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COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

COMMISSION ON SOCIAL DETERMINANTS OF HEALTH. Sir Michael Marmot Chair of the Commission on Social Determinants of Health. AN ANALOGY: CSDH INCREASING NETWORK CONNECTIONS. March 2005. July 2006. Wiring of the brain in childhood:. At Birth. 6 Years Old.

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COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

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  1. COMMISSION ON SOCIAL DETERMINANTS OF HEALTH Sir Michael Marmot Chair of the Commission on Social Determinants of Health

  2. 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.

  3. At Birth 6 Years Old 14 Years Old Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

  4. STRUCTURE OF PRESENTATION • KEY MESSAGES • CORE VALUES AND GOALS • STRUCTURE OF COMMISSION • KEY ISSUES

  5. Health is not only (primarily?) a matter of medical care Social and political circumstances affect life and well-being and, hence, health Therefore 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.

  6. 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

  7. 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

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

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

  10. STRUCTURE OF PRESENTATION • KEY MESSAGES • CORE VALUES AND GOALS • STRUCTURE OF COMMISSION • KEY ISSUES

  11. Equity and Core values for CSDH • Health equity: • "the absence of unfair and avoidableor 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

  12. 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 Jong-Wook, address to the World Health Assembly, May 2004

  13. STRUCTURE OF PRESENTATION • KEY MESSAGES • CORE VALUES AND GOALS • STRUCTURE OF COMMISSION • KEY ISSUES

  14. CSDH • Commissioners • Knowledge Networks • Country Work • Civil Society Work • Global Initiative • WHO Reference Group

  15. COMMISSIONER MEETINGS • CHILE – March 2005 • CAIRO – May 2005 • INDIA – September 2005 • IRAN – Jan 2006 • KENYA – June 2006

  16. Knowledge Networks

  17. Knowledge network priority themes Women/ gender Measurement / Evidence Priority Public Health Conditions Health Systems Early Child Development Health Equity Globalization Urban Settings Employment Conditions Social Exclusion

  18. Country Work

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

  20. Three strands of Country Work • 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 • training support 3. Global / international, ex.: • identifying the way that global/international institutions are enabling / disabling country action

  21. EURO • Sweden (Formal Partner) • England (Formal Partner) • Kyrgyzstan(Formal Partner) • Norway (Exploring) AFRO • Kenya(Formal Partner) • Senegal (Exploring) • Mozambique (Sending Letter - Exploring) • Malawi (Exploring) • Tanzania (Exploring) • Zambia (Exploring) WPRO • Mongolia (Exploring) • New Zealand (Exploring) AMRO / PAHO • Chile(Formal Partner) • Brasil (Formal Partner) • Canada (Formal Partner) • Bolivia (Formal Partner) • Peru (Formal Partner) • Nicaragua (Exploring) EMRO • Iran (Formal Partner) • Exploring with regional office SEARO • India (Exploring) • Sri-Lanka (Formal Partner)

  22. 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

  23. Regional activities • Nordic group • Asian group • Latin American regional meeting in Rio

  24. Civil Society Work

  25. Civil Society Work • Evidence • Advocacy • Sustainability

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

  27. Update Regional and Regional activities Regional Meeting National Meeting Next National Meeting Country Participants

  28. 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 (Bogotá) • 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.

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

  30. Global Initiative

  31. STRUCTURE OF PRESENTATION • KEY MESSAGES • CORE VALUES AND GOALS • STRUCTURE OF COMMISSION • KEY ISSUES

  32. INTEGRATION OF WORK STREAMS

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

  34. 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)

  35. CHALLENGES • WHAT ABOUT HEALTH SYSTEMS? • TOO DIFFUSE? • GOOD INTENTIONS DON’T ALWAYS ENSURE GOOD RESULTS

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

  37. 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

  38. HEALTH SERVICES AND SOCIAL DETERMINANTS

  39. 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 million people became newly infected (Source: UNAIDS)

  40. 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

  41. 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.”

  42. SOCIAL DETERMINANTS • Anti retroviral therapy hampered by lack of human resource capacity • Gender inequality – women’s 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

  43. …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

  44. BUSINESS AS USUAL • THE BETTER OFF DO BETTER THAN THE WORSE OFF

  45. DISTRIBUTION OF BENEFITS FROM GOVERNMENT SPENDING ON HEALTH, 21 COUNTRIES Filmer 2003 in Gwatkin et al. Reaching the Poor, 2005

  46. 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)

  47. DIABETES AND HYPERTENSION (CLINICAL REPORTS) BY INCOME, AGES 40 -70 Diabetes* Hypertension** % Prevalence **BP greater than or equal to 140/90 on medication * HBA1c >6.5% (Source: Banks, Marmot, Oldfield & Smith, JAMA, 295: 2037-2045, 2006)

  48. Self-employed Women’s Association (SEWA), Gujarat, India Source: SEWA Report to WHO Conference 2000

  49. The Programme • The Self-Employed Woman's Association (SEWA) seeks 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.

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