Addressing Social Determinants of Health

1. Addressing Social Determinants of Health Case study from I.R.Iran Presented by Dr Jihane Tawilah WHO Representative; I.R.Iran

2. 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.

3. Governance Financing Resource Creation Information Service Provision Strengthen Health Systems Health Outcomes Address Health Problems Tackle Health Determinants Social Cultural Economic Environmental Political Promotive Preventive Curative RehabilitativePalliative programs Health Systems, Programs, Determinants: Interrelationships

4. HEALTH SYSTEM CONCEPTUAL FRAMEWORK Social Determinants of Health GOALS OF HEALTH SYSTEM SYSTEM BUILDING BLOCKS Information Support Service provision Responsiveness Governance & leadership Coverage Health workforce Quality, safety Health Efficiency Medical products, technology Provider performance Financing Financial protection Equity

5. Examples of Priority SDH in EMR • 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

6. 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

7. Conflict: Palestinian checkpoints • Photo here

8. Three principles of action • Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age. • Improve the well-being of girls and women • Circumstances in which their children are born, • Put major emphasis on early child development • Education for girls and boys, • Improve living and working conditions • Create social protection policy supportive of all, create conditions for a flourishing older life.

9. Governance • Tackle the Inequitable Distribution of Power, Money, and Resources • Gender inequity • Requires a strong public sector that is committed, capable, and adequately financed. • Requires a strong public sector that is committed, capable, and adequately financed. • legitimacy, space, and support for civil society, for an accountable private sector, • people across society to agree public interests and reinvest in the value of collective action.

10. Action 3. Acknowledge that health inequalities exist: • Measure the problem, • evaluate action, • expand the knowledge base, • develop a workforce that is trained in the social determinants of health, • and raise public awareness about the social determinants of health.

12. Border between the rich and the poor; Favels, Brazil 

13. What is Urban HEART • Kobe Centre as knowledge hub for SDH commission, together with WHO-Regional Offices, produced: • The Urban Health Equity Assessment and Response Tool aims at directing local/ national policy-makers to • Identify the differences between the health of people living in disadvantaged urban areas and the general population • Decide what strategies, interventions/actions should be used to reduce health equity gaps Global Mayor Forum, Kobe, Nov 2010

14. Urban Health Equity Assessment & Response Tool • Tool to aid policy-makers, globally, with a user-friendly guide to address health inequities: (a) assess the situation, and (b) respond by identifying interventions • Three main pillars of implementation: • sound evidence • inter-sectoral action • community participation • Key target audience: • Mayors and local governments • Ministry of Health, Education, Transport etc. • Independent organizations

15. Component I: Assessment Health Outcomes Health Determinants Physical environment and infrastructure e.g. access to safe water Social and human development e.g. literacy rate • Indicator examples: • life expectancy • under-five mortality • disease specific mortality rate Economics e.g. employment rate Policy domains Nutrition e.g. Nutrition insecurity, BMI Governance e.g. voter participation rate

16. Tehran AFHC- 25 Oct 2012, Brisbane

17. Tehran in a glance AFHC- 25 Oct 2012, Brisbane

18. The objectives of Urban HEART Project • To identify the differences between the health, health determinants and well being of people living in urban areas. • To determine appropriate, feasible and cost effective interventions reduce gaps between people living in the same or different cities. • To promote community involvement and inter sectoral collaboration in urban development.

19. Methodology; Tehran Urban HEART Conducted in two rounds At first round, in 2008, about 22,000 households in 22 regions of Tehran were studied, 1000 households per region, in order to assess 42 health and SDH Related indicators. At second round, in 2011, in order to have valid indicators for 374 local areas of Tehran city 34,700 households were interviewed and 70 indicators were assessed. In both studies the indicators were measured for 6 domains.

20. Partnership UH in Tehran With Support of WHO/EMRO, late 2007 Tehran Municipality involved; based in Tehran Centre for Studies and Planning Steering committee and 4 working groups established Kobe model adopted MDG, UN-HABITAT, national and local survey indicators were reviewed, adding some more to highlight urban health

21. Developing the tool Working groups finalized indicators Presented to the workshop, being acknowledged Proposed the final draft of indicators to ‘advisory committee’ Deletion, combination, modification Variables identified and a questionnaire developed to be piloted Each indicator has a responsible organization.

23. Urban HEART domains and indicators in Tehran Project (2011)

32. Indicators of UH-Tehran Human and social development Education: NER/ GER/ primary school completion/ Higher education (5 indices) Violence: domestic, street Smoking/ addiction Smoke-free places Mental health Social capital Physical and infra-structure Safe drinking water Accidents and injuries (5 indicators) Air pollution Noise nuisance Access to public transport Solid waste management Health centre utilisation Health Safe delivery Vaccination Early pregnancy Breastfeeding (excl & 24m) IMR/ U5MR/ MMR HRQL Disability Economic development Employment Residency in normal home/ Person/ room Fair Financial Contribution Index (FFCI) Household costs Absolute/ Relative poverty Social Welfare Index Human Development Index Governance(Municipality) Annual reports Contracts transparency Satisfaction Responsiveness (Hot Lines) Community participation (local elections) Lawfulness Standard activities Nutrition Calorie poverty Wasting Stunting LBW (IUGR/ NMR) BMI: obesity Food diary Food costs Cereal costs

33. Implications • Local level: • Tehran 5-year plan • Redistribution of budget, 2009 • National level: • Endorsement of 52 indicators by The Cabinet, Feb 2011: all 400 districts will collect data to improve the indicators by 2013 to national level. • SDH plan of actions • International level • Kobe Global Mayors Forum, Nov 2010 (Global Action Plan) • 2nd Asian Mayors Forum, Istanbul, March 2011 (a special working group for Urban Health and Equity) • Inter-Country Meeting in Cairo, Sep 2010 (5 EMRO countries reviewed Tehran experience)

34. Implications of Urban HEART • Institutionalization of UH in the Municipality • Neighbourhood –based data collection and analysis= 375 • Changes in indicators: • Deletion of access to pipe water, absolute poverty • Improvements in: quality of drinking water, poverty indicators, etc. • Adding: public transport, oral health, physical activity, solid waste management, chronic diseases • Response-orientation: selection of 2 priorities in each neighbourhood for suitable interventionusing community based interventions.

35. Social Matrix Global Mayor Forum, Kobe, Nov 2010

36. Economic situation Global Mayor Forum, Kobe, Nov 2010

37. Example of Maps: Mental Disorders Global Mayor Forum, Kobe, Nov 2010

38. Percentage of home owners in different regions of Tehran, 2011

39. person per room in different regions of Tehran, 2011

40. Percentage of families who have at least one cell phone in different regions of Tehran, 2011

41. illiteracy rate among 15+ years old in different regions of Tehran, 2011

42. Health Domains matrices in Tehran, 2011

43. Urban HEART Project in Tehran: Improvement of Health • Institutionalization of UH in the Municipality • Response-oriented: selection of 2 priorities in each neighbourhood for suitable intervention using community based interventions. • Community mobilization and empowerment for priority setting, designing interventions and evaluation of implemented programs in Tehran Municipality • Resource allocation for different regions based on results of Urban HEART Project by Tehran City Council. • Ministerial Cabinet endorsement of 52 health equity indicators for all 420 districts of the country.

44. According to the request no. 100/305821 dated 6 Nov 2010 from MOHME, the cabinet in the meeting dated 2 January 2011 has approved the following actions: Implementing bodies (responsible org/Ministry for the related indicator) should prepare policy action plan package for improvement of situation for those areas lower than national average and submit to high council for health and food security Planning and development council of provinces should be committed and direct their resources to improvement situation of province and related districts, which are below national average and report to HCFHFC in bi-annually MOHME and university of medical sciences (UMS) should supervise this approval based on developing health equity monitoring system and data banks by end of Iranian calendar 1392(20 March 2013).

45. Neighbourhood based community involvement in healthy city and social development: Tehran experience AFHC- 25 Oct 2012, Brisbane

46. Urban Management in Tehran • Vision: • Healthy people: The axis of urban management • Healthy people in healthy environment • Mission: • To change the municipality from a ‘service’ organisation to a ‘social’ entity • Strategies: • Neighbourhood-oriented approach • Community participation through 6 neighbourhood councils like: ‘social’, ‘health’, etc. AFHC- 25 Oct 2012, Brisbane

47. Tehran Experience in Providing Urban Health-1 • Establishment of Board of Trustees in all 374 neighbourhoods • Assignment of neighbourhood manager • Physical building for Neighbourhood House for all neighbourhoods • Establishment of ‘Health Houses’ in all neighbourhoods • Assignment of specific task Forces: • Smoke-Free City • Disabled-Friendly City • Elderly-Friendly City • Child-Friendly City AFHC- 25 Oct 2012, Brisbane

48. Green spaces in Tehran AFHC- 25 Oct 2012, Brisbane

49. Duties of the "Neighborhood Board of Trustees “: (Article 4) • Selection of neighborhood manager • Assisting to moving ahead the responsibilities and duties of the neighborhood management • Ground-making for the participation meeting of the neighborhood inhabitants in cultural and social areas • Assisting in promotion of Expert/civic working groups • Assessment and approval of programs and the modalities of executing neighborhood management responsibilities • Recognition of capacities and capabilities of the people at the neighborhood level • Efforts to attract the participation of other institutions and related local organs AFHC- 25 Oct 2012, Brisbane

50. Each neighborhood has board of trustees some elected by the people and some chosen by the district mayor AFHC- 25 Oct 2012, Brisbane