Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks

OBJECTIVE: To systematically review and analyze various ways that health systems frameworks 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 criteria 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 consideration 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.