SOCIAL DETERMINANTS OF HEALTH NETWORK RIF-REDET

1. SOCIAL DETERMINANTS OF HEALTH: • INTRODUCTION • Dr. Eduardo Guerrero Espinel • Facultad Nacional de Salud Publica • Coordinador de la Especializacion en Salud Internacional • Universidad de Antioquia, Medellin, Colombia • APRIL 2012 SOCIAL DETERMINANTS OF HEALTH NETWORK RIF-REDET 1

2. Recognition: Social Determinants of Health Network PAHO/WHO FAO UNICEF OBSAN FNSP-UDEA LIHP 2012 2

3. Presentation Outline • What is the current SDH situation in LAC? • What are the SDH? • How do you act on the SDH? • Recommendations from the CSDH • SDH and PHC • Conclusion

4. The Americas is the region with the greatest inequality in the world with 220 million people living in poverty

5. La Región más Desigual del Mundo The richest ten percent of the population in Latin America earn 48% of the total income, while the poorest tenth percentile of the population earn 1.6%. IN COMPARISON: In industrialized countries, the tenth percentile of the population with the highest income receives 29.1%, while the tenth percentile with the lowest income earns 2.5%. LAC is the most unequal region in the world, with the highest “average Gini coefficient”. The distribution of income, wealth and resources is more polarized than in any other region. Source: UNDP/2007-2008

6. Relationship between Equity, Poverty and Health “The Poverty Trap” The future of a child is determined by the home that he/she is born into, the region, the educational level of his/her parents, their nutrition and his/her initial health status. Schools 20% do not have portable water, 33% do not have enough sanitary facilities, 47% do not have libraries, 63% do not have computer rooms There is a strong statistical correlation between the average GINI coefficient and school performance, therefore… ** Higher inequity means lower school performance 10% of the richest population receive 7 more years of learning than the poorest 30% of the population **The 2009 Serce-UNESCO study Source: UNDP

7. Reducing Inequalities Reducing inequalities in Latin America Constant challenges: • The environment built by society – the case of urbanization and its effect on inequality • Increase in the frequency and intensity of extreme climate events, including disasters and their effect on inequality • Changes in eating habits and the provision of water have an effect on nutritional safety with the potential of increasing inequality • Create opportunities for more participative governance and decision-making

8. Concept of Health • Determined by biological, psychological and social components in dynamic unity with disease. • Result of interaction between individuals and their environment, determining levels of physical, mental and social wellbeing. • Allows for full development of a social, active, and economically productive community. The health of individuals is a necessary condition but not sufficient to promote the process of socio-economic development.

9. Concept of Health(cont.) • Is a condition of each historical development in society. • Health is a fundamental human right and is an invaluable social good. • It is a basic need of every individual Villar & Capote

10. Concept of Health “Health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.” “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.” OtawaCharter Canada, 1986.

11. Determinants of Health Definition: • Factors influencing individual health that interact at different levels of organization to determine the health of the population.

12. What are the Social Determinants of Health? SDH are the circumstances in which people are born, grow, live, work and age, including the health system – resulting from the distribution of income, power and resources They explain health inequities (World Health Organization, 2008)

13. Social Determinants of Health (SDH) BACKGROUND AND CONCEPTS 1970-80s: Criticism of the traditional health approach (risk factors) Creation of the SDH social and structural models 2008: WHO launches report of SDH (goal to reduce health inequities through action on social determinants of health) WHO, 2009: 62nd World Health Assembly considers the CSDH Reportand creates recommendations to governments 2009, 2011: ALAMES supports the CSDH report but has criticism on the stance. Global Meeting SDH, Rio de Janeiro

14. The WHO Commission on the Social Determinants of Health (CSDH) Initially created in 2005 by the late Dr. J. W. Lee, D. G. of the WHO Three years of unprecedented collection of knowledge and data on health inequities and SDH Final report published on August 28, 2008

15. Why pay attention to the Social Determinants of Health? Because they: Have a direct effect on health Allow you to predict the greatest proportion of variability in health status (health inequity) Structure the behaviors related with health Mutually interact with the generation of health

16. FOCUS OF THE SOCIAL DETERMINANTS WHO defines social determinants such as the social conditions in which people live and work.These conditions reflect the differences between people in their social position, power, prestige and resources, and reflects the social hierarchy.

17. Health Promotion • Orientation with a focus in the determinants • Support of national public health policies • Support from CNDSS • Development of healthy settings (cities, schools, residences, workplaces) • Urban health attention in large urban areas • Urban security, violence, green areas, management in the city system • Network of potentially Healthy Municipalities • Healthy Lifestyles (Tabaco, nutrition, physical activity) • Social Participation

18. EQUITY IN HEALTH It is an ethical concept assicoated with principles of social justice and human rights Is equity the same as equality? The equalitarian concept of equity is in terms of how attention is distributed en términos de cómo la atención se distribuye de acuerdo con la necesidad y, se financia de acuerdo con la capacidad de pago(Braverman)

19. EQUITY IN HEALTH Is minimizing avoidable disparities in health and its determinants in care, between groups of people who have different levels of social privilege   (Braverman, Paula), 1998., module 6 REDET Absence of systemic disparities in health between groups with different levels of underlying social advantages / disadvantages                                 (Braveman and Gruskin 2003) According to AmartyaSen, Equality is opportunities ...... Capacity Development Model ...

20. Renovation of Primary Healthcare in the Americas • Challenges for 2015: Achieving the MDGs • The Health Agenda for the Americas Achieving MGDs in 2015 Representación OPS/OMS Chile 2008

21. Renovation of Primary Healthcare in the Americas • Work to identify the strategies to address the structural and intermediate determinants Representación OPS/OMS Chile 2008

22. Alma Ata 1978

23. Alma Ata Conference, 1978 A call for action! “Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?”

24. Primary Health Care • Primary Health Care • Alma Ata Declaration “ Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

25. Renewing PHC through 4 areas for reform

26. The PHC Sun • Core Values, Principles and Elements in a PHC-Based Health System:

27. Millenium Development Goals Improve Maternal Health Eradicate Poverty and hunger Combat HIV/AIDS, Malaria, and other diseases Universay Primary Education Guarantee Environmental Sustainability Gender Equity and Women’s Empowerment Promote a Global Alliance for Development Reduce Infant Mortality

28. Malnutrition in Women and Children • Diseases • Poor food security • Unhealthy Living • Illiteracy • Inadequate health services • Environmental contamination • Unemployment • Family violence • Low production Determinantes • Poverty • Violation of rights • Inequality • Discrimination

29. School-age Preschoolers Infants 6 m to 2 y Infants < 6 m Childbirth and Newborns Pregnant Teenagers • No exclusive breastfeeding • Lack of care and stimulation in the home • Incomplete vaccination • Non-institutional delivery • Childbirth poorly served • Inadequate handling of the Newborn • Incomplete vaccination • Poor and insufficient diet • Parasitic Infections andaccidents • Not Breastfeeding • Inappropriate complementary feeding • Incomplete vaccination • Inadequate attention to disease • Lack of care and stimulation in the home • Poor access and quality of prenatal care • Smoking / alcohol use • Maternal malnutrition / anemia • Domestic Violence • Parasitic infections • Teen Pregnancy • Ignorance of sexual and reproductive health

31. Framework of the main categories and areas of action on the determinants Comisión DSS –OMS Solar e Irwin2005

32. Conceptual Framework Comisión DSS –OMS Solar e Irwin2005

33. International health Conceptual model: LIHP 2009

34. Issues Addressed:

35. “Health equity is an indicator of progress and social justice.” (Technical Secretariat WHO Commission on Social Determinants of Health) Mortality Poor Increasing the gap GAP Wealthy Time . Reunión CG3 Marzo 2007

36. “All men are born equal, but that is the last time this is so” (Abraham Lincoln)

38. Action on the social determinants of health Recommendations from the commission:

39. To maximize the contributions of the focus on sustainable health environments, it will be necessary to refocus our work towards recognizing and facing the challenges of the current globalized world

41. 1. Improve living conditions • Improve the wellbeing of girls and women and the circumstances in which children are born • Management of urban development • Ensure that urban planning promotes healthy and safe behaviors according to equity criteria • Ensure that policies regarding climate change take into account health equity.

42. 1. Improve living conditions (2)_ • Make full and fair employment along with decent work a central element in policy formulation and development strategies • Help from international organizations for countries to protect their workers • Progressively improve social protection systems • Create quality health systems with universal coverage and centered on primary health care

43. 2. Fight against the unequal distribution of power, money and resources (1) • Place responsibility for action on health and health equity at the highest level of government • Create a coherent set of social determinants of health, focusing on the Poverty Reduction Strategy Papers • Institutionalize the consideration of health consequences and health equity of national and international economic agreements and the formulation of policies • Reinforce the fundamental role of the State in the provision of essential basic services for health and the regulation of goods and services with important consequences for health

44. 2. Fight against the unequal distribution of power, money and resources (2) • Approve and apply laws that promote gender equity • Increase the investment in sexual and reproductive health services and programs, with universal coverage and the respect of rights • Ensure the representation and participation of individuals and communities in decision-making related to health • Enable civil society to organize and act in a manner that promotes and respects their political and social rights affecting health equity. • Make health equity a global development goal

45. 3. Evaluate and analyze the problem and conduct impact assessments • Ensure that routine monitoring systems of health equity and the social determinants of health are in place, locally, nationally and internationally • Invest in generating and sharing new data on the social determinants of health and the effectiveness of the implemented measures • Train policy actors, stakeholders and health professionals on the social determinants of health, and invest in raising public awareness

46. SDH and PHC • Many elements in common • Different relationships with the health systems and the broader context • Synergies

47. Conclusion

48. "The same humanity able to send instruments to Mars to study the composition of its rocks witnesses indifferently the deaths of millions from hunger José Saramago. Nobel Prize in Literature

49. The End THANK YOU