Theory of Change for Integrating Social Determinants of Health into Education, Training and Service Delivery

The project works with partner countries and local stakeholders to reduce financial barriers to care and treatment, ensure equitable access to essential health services for all people, and improve the quality of health services. The project is led by Abt Associates and has a five-year budget of $209 million. The social determinants of health (SDoH) play a significant role in driving health inequalities and impacting the health, wellbeing, and economic productivity of populations. The distribution of money, power, and resources, influenced by policy choices at global, national, and local levels, shapes the circumstances in which people are born, grow, live, work, and age. Socially stratifying forces, such as place of residence, race, ethnicity, culture, language, occupation, gender, religion, education, and socioeconomic status, drive inequities across populations for incidence of disease, health outcomes, and access to healthcare. The health workforce plays a key role in mitigating the effects of SDoH. Evidence suggests that not only do SDoH affect access to care, but the quality-of-care patients receive. To deliver relevant quality care effectively and equitably, the workforce, including health professionals, planners, and health managers, must understand the complex factors and SDoH that impact patients and communities and possess competencies aimed at reducing their effect. The LHSS project's Core Activity 10 seeks to identify, analyze, and document examples of successful efforts in integrating SDoH into health workforce education, training, and service delivery for improved quality of care and equity in health outcomes. A scoping review conducted as part of this activity revealed thousands of articles, documents, and reports highlighting the importance and impact of SDoH and calling for addressing them at policy and community levels in both low- and middle-income countries (LMICs) and high-income countries (HIC). However, available literature reflects the lack of integrated approaches to addressing SDoH and the dearth of implementation research and systematic assessment of the impact of SDoH interventions on clinical practice and patient outcomes. The current body of knowledge on health workforce education and SDoH comes from HIC and tends to focus on describing specific courses and learning outcomes but is limited in terms of information about downstream impacts related to the effect on clinical practice, quality of care, and equity outcomes. Despite these limitations, there are examples from LMICs where an understanding of SDoH has informed both institutional and instructional strategies and the curricular content of health workforce education institutions. Evaluation of the impact of such institutions that employ strategies often associated with social accountability suggests that integrated SDoH-informed strategies can improve the relevance and quality of care and reduce health inequities. A Theory of Change (ToC) is a useful tool for developing interventions to address and mitigate the effect of SDoH on health. It helps stakeholders explore causal pathways to change and identify necessary inputs, outputs, outcomes, and conditions needed to achieve specific goals. Addressing SDoH is highly context-driven, and each institution, community, region, or country will need to adapt their ToC, strategies, and stakeholder engagement to their local context. The ToC presented here focuses on interventions related to building the capacity of the health workforce to address or mitigate the effect of SDoH. The ToC elements and assumptions are based on currently available resources and experiences and should only be seen as a starting point for stakeholder discussions that need to take place in each setting. The goal of integrating SDoH into education, training, and service delivery is to empower workers and leaders at all levels of the health system to collaborate with stakeholders and integrate action on SDoH into health programs and the provision of care. This could range from advocating for policies that impact health across other sectors to educating service providers on the social and economic factors that may affect patients' vulnerability and exposure to risk and their behavior, response to treatment plans, medication adherence, or ability to follow sanitary requirements. The ToC presented here is centered on the people that interventions seek to affect, namely communities and patients, particularly those most vulnerable to the negative effects of SDoH. The ToC aims to identify necessary inputs, outputs, outcomes, and conditions needed to achieve specific goals, including building the capacity of the health workforce to address or mitigate the effect of SDoH.