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COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

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Title: COMMISSION ON SOCIAL DETERMINANTS OF HEALTH


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

2
(No Transcript)
3
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.
4
At Birth
6 Years Old
14 Years Old
Rethinking the Brain, Families and Work
Institute, Rima Shore, 1997.
5
STRUCTURE OF PRESENTATION
  • KEY MESSAGES
  • CORE VALUES AND GOALS
  • STRUCTURE OF COMMISSION
  • KEY ISSUES

6
  • 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.

7
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

8
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

9
Principles of Action 2
  • Action should be based on evidence and expert
    advice

10
Principles of Action 3
  • System of measurement for health equity
  • Targets determinants and outcomes
  • Evaluation framework

11
STRUCTURE OF PRESENTATION
  • KEY MESSAGES
  • CORE VALUES AND GOALS
  • STRUCTURE OF COMMISSION
  • KEY ISSUES

12
Equity and Core values for CSDH
  • Health equity
  • "the absence of unfair and avoidable or
    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

13
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
14
STRUCTURE OF PRESENTATION
  • KEY MESSAGES
  • CORE VALUES AND GOALS
  • STRUCTURE OF COMMISSION
  • KEY ISSUES

15
CSDH
  • Commissioners
  • Knowledge Networks
  • Country Work
  • Civil Society Work
  • Global Initiative
  • WHO Reference Group

16
COMMISSIONER MEETINGS
  • CHILE March 2005
  • CAIRO May 2005
  • INDIA September 2005
  • IRAN Jan 2006
  • KENYA June 2006

17
Knowledge Networks
18
Knowledge network priority themes
Women/ gender
Priority Public Health Conditions
Measurement / Evidence
Early Child Development
Health Systems
Health Equity
Urban Settings
Globalization
Social Exclusion
Employment Conditions
19
Country Work
20
Country Work
  • To facilitate and strengthen action across
    government to systematically tackle the socially
    determined causes of health inequities

21
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

22
  • 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)

23
  • 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

24
Regional activities
  • Nordic group
  • Asian group
  • Latin American regional meeting in Rio

25
Civil Society Work
26
Civil Society Work
  • Evidence
  • Advocacy
  • Sustainability

27
Civil Society Work
  • Regional Civil Society Facilitators
  • Africa,
  • Asia (incl. People's Health Movement India),
  • Eastern Mediterranean,
  • Latin America and Caribbean

28
Update Regional and Regional activities
Regional Meeting
National Meeting
Next National Meeting
Country Participants
29
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.

30
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.

31
Global Initiative
32
STRUCTURE OF PRESENTATION
  • KEY MESSAGES
  • CORE VALUES AND GOALS
  • STRUCTURE OF COMMISSION
  • KEY ISSUES

33
  • INTEGRATION OF WORK STREAMS

34
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

35
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)

36
CHALLENGES
  • WHAT ABOUT HEALTH SYSTEMS?
  • TOO DIFFUSE?
  • GOOD INTENTIONS DONT ALWAYS ENSURE GOOD RESULTS

37
KEY ISSUES
  • IMPORTANCE OF HEALTH SERVICES IN THE CONTEXT OF
    SOCIAL DETERMINANTS OF HEALTH
  • BOTH HEALTH SERVICES AND WIDER DETERMINANTS

38
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
39
  • HEALTH SERVICES AND SOCIAL DETERMINANTS

40
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)
41
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
42
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.

43
SOCIAL DETERMINANTS
  • Anti retroviral therapy hampered by lack of human
    resource capacity
  • Gender inequality womens 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

44
  • 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
45
BUSINESS AS USUAL
  • THE BETTER OFF DO BETTER THAN THE WORSE OFF

46
DISTRIBUTION OF BENEFITS FROM GOVERNMENT SPENDING
ON HEALTH, 21 COUNTRIES
Filmer 2003 in Gwatkin et al. Reaching the Poor,
2005
47
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)
48
DIABETES AND HYPERTENSION (CLINICAL REPORTS) BY
INCOME, AGES 40 -70
Diabetes Hypertension
Prevalence
BP greater than or equal to 140/90 on
medication
HBA1c gt6.5
(Source Banks, Marmot, Oldfield Smith, JAMA,
295 2037-2045, 2006)
49
Self-employed Womens Association (SEWA),
Gujarat, India
Source SEWA Report to WHO Conference 2000
50
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.

51
Interventions
  • SEWAs health approach includes
  • health education,
  • immunisations,
  • sanitation activities,
  • family planning,
  • drug therapy and referrals,
  • occupational health care,
  • promotion of low cost traditional medicines and
    creating health centres.
  • SEWA's team of 200 mid-wives and health workers
    serve as health educators-cum-barefoot doctors
    for 75,000 women workers.
  • The SEWA Bank has 125,000 depositors and a
    working capital of over Rs 300 million (over US7
    million).
  • SEWA has promoted more than 1500 small self-help
    groups, co-operatives and district level
    associations of women in India and abroad.

52
Impact
  • An increase in health awareness among women and
    their families including alcohol and "gutkha" (a
    tobacco product)
  • In 1998, SEWA's services resulted in
  • no maternal deaths reported,
  • no measles deaths in children,
  • 65 reported savings due to the low cost drug
    distribution system .

53
QUANTIFYING RESULTS
  • WHAT IS THE COST OF AN INTERVENTION?
  • WHAT ARE THE HEALTH BENEFITS?

54
Transport Interventions for Public Health
Source Morrison et al (JECH 2003)
55
Systematic Review
  • To review the evidence on effectiveness of
    transport interventions in improving population
    health

56
Select findings
  • Motorcycle helmet legislation 30 reduction in
    fatalities
  • Area wide traffic calming 15 reduction in
    accidents
  • Fatal accidents reduced by 65 as a result of
    public lighting
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