The Social Determinants of Health in EMR: Working towards Regional and Country Policies

1. The Social Determinants of Health in EMR:Working towards Regional and Country Policies WHO Eastern Mediterranean Region Capacity Development Workshop on Health System Development Alexandria, Egypt 20-24 May 2007

2. Why the social determinants of health? SDH emphasize the PHC approach Recent concern has been encouraged by the WHO Commission on the Social Determinants of Health. This presentation will identify priority SDH in the Region and relate the SDH and health equity agenda to regional and country policies, and to health systems.

3. The Social Determinants of Health 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 Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700

4. The core problem Throughout the world, people who are vulnerable and socially disadvantaged have less access to health resources, get sicker, and die earlier than people in more privileged social positions�Health gaps are growing. Irwin A. et al. The Commission on Social Determinants of Health: Tackling the social roots of health inequities. PLoS Medicine 2006; 3 (6), e 106.

5. Social determinants of high maternal mortality Proximal determinants Low level of mothers� education Lack of decision making power among women Cultural norms which encourage women to downplay their health problems Poor quality health services Distal determinants Poverty Lack of national resources for health care Lack of concern for the status of women on the part of governing elites National and global failure to prioritize RH

7. Health equity The absence of systematic disparities in health (or its determinants) between more and less advantaged social groups Certain differences are unfair and unjust WHO has declared that health is a human right Therefore health actions should be directed, at least in part, towards eliminating inequities in health

8. Health Systems, Programs, Determinants: Interrelationships

10. WHO Commission on the Social Determinants of Health (CSDH) Launched March 2005 to: Identify and tackle persistent health inequities experienced by socially disadvantaged and marginalized populations Draw attention to the importance of the social causes of illhealth and to inequalities in health at the global, national and subnational levels Revisit Health for All and the Alma Ata Declaration, 1978, and Primary Health Care as a mechanism for providing universal health care

11. CSDH activities include: Knowledge Networks: to synthesize the knowledge base for the various SDH and provide examples of best practice Working with civil society Country level work Preparation of a final report by the Commission

12. Work of EMROIdentification of priority SDH: working towards a knowledge base Gender issues and women�s enablement: Improving access to health care for women Education/literacy for girls and women Employment and social protection Female genital mutilation as a gender and health issue in some countries of EMR Child labour and street children: the causes originate in poverty and its corrosive effects on family life

13. Priority SDH in EMR cont. Migrant workers: concerns about health rights and limited access to health services Social exclusion Low status occupational groups The disabled Groups with a sexual orientation labeled as deviant Groups excluded on the basis of religion, ethnicity or language Those with stigmatized diseases or conditions: the mentally ill, those with HIV/AIDS, TB, cancer etc.

15. Priority SDH in EMR cont. Inequitable health systems as a barrier to health care: Scarce resources or a low national priority for health National health policies that fail to prioritize health equity Maldistribution of facilities and/or funding Socially determined life styles and behaviors (the disadvantaged have fewer choices than the more advantaged) Smoking Nutrition related problems: obesity and lack of adequate nutrition among the disadvantaged Traffic accidents

16. Priority SDH in EMR cont. Conflicts and emergencies: loss of human rights is the major underlying social determinant, involving: Lack of security, living daily in fear Displacement from �home� and the familiar Loss of social networks and family structures Loss of livelihood: daily activity, access to land, employment etc. resulting in extreme poverty Food insecurity due to lack of livelihood Lack of shelter, services etc. necessary to live in dignity Shelter: a plastic sheet or the shade of a tree Lack of clean water and safe sanitation Lack of essential health and other services Lack of communications: isolation

17. Conflict: Palestinian checkpoints Photo here

19. For EMRO the following SDH policy areas have been identified: Developing a regional perspective on SDH, based on solid local evidence Identifying �best practices� to tackle SDH Improving health systems and financing to increase fairness Advocating for inclusion of SDH in all national policies and programs Implementing/facilitating interventions on the ground Expanding partnerships with stakeholders in the Region

20. EMRO activities so far:Improving the knowledge base A regional discussion paper on SDH Papers on the knowledge base in: Egypt, Iran, Jordan, Morocco, Oman, Pakistan and Palestine Publication of paper in The British Medical Journal Policy brief: Tackling health inequities through action on the social determinants of health Paper on conflict and SDH in EMR, for CSDH

21. Egypt: the country study identified the following SDH Child labor Poverty is the main cause of child labor 21% of children aged 6-14 work at some time during the year, most of them in rural areas 25% of working children had injuries at work 4% of the injured suffered long-term problems Gender issues: Female-headed households 22% households were headed by females of whom 83% were illiterate (compared to national figure of 50%) Expenditure and income levels for these households were predominantly in the poorest two quintiles.

23. Jordan: the country study identified the following SDH Gender and employment issues Women have had the right to vote and contest elections since 1974 Women�s participation in the formal labor force grew from 15% to 24% between 1980 and 2002. BUT average unemployment rates among women were 25%, compared to 15% for men

24. Islamic Republic of Iran: current collaboration between EMRO, WHO HQ, country office and MoHME Preparation of an updated, revised situation analysis of SDH in IRI, as a basis for future collaboration in the preparation of a strategic plan for tackling SDH and health equity. This collaboration supports work in IRI, identified by Geneva as a �champion� country in the Region for SDH and health equity.

25. For country action, request from EMRO: Support to: Generate information on SD and the pathways through which they influence health Promote intersectoral collaboration, for example by establishing a formal body with responsibility to forward the SDH and health equity agenda across government sectors, with civil society and private partners Develop a national strategy for SDH

26. For further information see: Regional Observatory: papers and data on SDH http://www.who.int/social_determinants/en/