Bounded more interwoven or joint relationship
between HS and SDH (Table 4). Here
the HS and population, often separated
TABLE 1. The Bounded model of integration between the Social Determinants of Health (SDH)
by arbitrary boundaries, are in balance;
and Health Systems (HS) frameworks, 2012 they drive the structure and outcomes
of each other through their implicit and
Source Review analysis explicit actions (27, 28, 30). In this model,
Londoño and Frenk, 1997 (25) The HS model based on “equity, quality, and efficiency” described in
the relationship between poverty, educa-
this piece can be adapted to context. tion, and empowerment and the HS is
World Health Organization, 2000 (17) The 2000 World Health Report focused on defining the boundaries
explicit, with the SDH driving HS out-
and goals of the HS noting the HS is composed of “all actions whose comes and vice versa (29, 31).
primary intent is to improve health.”
Murray and Frenk, 2000 (26) This article proposed a framework, including boundaries, goals, Systems model
components, and functions of the HS while noting that, in some
cases, for those entities whose “primary intent is to improve or Systems model frameworks (Table 5)
maintain health,” this includes actions in other sectors.
suggest that the interactivity of Joint
Kruk and Freedman, 2008 (24) This article outlined a framework for HS performance assessment models may be mapped and, once
although constrained the extent of this HS reach to include only
mapped, used to drive action (9, 12).
functions under government control.
Systems models focus on characterizing
Rev Panam Salud Publica 34(6), 2013 463Review Russell et al. • Systematic review of the social determinants of health within health systems
TABLE 2. The Production model of integration between the Social Determinants of Health (SDH) models shifted the balance even further
and Health Systems (HS) frameworks, 2012 toward processes by characterizing how
the fluidity among and between the en-
Source Review analysis
vironment, actors, and institutions inter-
Roemer, 1989 (16) This analysis suggested that population health status is the outcome of Health acted to impact health over time.
Services and Biological Status, as determined by the Physical and Social How stakeholders—policymakers, pub-
Environment.
lic health practitioners, health care pro-
Hsiao, 1992 (32) This multi-country analysis of HS designs proposed that financing has particular fessionals, different organizations, and
implications for the HS as it may lead to economic vulnerability and access.
the community—confront the complex,
Roemer, 1993 (35) Examining several different types of designs, this article suggested that any HS international, and interdisciplinary na-
reflects history, economic development, and politics.
ture of the SDH depends intimately on
Unger and Criel, 1995 (36) This article presented guiding ideas for HS design noting that community and how they conceptualize the HS. The five
context are important inputs to the health system particularly at the district level.
models identified in this review offered
Melgaard et al., 1998 (33) This piece suggested that well planned eradication programs in fragile several important conclusions about the
environments can achieve their goals, but that they should consider the critical
impact that the SDH have on the strength of the HS that supports eradication
link between the HS and SDH.
programs. First, many of the articles reviewed
Handler et al., 2001 (13) This article focused on defining the United States HS and its components noting
here suggested that there is strong evi-
that the HS is an “open system” with HS components influenced by the larger dence for not only the relationship be-
context. tween the HS and the SDH, but also for
Mills and Ranson, 2006 (34) This overview covered key international HS types, functions, challenges, and the central importance of acknowledging
trends noting that the HS, a product of its context, should acknowledge the SDH the relationship to achieve action (2, 7, 8,
and distribute health appropriately. 10, 47). Led by the World Health Organi-
zation, the World Bank, and other prom-
inent theorists, the conceptualization of
TABLE 3. The Reciprocal model of integration between the Social Determinants of Health (SDH) this relationship is generally shifting
and Health Systems (HS) frameworks, 2012 from linear models toward systems and
more recently, CAS paradigms. Accord-
Source Review analysis ingly, Joint and Systems models, in cap-
Welton et al., 1997 (39) In this article, the authors proposed a framework for the integration of turing these interactions, appear more
public health and health delivery systems where SDH are both inputs suitable for adoption and widespread
and outcomes of community HS actions use than other models that do not take
Roberts et al., 2004 (38) This health reform guide outlined how the HS is defined by its providers, into account the complex interactions
human and financial inputs, and preventive health activities although between the HS and SDH. The nearly
these are influenced by (and do influence) the SDH. unanimous call for interdisciplinary
Mossialos et al., 2007 (37) The authors proposed that the SDH should be considered in the analysis training and collaboration to understand
of country-level policy as they have wide ranging impact on health and manage these increasingly complex
although this impact may not be included explicitly in the HS framework.
depictions of the HS further reinforces
World Health Organization (WHO), In introducing their “building blocks” approach, WHO suggested that the relevance of frameworks that ac-
2007 (40) SDH impact the burden of disease and HS response while, at times, are
simultaneously important targets for achieving better health.
knowledge this dynamic interface.
Second, as the implementation of the
Pan American Health Organization, This PAHO report examined social protection programs in Latin America
2008 (7) noting that, along with the SDH, these programs impact the interaction with
HS is highly dependent on context (48),
the HS while the HS and protection schemes can in turn impact the SDH. all HS frameworks require some form of
adaptation before they can be success-
fully used to guide policy. An HS frame-
work that adequately takes into account
the relationship between system pro- DISCUSSION the local structure of the SDH may lead
cesses and outcomes. Often referring to to more efficient reform, a better service
the HS as a “Complex Adaptive Sys- Analysis of these 27 articles found that mix, and ultimately, improved health
tem” (CAS), they aim to capture the the relationship between the SDH and the outcomes. Systems principles and tools,
potentially unpredictable ways in which HS could be classified in five categories: discussed elsewhere (41, 49–52), may be
self-organized yet interconnected agents Bounded, Production, Reciprocal, Joint, useful in gaining a thorough conceptual-
may influence each other’s context (18, and Systems models. Bounded models ization of HS-SDH interactions and for
41, 45, 46). Here, while core HS func- rested on clear boundaries between “pri- guiding action.
tions and entities exist, their relationship mary purpose” activities and external Third, while most articles proposed
with the SDH is defined not only by factors. Production models retained the or alluded to categories of SDH, there
contextual factors like disease burden, boundaries, but placed the HS within a was no standardized taxonomy for the
resources, and expectations, but also by larger process where it is influenced by or SDH across the frameworks. While a mix
aspects of this interaction like feedback could influence the SDH. In Joint models, of selection, adaptation, and creation
loops, emergent processes, and influen- SDH were considered as dynamic, con- may be appropriate for all indicators,
tial actors (42, 43). nected components of the HS. Systems in practice, this lack of standardization
464 Rev Panam Salud Publica 34(6), 2013Russell et al. • Systematic review of the social determinants of health within health systems Review
TABLE 4. The Joint model of integration between the Social Determinants of Health (SDH) and consider this relationship. Second, as the
Health Systems (HS) frameworks, 2012 relationship between the SDH and the
HS across multiple HS frameworks has
Source Review analysis
not been previously explored in the HS
Kleczkowski et. al., 1984 (28) This WHO published book suggested that HS includes the components that literature, the groupings that emerged
contribute to health in “homes, communities, and workplaces.” during analysis were intended to guide
Smith and Bryant, 1988 (30) In this paper analyzing the intersection between primary care and disease discussion, but are themselves some-
specific programs, the HS was considered as encompassing the structures what arbitrary. Further analysis may
producing health, the context in which health is achieved and evaluated, and
the community agents who produce this change.
be useful in categorizing these models.
Third, as certain models reflect the ori-
World Bank, 1993 (31) The 1993 World Development Report promoted investment in health as an
essential priority for development noting education, empowerment, and poverty
entation of a particularly influential HS
reduction are prerequisites for and outcomes of better health at the individual model, some of the frameworks pre-
and household level. sented may not truly reflect distinct
Frenk, 1994 (27) This article framed the HS as the relationship between providers, the conceptualizations of the HS as much as
population, state, resource generating organizations, and other health revision or reapplication of an existing
producing sectors arguing for the evolution of the HS and frameworks toward framework. Finally, while the search
more population “inclusive” models.
criteria was as inclusive as possible and
Peters et al., 2009 (29) This catalogue of strategies for health systems strengthening suggested that was supplemented by both a snowball
the HS, both at the micro and macro level is affected by the context, a core
sampling technique and expert input,
component of the HS.
some frameworks may have been unin-
tentionally omitted.
TABLE 5. The Systems model of integration between the Social Determinants of Health (SDH) and Conclusions
Health Systems (HS) frameworks, 2012
Source Review analysis
This systematic review found that
various HS models—classified here as
World Bank, 2007 (18) This strategy report proposed that the HS meets all the criteria of a Bounded, Production, Reciprocal, Joint,
Complex Adaptive System (CAS).
and Systems models—have proposed
Balabanova et al., 2009 (12) This historical analysis detailed how development, function, and expansion relationships between SDH and the HS.
of the HS are dictated by “broader environmental factors” working through
non-linear feedback. Results from this review suggest that,
when preceded by a careful assessment
De Savigny and Adam, 2009 (41) Using a CAS lens to model the HS, this systems thinking report noted that
context has a strong influence on the HS and vice versa. of the interaction between the SDH and
the HS, Joint and Systems models may
Solar and Irwin, 2010 (9) This framework from the Commission on the Social Determinants of Health
placed the HS as a SDH seeing it as one of many factors both impacting be more useful than other frameworks
and impacted by other determinants. in developing a better understanding of
van Olmen et al., 2012 (20); The framework presented in the 2010 working paper and the revision/ the complex interactions between them.
van Olmen et al., 2010 (42) upgrade in the 2012 article offered a view of the HS as components work With a clear, appropriate framework and
together in a “reciprocal and interconnected” CAS fashion. pertinent indicators, policymakers, pub-
lic health practitioners, health care pro-
fessionals, different organizations, and
precludes the comparative analyses that Together, these points suggest that the community will be better equipped
often accompany larger scale efforts like there is a dynamic, context-dependent re- to understand the complex challenges
the MDGs (48). Even when a set of indi- lationship between the SDH and HS that presented by the SDH and guide action
cators was proposed, they often reflected is being overlooked or oversimplified by that results in better health.
Bounded, Production, or Reciprocal some frameworks. When adapted to their
models not the more contemporary Joint context, Joint and Systems models, are Acknowledgments. This study was
or Systems models that appear more likely to afford a higher degree of clarity supported by the Johns Hopkins Bloom-
theoretically relevant. Since indicators with regard to the SDH-HS relationship. berg School of Public Health (Baltimore,
and subsequent benchmarks have, both Combined with pertinent, shared met- Maryland, United States), Brigham
in negative and positive ways, played rics, these frameworks are better suited Young University (Provo, Utah, United
a critical role in larger development to guide effective action on the SDH than States), and the Institute of Tropical
agendas (22), ensuring their accuracy other frameworks reviewed here. Medicine (Antwerp, Belgium), although
and completeness is a top priority. Ac- none of the funding sources influenced
cordingly, as geographic areas such as Study limitations the topic or content of the review in any
Latin America and the Caribbean move way. The authors wish to thank Alicia
forward to address local and global de- This review has several important Pantoja for providing editorial assistance
velopment priorities, identifying a com- limitations. First, while articles were in- with this manuscript. We also thank two
prehensive yet shared set of SDH metrics cluded that discuss both the HS and the anonymous reviewers.
will lead to better guidance and mea- SDH in some respect, it may have not
surement of action. always been the articles’ explicit intent to Conflicts of interest. None.
Rev Panam Salud Publica 34(6), 2013 465Review Russell et al. • Systematic review of the social determinants of health within health systems
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466 Rev Panam Salud Publica 34(6), 2013Russell et al. • Systematic review of the social determinants of health within health systems Review
resumen Objetivo. Examinar y analizar sistemáticamente las diversas maneras en que los
marcos de los sistemas de salud abordan las interacciones con los determinantes
sociales de la salud (DSS), así como las implicaciones de estas interacciones.
Sistemas de salud en su Métodos. En el 2012, se llevó a cabo una revisión de la bibliografía mediante la
contexto: revisión sistemática adopción de criterios predeterminados para consultar tres bases de datos integrales
de la integración de los (PubMed, la Base de Datos Cochrane de Revisiones Sistemáticas y la Biblioteca elec-
trónica del Banco Mundial) y la bibliografía gris, en busca de artículos que incluyeran
determinantes sociales de la cualquier tipo de consideración de los DSS en los marcos de los sistemas de salud.
salud en los marcos de los Se utilizó el muestreo de bola de nieve y la opinión de expertos con objeto de incluir
sistemas de salud cualquier artículo potencialmente pertinente no detectado en la búsqueda inicial. En
total, se encontraron 4 152 documentos; de estos, 27 se incluyeron en el análisis.
Resultados. Se observaron cinco categorías o modelos principales de interacción
entre los sistemas de salud y los DSS: Vinculado, de Producción, Recíproco, Conjunto
y de Sistemas. En un extremo se situaban los modelos Vinculado y de Producción,
que contemplan los DSS como externos al sistema de salud; en el otro extremo, los
modelos Conjunto y de Sistemas, que conciben una interacción continua y dinámica
entre ellos.
Conclusiones. Si se tienen en cuentas las complejas y dinámicas interacciones entre
los diferentes tipos de organizaciones involucradas en y con el sistema de salud, los
modelos Conjunto y de Sistemas parecen reflejar mejor estas interacciones y, en con-
secuencia, son los que deberían guiar a los interesados directos en la planificación de
los cambios.
Palabras clave Política social; equidad en salud; sistemas de salud, tendencias; guías como asunto;
Américas.
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