commission on social determinants of health commission and... · action on the social determinants...

World Health Organization

Commission on Social Determinants of Health

Hernan SandovalCommissioner for the CSDH

Regional ConsultationBrazzaville, Congo

27 July 2005


Presentation Outline

WHAT WE MEAN BY SOCIAL DETERMINANTS OF HEALTH (SDH)

WHY THEY MATTER

WHY A COMMISSION ON SDH?

HOW THE CSDH WILL OPERATE

EXPECTED OUTCOMES


Dahlgren and Whitehead: layered influences


Social Determinants and Health Disadvantage Source: Adapted from Diederichsen and Hallqvist 1998 Challenging inequities in health

Social Context

Policy Context

Social Position

Specific exposure

Disease / injury

Social Consequences of ill health

IV

II

I

I

III


Social Determinants and the Spectrum of Health Disadvantage

Risks to ill-health–Exposures–Vulnerabilities/susceptibilities

Access to health services–Location, appropriateness, affordability

Consequences of ill-health–Work-related income loss–Costs associated with providing care


PRINCIPLES TO INFORM POLICY

Socio-political Context

Community participation in

decisions

Intersectoral action

Effective interventions

MA

IN P

OLI

CY

ENTR

Y PO

INTS

Decrease differential exposure

Decrease differential vulnerability

Decrease differential access

Decrease differential consequences

Decrease social stratification

Adapted model Diderichsen and Mackenbach




WHY THEY MATTER



EXPECTED OUTCOMES


What good does it do to treat people's illnesses ...

then send them back to the conditions that made them sick?


A very complex health development landscape…Outcomes-based development"Scaling Up!"Growing rapidly: from millions to billionsPredominant disease/intervention program (vertical) focus Unsatisfactory performance of health systems


Grand challenges in systems performance

Scale --- safe, proven and cheap interventions not reaching those in needDistribution --- those with unmet needs are disproportionately those with lesser meansProtection/Safety --- too many are worse off through encounters with the health system


JLI report JLI report recommends at least recommends at least

1,000,0001,000,000health workers health workers required in SSA required in SSA

over next 6 years to over next 6 years to ensure access to ensure access to essential health essential health interventions.interventions.

More informationhttp://www.globalhealthtrust.org


Trends in skilled birth attendance by income quintileEgy[t

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

199520001992

Indonesia

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

199419971991

Zimbabwe

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

199419991988

Bolivia

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1 2 3 4 5

199419981989


Number of People Suffering Financial Catastrophe and Impoverishment due to Health Spending

- 30 60 90

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (million)

impoverishment

catastrophic


Risk and Treatment Disparities in Tuberculosis, Kenya 2003

01020304050607080

% of patients surveyed

Expected Cases Rx Completion

PoorNon Poor

Adapted from Hanson et al 2003


Tuberculosis Treatment Disparities, Kenya

DOTS for Rx of Smear +ve

TB

Expected Efficacy

Case detection

Diagnostic delay

Visits to providers

Patient Adherence

Cost of Care

Actual Effectiven

ess

Least Poor:PoorestRatio

Poorest 98% low high high

low

high 20%

Least Poor 98% high low

high

high low 80%4

Sources of disparities

More equitable service provision requires action on the social determinants of health

Adapted from data from Hanson et al 2003 and from framework of Peter Tugwell


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?




WHY THEY MATTER



EXPECTED OUTCOMES


C-PHC S

-PHC Reforms & Minimum Packages

MDG S

caling-up

1978

1993

2000

2001

2002

1982

Social dimensions of health affirmed in WHO Constitution (1948), downplayed during 1950s era of disease campaigns.

Determinants re-emerge under Health for All agenda (1970s), action falters in 1980s.

1990s: paradigm of health as "private" issue dominant; some exceptions.

2000s: "pendulum swing" and new chance for action.

History: trends and opportunities

1948

2005

2005 Commission social Determinants of Health


Why do we think the CSDH can do better?

Will learn historical lessons, build on gains of previous erasMillennium Development Goals indicate a policy space– adopted by 189 countries– intersectoral connections– health central– health MDGs require action

on social determinants




WHY THEY MATTER

WHY A COMMISSION ON SDH


EXPECTED OUTCOMES


A broad consultative processJan 05:

CSDH discussed at WHO Executive Board

May 04:

D-G Lee announces CSDH at WHA

June 04:

major meeting with int'l public health experts, London

Dec 2003 Present

From Feb 2004: consultations in WHO HQ and Regions

From June 2004: outreach to civil society

From July 2004: initial contacts with potential partner countries

From Aug 2004: linking with UN agencies and projects (FAO, ILO, MP, etc)


IMPROVED HEALTH & HEALTH EQUITY

AdvocacyAdvocacyLearningLearningActionAction

Integrating Social Determinants of Health into Policy and Programs

Communication/ExchangeCommunication/Exchange

LeadershipLeadership


Strategic decisionsEvidence/learning

Evidence is knowledge for action Prioritize learning in developing countriesFocus on limited number of determinants

Leadership/advocacyKeep it real: meetings sited to engage real experience of social disadvantageEngaging civil society is key for sustainabilityFocus on promoting action on SDH policy/programs that differ by country


Phases of work

Produce policy & Produce policy & institutional changeinstitutional change

Expand policy interest,Expand policy interest,ScaleScale--up & up &

Develop communities of practiceDevelop communities of practice

Building knowledge Building knowledge & leadership& leadership

Jan 05- Dec 06

Jan 06- Dec 07

Jan 08-


Commission report; WHO institutional Commission report; WHO institutional Integration; public lobbies; countryIntegration; public lobbies; country

and global championsand global champions

Regional, international, Global Regional, international, Global policy interest and practice, policy interest and practice,

societal debate on SDHsocietal debate on SDH

Organised knowledge, Organised knowledge, Country models, Country models, visible leadershipvisible leadershipJan 05-Dec 06

Jan 06-Dec 07

Jan 08-May 08

Outcomes across phases of work




WHY THEY MATTER

WHY A COMMISSION ON SDH


EXPECTED OUTCOMES


Progress can be achieved in short time periods

In 7 years In 9 years In 15 yearsLIFE

EXPECTANCYPOTABLEWATER

PRIMARY SCHOOL ENROLLMENTPOVERTY

15m56 yrs 33% 89%

46%48 yrs 18%7m

Botswana1970 - 85

Sri Lanka1946 - 53

South Africa1994-2001

China1990 - 99


CSDH's vision of a changed world

Local, national and global institutions using knowledge on SDH to implement public policy that

affects health

SDH are understood, widely debated and

recognised as importantLeadership, public

interest and capable institutions sustain policy and action

SDH incorporated into WHO planning, policy and technical work


Social determinants incorporated into national policy processes.

Knowledge consolidated, gaps clarified for action.

Working with selected country towards improving health and reducing inequities.

Incorporation of social determinants of health into the strategy and program of WHO.

CSDH Outcomes

Poverty and painting: representations in

19th century EuropePhilippa

Howden-Chapman, Johan Mackenbach

BMJ VOLUME 325 21–28 DECEMBER 2002

Poverty and painting: representations in 19th

century EuropePhilippa Howden-Chapman,

Johan MackenbachBMJ VOLUME 325 21–28

DECEMBER 2002

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