Social Determinants of Health in the Eastern Mediterranean Region

1. Social Determinants of Health in the Eastern Mediterranean Region S. J. Watts Health Policy and Planning Capacity Building Workshop on Health System Development, Alexandria, June 8-12, 2008

2. Outline of presentation • Define SDH and identify major themes • Identify stages in developing policy and interventions • Identify some SDs responsible for poor health outcomes in EMR • Examples of action on SDH • Sources of information

3. Define SDH and identify major themes

4. Definitions “The social determinants of health refer to both specific features and pathways by which societal conditions affect health and that potentially can be altered by informed action.” Source: Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700

5. Definitions “the fundamental structures of social hierarchy and the socially determined conditions these structures create in which people grow, live, work and age” Source: Interim Report, CSDH, 2007.

6. Two kinds of social determinants: - structural – “fundamental structures of social hierarchy” - intermediate - “socially determined conditions these structures create in which people grow, live work and age” Both have an impact on health outcomes and the opportunities people have to enjoy good health. Both need to be addressed.

7. Themes addressed through SDH • Health systems as social determinants that can promote or prevent good health. • Community Based Initiatives, especially Basic Development Needs, as a mechanism for addressing SDH in the community

8. Themes addressed through SDH Health equity • The absence of systematic disparities in health (or its social determinants) between more or less advantaged groups, or geographical areas. The right to health • “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”(WHO Constitution 1946).

9. Identify stages in developing policy and interventions

10. From knowledge to action • Building a knowledge base that can be used for advocacy, policy making and action • Advocating the inclusion of SDH in national policies and programmes • Improving health systems and providing equitable (fair) financing • Fostering intersectoral collaboration • Expanding partnerships with stakeholders: civil society, academia, media etc.

11. Building a knowledge base that can be used for advocacy, policy making and action.

12. Building a knowledge base In EMR there has been limited research on the pathways through which social determinants affect health outcomes. Such information needs to be collected and collated so that it can be used to guide policy. In order to address SDH need to identify: • priority social determinants related to poor health outcomes, and the pathways through which they impact health • and/or those SDs associated with the greatest inequalities/inequities in health outcomes.

13. Poverty is an underlying cause of ill-health. The Commission on SDH is concerned with the social determinants related to poverty and marginalization and how these can be influenced in ways that promote health equity. The emphasis therefore is on social groups who share certain characteristics rather than on individuals.

14. Health systems as social determinants of health • Inequitable health systems, which do not provide equitable access: • Geographical access - distance • Economic access - barriers of cost • Cultural and social access • Inadequate, or inappropriate services • Barriers for certain groups, women etc. • Providers do not deal with all patients/clients fairly, equally.

15. Health systems as social determinants of health Fair financing: • Inequalities in distribution of funding for services • Unfair burden of out of pocket expenses. The inverse care law – the affluent get more care than the poor – yet the poor are sicker and therefore need more care. Provision should be according to need.

16. Women and gender equity • Discrimination and low status at all stages in the life cycle limit women’s contribution to the health and well-being of their family and community, as well as their own health • Relevant issues include: • Improving women’s access to health care • Education/literacy for girls and women • Employment and social protection for women • Female genital mutilation

17. Early Child Development • Early childhood development means providing optimum conditions for children to realize their potential and to enjoy good health throughout life. • Relevant issues include ensuring: • A nurturant environment for children, that supports their physical, mental, social and developmental wellbeing • Security and freedom from violence • Support to families to enable them to provide what their children need to develop into healthy adults; to send children to school; to prevent children working or leaving home to live on the street.

18. Social exclusion A mechanism originating in attitudes (stigma) and practices (discrimination) that adversely affect the lives of certain social groups: • Occupational groups, such as garbage collectors • Groups excluded on the basis of social identity, religion, ethnicity or language • People with disability • People with mental health disorders or substance addiction • People living with HIV/AIDS, HCV, breast cancer etc.

19. Socially determined lifestyles and behaviour • These include smoking, nutrition problems, and road accidents, which have a greater effect on the health of the disadvantaged. • They are often portrayed as “life style choices”, but they are strongly influenced by peer groups, social norms; study of qat among women and children in Yemen. • The disadvantaged have little choice in lifestyle matters. • These are social issues, as much, if not more than, “individual choices”.

20. Employment conditions • Informal sector employment, which usually provides limited or no social protection, and unemployment are major social determinants that have an adverse impact on physical and mental health.

21. Urbanization • Residents of constantly expanding, unplanned housing areas, with poor access to health and social services and poor living conditions are likely to suffer disproportionately from poor health due to: • Overcrowding • Malnutrition • Social stress

22. Migration • Lack of health rights and access to health services for citizens and non-citizen migrant workers, moving within and beyond national borders, are a concern for all countries of the region. A key to approaching these issues is the recognition that a healthy work force is an efficient workforce.

23. Environmental conditions In EMR environmental conditions are social determinants of health as they affect social behaviour and differentially affect the life chances of various social groups: • Lack of access to safe water and sanitation • Overall water scarcity in EMR, for agriculture, domestic use etc.

24. Environmental conditions • Air pollution • Unsafe working conditions • Climate change, has the most serious impact on the disadvantaged, fewer options/choices to maintain health and wellbeing.

25. Conflict and post-conflict emergencies • Conflict and its consequences destroy health and other infrastructure, cause death and destruction, loss of human rights and widespread mental health problems. • EMRO collaborated with regional civil society facilitator organization, and CSOs in conflict affected countries to document the grass roots impact of conflict on health and wellbeing; • EMRO commissioned a study of SDH in Occupied Palestinian Territories, and the mental health of children and women in Gaza.

26. Examples of action on SDH

27. Action on SDH Actions on country and local levels can include: • Advocating the inclusion of social determinants of health in national policies and programmes • Making health systems and health financing more equitable • Fostering intersectoral collaboration • Expanding partnerships with stakeholders

28. Intersectoral action for health (IAH) “a recognized relationship between part or parts of the health sector with part or parts of another sector which has been formed to take action on an issue to achieve health outcomes (or intermediate health outcomes) in a way that is more effective, efficient or sustainable than could be achieved by the health sector, acting alone” (WHO 1997). Process begun through ministries of health in Sudan and Yemen, and planned for others this biennium. Iran as a CSDH “partner country”

29. Intersectoral action on SHD - Sudan An informal task force consisting of members from various health sectors, other government sectors - including water, education, planning, and child welfare and women’s affairs, and an NGO - held five weekly meetings between 3 February and 10 March 2008. Members conducted a stakeholder analysis, identifying organizations and issues prioritized according to potential impact and priority.

30. Intersectoral action on SHD - Sudan The task force identified SDH for priority action, in three clusters: • women’s empowerment and access to health care • water, sanitation and hygiene promotion • social exclusion and education.

31. Intersectoral action on SHD - Sudan Outcomes of action: including SDH in national policies and programmes: • Advocated for IAH within the National Health Coordination Committee, and for an integrated approach for the social sector chapter in the current PRSP. • Contributed to adding an additional clause on IAH to the Public Health Act, 2008. The act was endorsed by the Cabinet, and is now waiting for adoption by the Parliament.

32. Intersectoral action on SHD - Yemen • A discussion paper on SDH and health inequities in Yemen concluded that the main social determinants of health are poverty and its consequences; female education; and discrepancies between rural and urban areas. • Working through the highest levels of the Ministry, and in collaboration with the director of the Health Policy Unit, invitations, under the signature of the Minister of Health, were sent to ten related sectors, NGOs and media to attend a first meeting for familiarization with IAH issues.

33. Intersectoral action on SHD - Yemen A second meeting, 22 March 2008, recommended to increase awareness and activities in IAH through: • workshops to identify further activities and conduct a stakeholder analysis • coordination with administrative authorities of related sectors at the level of governor and districts • learning from lessons and experiences regionally and internationally • translation, printing and dissemination of documents on SDH and IAH in Yemen.

34. Intersectoral action on SHD - Yemen This meeting made recommendations to operationalize IAH, and ensure sustainability including: • MoPHP to lead advocacy for IAH to tackle SDH through a focal point in the Health Policy Unit • An IAH team should be established to develop strategies and an implementation plan, and to follow up the implementation at both central and peripheral levels • A Memorandum of Understanding should be signed between MoPHP and related sectors.

35. Iran as a WHO partner country • Commitment to health as a human right and health equity • Established an SDH Secretariat within MoH&ME to coordinate SDH activities: research and dissemination, advocacy, IAH and collaboration with stakeholders • IAH on traffic accidents, major burden of disease • Preparation of SDH situation analysis • Currently working on a National Strategy for SDH

36. Partnership with stakeholders • Civil society continuing work with regional facilitator organization on SDH, Association for Health and Development (AHED); beginning a pilot a community study to identify and tackle SDH in Hagana, a disadvantaged area of Cairo.

37. Partnership with stakeholders • Academia – continuing work with Social Research Center, American University in Cairo, on SDH and health equity; • Workshops on SDH and health equity issues • Identify measures of health equity.

38. Partnership with stakeholders • Community Based Initiatives, including Basic Development Needs, addresses SDH on the local level through intersectoral action and involving communities in identifying needs, and solutions that will improve health, as a bottom up approach. An EMRO initiative that is being institutionalized in various countries in EMR. • A CBI site, Ariana, Tunisia, for pilot project to tackle health issues through a social determinants approach.

39. Sources Two EMRO Regional Papers are almost ready: Building a knowledge base: a review of seven countries in the Eastern Mediterranean Region. (Egypt, Jordan, Iran, Morocco, Oman, Occupied Palestinian Territories, Pakistan) The Social Determinants of Health in countries in conflict in the Eastern Mediterranean Region. (Afghanistan, Iraq, Lebanon, Occupied Palestinian Territories, Somalia, Sudan)

40. Commission Website http://www.who.int/social_determinants/resources/latest_public ations/en/index.html • Knowledge network reports • Tackling social determinants of health through community based initiatives. Assai M et al. BMJ, 21 October, 2006. • Health equity through intersectoral actions: an analysis of 18 country case studies • Interim Statement of the Commission on Social Determinants of Health 2007.

41. Regional Health Systems Observatory http://gis.emro.who.int/healthsystemobservatory/main/Forms/main.aspx Research, publications: EMR Policy Brief: Tackling health inequities through action on the social determinants of Health. In English and French. Achieving health equity: from root causes to fair outcomes: CSDH Interim Statement, 2007.

42. For more information please contact: wattss@emro.who.int or php@emro.who.int EMRO is here to help countries develop strategies to tackle social determinants of health.