Addressing the Social Determinants of HealthChallenges and Pathways

Thelma NarayanCentre for Public Health and Equity, SOCHARA

Bangalore, IndiaMember , People’s Health Movement (PHM)

Nuffield Council on Bioethics Symposium , 22nd June 2011, London, United Kingdom

Plan of Presentation• The first 10 slides offer brief reflections about the societal determinants of health and health inequalities

•The following 5 slides provide an overview of health indicators from India which are dependent on the SDH

•Together they highlight the nature of the challenges

• The last 15 slides are a snapshot of responses by the community, civil society, governments and academics over the past decade indicating critical pathways and partnerships to address health inequalities

Social relevance & community orientation of global health efforts? Ethics and Responsibilities.

Is there need for a paradigm shift?

Tackling the Social Determinants of Health in an Era of Globalization

There is an urgent need to address the root cause of inequalities in disease, disability and health.

Social conditions in which people live and work or the social determinants of health.

Source: WHO Commission on Social Determinants of Health (WHO- CSDH), 2005 -2008

Need for policies and practice that tackle the underlying determinants of health inequalities, within a framework of cross-cutting rights.

Health is a determinant of Development – UNDP 2005Development is a determinant of Health

The deeper determinants of both need to be addressed as a priority at global, national and local levels

Poverty, Inequality, Discrimination

Development Health

Corporate led globalization, Neo-liberal economic

reforms,Negative macro-policies

Adversely affect the social majority,

nationally & globally

Livelihoods,Incomes,

Food security,Increased conflict,War and violence,Access to water,

Access to health care,Environmental degradation,

Macro-policy driven politico-economic determinants, backed by unprecedented wealth, and concentration of power

Enhance existing socially embeddeddeterminants and inequalities due to

GenderRace, Ethnicity, CasteLanguageBelief systemDisabilities, Mental Illness

“Disparities hampering progress are systematic, reflecting hierarchies of

advantage and disadvantage and

public policy choice”UNDP, 2005

Global Inequalities

High income countries represent 15 % of the world’s population

40% of the world’s population, ie 2.5 billion people living on less than $2 a day,

account for 5% of the global income

UNDP 2005

Trade, Development and Health

Over 2/3rd of the poor are small farmers and agricultural laborers

Unfair trade undermines their livelihood Led by the EU and USA developed country

agricultural subsidies are over $ 350 billion a year, ie, almost $ 1 billion a day, supporting large farmers and corporate agri-business

For a fraction of the cost, universal education, health and water for all can be achieved.

UNDP, 2006

International organisations & institutions

Roles and responsibilities for Global Health

INDIA: ? shining global example Overall employment growth in 1990s was 2/3rd to

half of 1980 For agricultural labourers, bulk of poor in India,

rate of growth of real wages per annum almost halved in the 1990s, compared to 1980s. Worsening of working conditions of labourers

in the informal sector and agriculture in past decade Open unemployment serious

- Jeyarajan and Swaminathan, 2003

JOBLESS GROWTH

ANAEMIA Women – 53% Men- 24% Children- 70%

( 6-59 months) Source: India, NFHS- 3 , 2005-6, Key Findings.

Prevalence of Anaemia above 10 % is a public health emergency.

What are the ethics and responsibilities underlying this situation?

Trends in Child Nutrition in IndiaPercentage of Children under age three years.

Nutritional Status NFHS 2 NFHS 3

Stunting(Low height for age)

51 45

Wasting( Low weight for

height)

20 23

Underweight( Low weight for age)

43 40

Source: India, NFHS – 3, 2005-6, Key findings.

In Bihar the child nutrition situation worsened from 1998 -99 to 2005-06

National Family Health Survey (NFHS ) NFHS 2 - 1998 -99; NFHS 3 – 2005-2006

National Health Goals & MDGs - India

X FY Plan 2007 NPP 2010 MDG 2015 Current

Infant Mortality Rate(IMR)

45 <30 27 58(SRS 2005)

Maternal Mortality Ratio (MMR) 200 <100 100 301

(SRS 01-03)

Total fertility Rate (TFR) 2.1 2.1 2.9

Institutional deliveries 80% 80% 40.7 (NFHS III)

X FY – 10th Five Year Plan, NPP – National Population Policy, MDG – MilleniumDevelopment Goals, SRS – Sample Registration Scheme, NFHS – National Family Health Survey

Source: NFHS 3; SRS 2005

State/UT IMRSRS 2005

MMR SRS 01-03

TFR SRS 2005

Kerala 14 110 1.7

Madhya Pradesh 76 379 3.6

Orissa 75 358 2.6

Tamil Nadu 37 134 1.7

Uttar Pradesh 73 517 4.2

All India 58 301 2.9

Large inter state variations

India’s Health Indicators

What are the people saying?

Less Food No jobNo water

Meeting Challenges in the New Millennium: with a People Centric Approach

With people back into the centre of primary health careThe public back into public health and

health systems and community voice and power back

into health policy discourse & decisions,As subjects & co-creators not objects

1978 Alma - Ata Declaration Health For All by 2000

1985 WHA - Three NGO leaders recognized the need to involve poor people in health decision making

10 Years after Alma AtaRIGA ConferenceACHAN Consultation

1988

1990's (Early)

International Peoples Health CouncilStruggle for liberation from poverty, hunger and unfair socio-economic structures

1990's (Late)

PHA Core Group Formed by 8 Organizations The G 8

1997-98 National Coordination Committees And working groups began to emergeeg. India

People’s Health Assembly 2000 (PHA)

Over 2000 participants in 5 peoples health trains

Mobilization across 19 states

Adopted 20 point IndianPeople’s Charter

Launched the Jan Swasthya Abhiyan,

Campaign for Health for All Now

Health as a Fundamental Human Right

Globalization Of Health From Below The First Global People’s Health Assembly

In 2000 December , 1454 health activists from 75 countries met in Savar, Bangladesh to discuss the challenge of attaining Health for All, Now! Over 250 Indian delegates attended

Globalization Of Health From Below

The People’s Charter for Health, 2000“Health is a social,

economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of poor and the marginalized people.”

Campaign on the Right to Health Care PHM - IndiaPublic Hearing

State and district action, from 2000 onwards

Indian Social Forum, November 2006

Second National Health Assembly – February 2007

Critical collaboration with National Rural Health Mission

Participation in the World Social Forum

Socio Epidemiology of Diarrhoea

3rd SDTT symposium CHC 2003

Asian Social Forum, January 2003, Hyderabad

JSA members organized workshopson:1. The Right to Health Care2. Environment and Health3. Tobacco and Health4. The People’s Health Movement

Asian Social ForumJanuary 2003, Hyderabad - INDIA

World Social Forum, January 2004, MumbaiWorkshops on health rights & determinants by JSA and PHM

Campaigns on Gender Issues (an example from among several campaigns)

Campaign Against Sex Selective Abortion or Female Foeticide – 2001 onwards

Campaign on Violence against Women as a Public Health Challenge – 2000 onwards

Women’s Access to Primary Health Care - 2003 People’s Tribunal on Population Policies – 2004 10th International Women and Health Meeting –

2005 Gender and Power Issues in Medical Education Women’s Health Charter - 2007

Participants converge from many streams, groups,not only PHM/ JSA

Health Policy Dialogue and ActionAdopted by Karnataka State

Cabinet in 2004

Interim Report in April 2000Final Report in April 2004

Accepted by Govt of KarnatakaHigher Level Implementation Committee setup

MAINSTREAM DEVELOPMENTS IN PUBLIC HEALTH WITH PARTNERSHIP OF ALTERNATIVE SECTOR – 1998-2008

National Health Policy Interaction - INDIAwith the National Rural Health Mission (NRHM)2005 0nwards

Members of Task Forces and Advisory Committees Shifted focus from Demography to Public Health

and community involvement Community Monitoring of the Health System. People’s Rural Health Watch Community Action for Health National ASHA Mentoring Group Universal Access to Health Care

Recently a National Mental Health Policy Group

Antibiotic Resistance

Inadequate treatment guidelines

Inadequate infection control

Inadequate control of Veterinary

use

Poor monitoring, surveillance

Environment pollution as

reservoir

Inadequate Primary Health Care

Weak Public Health Systems

Decline in Research

funds

Consumer Behavior

Lack of patient

education

Inadequate provider

education

Cost

Over use/ misuse

Irrational drug use

Malnutrition, Immunity

Combination & substandard

drugs

Understanding why? Policy AnalysisINEQUALITY

MARGINALISATIONNEW ECONOMIC POLICIES

Liberalization, Privatization, Globalization

ECO

NO

MIC

CO

NST

RA

INTS

COM

MER

CIA

LIZA

TIO

N

OF

HEA

LTH

CA

RE

DECREASED INVESTMENT IN SOCIAL SECTOR

INTERNATIONAL TRADE: WTO/IPR

INTE

RN

ATIO

NA

L TR

AVEL

UN

SUST

AIN

AB

LE

DEV

ELO

PMEN

T A

ND

D

ISPL

ACEM

ENT

Antibiotic resistance

Antibiotic treatment guidelines/ schedules

Strengthening infection control in health care

institutions

Veterinary Use

Guidelines

Improving surveillance

Hospital waste

disposal.

Strengthening Primary Health Care

Strengthening Public Health Systems

Promoting more

research on the

problem

Promoting rational

consumer education

Multifaceted approaches for

Behavioral change

Provider / prescriber education

Cost control

Controlling OTC sales

Rational prescribing

Strengthening Nutrition

Controlling combination

drugs

What can be done…. Policy ActionLocal/national/regional

global actionPeople’s need oriented

economic/trade policies

Poli

tica

l Aw

aren

ess

and

supp

ort

Increased investment in health, nutrition, social welfare, education

sectors

Countering commercialization of health care

Equi

tabl

eto

uris

m

opti

ons

Tack

lin

g En

viro

n m

enta

l ch

alle

nge

s

Safe

dri

nki

ng

wat

er,

san

itat

ion

Globalization Of Health From Below Globalizing Solidarity

Folk from over 80 countries at the Second People’s Health Assembly, Cuenca, Ecuador, 2005

Second People’s Health Assembly (PHA2)July 2005, Cuenca - Ecuador

PHM Evaluation, 2004

ConclusionWorking together towards greater social justice in global health is imperative. The pathways are many. What will be our path?

Is there a role for community and civil society engagement?

What are the barriers in reaching the Health for All Goal?