What enables and constrains the inclusion of the social determinants of health inequities in government policy agendas? A narrative review

Background: 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? Methods: 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. Results: 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. Conclusion: 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.