COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

RAHUL KANKANE 08DDCS458 ICFAI UNIVERSITY

AN ANALOGY: CSDH INCREASING NETWORK CONNECTIONS

March 2005 July 2006
Wiring of the brain in childhood: At Birth 6 Years Old

Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

At Birth

6 Years Old

14 Years Old

Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

STRUCTURE OF PRESENTATION
KEY MESSAGES CORE VALUES AND GOALS STRUCTURE OF COMMISSION KEY ISSUES

Health is not only (primarily?) a matter of medical care Social and political circumstances affect life and well-being and, hence, health wellTherefore all policies should be framed with regard to their effect on health and health inequity. Major unsolved problems of inequalities in health among and within countries.

Policy Approach
Early life development and education
Including comprehensive primary care

People of working age

Working and living conditions

Economic and social conditions of older people

Principles of Action 1
Ministry of Health must think broader than health sector Other ministries and organizations should consider equity and health impacts Therefore, the process needs leadership from the top

Principles of Action 2
Action should be based on evidence and expert advice

Principles of Action 3
System of measurement for health equity Targets: determinants and outcomes Evaluation framework

STRUCTURE OF PRESENTATION
KEY MESSAGES CORE VALUES AND GOALS STRUCTURE OF COMMISSION KEY ISSUES

Equity and Core values for CSDH

Health equity:
"the absence of unfair and avoidable or remediable differences in
health among groups defined socially, economically, demographically or geographically"

within countries between countries

Governments accountable Tackling health inequities requires action on SDH

CSDH: Knowledge for action

The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change aiming toward practical uptake among policymakers and stakeholders in countries.
WHO Director-General LEE JongWook, address to the World Health Assembly, May 2004

STRUCTURE OF PRESENTATION
KEY MESSAGES CORE VALUES AND GOALS STRUCTURE OF COMMISSION KEY ISSUES

CSDH

Commissioners Knowledge Networks Country Work Civil Society Work Global Initiative WHO Reference Group

COMMISSIONER MEETINGS
CHILE March 2005 CAIRO May 2005 INDIA September 2005 IRAN Jan 2006 KENYA June 2006

Knowledge Networks

Knowledge network priority themes

Women/ gender
Priority Public Health Conditions

Measurement / Evidence

Health Systems

Health Equity

Early Child Development

Globalization Employment Conditions Social Exclusion

Urban Settings

Country Work

Country Work
To facilitate and strengthen action across government to systematically tackle the socially determined causes of health inequities

Three strands of Country Work

1.

Within country, ex.:

creating space for dialogue e.g Iran influencing national resources and investments e.g. Canada

2. Between countries, ex.:

exchanging and sharing know-how knowtraining support

3. Global / international, ex.:

identifying the way that global/international institutions are enabling / disabling country action

AMRO / PAHO Chile (Formal Partner) Brasil (Formal Partner) Canada (Formal Partner) Bolivia (Formal Partner) Peru (Formal (Formal Partner) Nicaragua (Exploring)

EURO Sweden (Formal Partner) England (Formal (Formal Partner) Kyrgyzstan (Formal Partner) Norway (Exploring)

EMRO Iran (Formal Partner) (Formal Exploring with regional office SEARO India (Exploring) SriSri-Lanka (Formal Partner)

AFRO Kenya (Formal Partner) Senegal (Exploring) (Exploring) Mozambique (Sending Letter Exploring) Malawi (Exploring) Tanzania (Exploring) Zambia (Exploring) WPRO Mongolia (Exploring) New Zealand (Exploring)

Brazilian Commission on Social Determinants of Health set up in March 2006 Kenyan Government planning to set up a Kenyan Commission on Social Determinants of Health

Regional activities
Nordic group Asian group Latin American regional meeting in Rio

Civil Society Work

Civil Society Work

Evidence Advocacy Sustainability

Civil Society Work

Regional Civil Society Facilitators
Africa, Asia (incl. People's Health Movement India), Eastern Mediterranean, Latin America and Caribbean

Regional Meeting National Meeting Next National Meeting Country Participants

Update Regional and Regional activities

Latin America: Progress

200 regional and national leaders and 100 social organizations engaged in 10 countries of the region. Advocacy with national governments (Venezuela, Bolivia and Uruguay) and local governments (Bogot) (Bogot Plans for discussion and dissemination on SDH in major regional and global fora in coming months: 3rd National Health Conference in Peru; World Public Health Congress in Brazil; and National Convention of ALAMES in Mexico.

Extending the reach of civil society in Country Work: the case of Bogot
November 2005: During visit of Commissioner G. Berlinguer to Colombia, Latin America CSF arranges for Dr Berlinguer to meet with Secretary of Health, Bogot. April 2006: Based on CSF and Commissioner mediation, Bogot submits formal letter of interest in CSDH via PAHO Country Office. Government of Colombia not responsive to CSDH, but city of Bogot engaged through CSF and Commissioner collaboration.

Global Initiative

STRUCTURE OF PRESENTATION
KEY MESSAGES CORE VALUES AND GOALS STRUCTURE OF COMMISSION KEY ISSUES

INTEGRATION OF WORK STREAMS

How? examples:
1. Civil society representatives included as KN members direct representation linkage to other and wider CS networks, incl. country and regional level 2. Build links with Reference Groups established by regional civil society: importance of context, generalizabiilty of evidence

Building Knowledge: Additional Key Issues

Themes that are not addressed as KN Raised at Commissioner Meetings and other CSDH fora including KNs and Civil Society Including: violence, aging, alcohol, SD in medical education Discussion papers, via Secretariat (e.g. violence), key experts (e.g. aging)

CHALLENGES
WHAT ABOUT HEALTH SYSTEMS? TOO DIFFUSE? GOOD INTENTIONS DONT ALWAYS ENSURE GOOD RESULTS

KEY ISSUES
IMPORTANCE OF HEALTH SERVICES IN THE CONTEXT OF SOCIAL DETERMINANTS OF HEALTH BOTH HEALTH SERVICES AND WIDER DETERMINANTS

Why are poorer populations

Two times more likely to have TB? Three times less likely to access care for TB? Four times less likely to complete TB treatment? Five (?) times more likely to incur impoverishing payments for TB care?
WHO

HEALTH SERVICES AND SOCIAL DETERMINANTS

HIV
By the end of 2005 1.3 million people in low and middle income countries were receiving access to anti retroviral therapy In Sub-Saharan Africa in 2005, an estimated 3.2 Submillion people became newly infected

(Source: UNAIDS)

SWAZILAND
HIGHEST PREVALENCE RATE OF HIV IN THE WORLD: 42.6% PREGNANT WOMEN BETWEEN AGES 25 AND 29: PREVALENCE RATE: 56.3%

UN Press briefing by Stephen Lewis, March 2006

HIV IN AFRICA
Stephen Lewis: We are dealing with a legacy of inequality that drives the virus and leads to the devastation of the women and girls of the continent.

SOCIAL DETERMINANTS
Anti retroviral therapy hampered by lack of human resource capacity Gender inequality womens vulnerability:
Rape and sexual violence Early and forced marriage Lack of educational access Lack of economic and learning power Lack of rights to own and inherit land or property

the pandemic of AIDS, the escalating violence against women, the contagion of conflict and rape, the absence of empowerment, the lack of legislation on equality

Stephen Lewis

BUSINESS AS USUAL
THE BETTER OFF DO BETTER THAN THE WORSE OFF

DISTRIBUTION OF BENEFITS FROM GOVERNMENT SPENDING ON HEALTH, 21 COUNTRIES

Filmer 2003 in Gwatkin et al. Reaching the Poor, 2005

EXPENDITURE ON MEDICAL CARE PER CAPITA IN US AND UK

UNITED STATES:

US$ 5274

UNITED KINGDOM:

US$ 2164 (adjusted for purchasing power)

(Human Development Report 2005)

DIABETES AND HYPERTENSION (CLINICAL REPORTS) BY INCOME, AGES 40 -70

Diabetes* England
% Prevalence

US

Hypertension**
45 40 35 30 25 20 15 10 5 0

England

US

12 10 8 6 4 2 0

ed iu m

ed iu m

ig h

Lo w

ig h

ow L

A ll

* HBA1c >6.5%

**BP greater than or equal to 140/90 on medication

(Source: Banks, Marmot, Oldfield & Smith, JAMA, 295: 2037-2045, 2006)

A ll

SelfSelf-employed Womens Association (SEWA), Gujarat, India

Source: SEWA Report to WHO Conference 2000

The Programme
The Self-Employed Woman's Association (SEWA) Selfseeks to improve the health of women workers in the unorganized sector. Using the association's funds, SEWA has developed a comprehensive health plan that links economic empowerment, organising and holistic health promotion.

Interventions
SEWAs health approach includes health education, immunisations, sanitation activities, family planning, drug therapy and referrals, occupational health care, promotion of low cost traditional medicines and creating health centres. SEWA's team of 200 mid-wives and health workers serve as midhealth educators-cum-barefoot doctors for 75,000 women educators-cumworkers. The SEWA Bank has 125,000 depositors and a working capital of over Rs 300 million (over US$7 million). SEWA has promoted more than 1500 small self-help groups, selfcoco-operatives and district level associations of women in India and abroad.

Impact
An increase in health awareness among women and their families including alcohol and "gutkha" (a tobacco product) In 1998, SEWA's services resulted in
no maternal deaths reported, no measles deaths in children, 65% reported savings due to the low cost drug distribution system .

QUANTIFYING RESULTS:
WHAT IS THE COST OF AN INTERVENTION? WHAT ARE THE HEALTH BENEFITS?

Transport Interventions for Public Health

Source: Morrison et al (JECH 2003)

Systematic Review
To review the evidence on effectiveness of transport interventions in improving population health

Select findings
Motorcycle helmet legislation 30% reduction in fatalities Area wide traffic calming 15% reduction in accidents Fatal accidents reduced by 65% as a result of public lighting