Primary Health Care and the Social

Determinants of Health: the common quest for

equity

Mirta Roses Periago

PAHO/WHO

Presentation to the WHO Commission on the Social Determinants of Health

Vancouver, Canada

9 June 2007

The Americas

remain being the most

unequal region of the

World:

220 million people 220 million people

living in povertyliving in poverty

The Region shows a demographic transition with still high population growth and ageing, fast unplanned urbanization.

Research has revealed the complex relationships between social, economic, environmental, political and culture conditions–so called the social determinants of health–and their impact on the health profile of people and communities.

The Social Determinants of Health

in the Americas

New focus on the SDH and human development recognizes that health has become central to the development agenda because:

– It is a basic human need– It is indispensable for the existence and persistence of democratic societies

– It is a fundamental human right

Any attempt to improve health must be linked to the broader economic, social and political context, and needs to ensure the inclusion of multiple actors

and sectors

The sisterhood between the Social Determinants

of Health (SDH) and Primary Health Care

(PHC)

Milestones that feed into the evolution of

PHC in the Americas include:

For the past 30 years, PHC has been struggling to be

recognized as a key component

of effective health systems.

WHO Commission on Macroeconomics and Health; focus on equity; MDGs with health at the core

2000

People at the center of development; health sector reforms and structural adjustments; decentralization of the State and elimination of polio in the Americas.

1990

“Health for All;” expansion of PHC and vertical programs in selected countries; SILOS; rebirth of community participation as countries came out of dictatorial ruling

1980

Lalonde Report establishing the concept of the “non-medical” determinants of health.

1970

Primary Health Care in the

Region of the Americas

– Need to overcome the tremendous exclusion (40%) in health

– Need to broaden social protection as a key element in health sector reforms and as a public policy

– Need to implement new strategic and programmatic orientations to accelerate the improvement of health outcomes

– Need to integrate and synergize the Millennium Development Goals (MDG)

There are still unacceptable, avoidable and

unfair disparities to overcome within and among the

countries of the Americas

The Social Determinants of Health and

Primary Health Care

PHC is a useful approach for equitable health and human developmentequitable health and human developmentsince it calls for more attention to the operational and structural needs of

health systemshealth systems(access, sustainable increased resources, political commitment, quality of care, social empowerment and citizen satisfaction)

Right to the highestRight to the highest

attainable level ofattainable level of

healthhealth

EquityEquity

SolidaritySolidarity

Responsiveness toResponsiveness to

peoplespeoples’’ healthhealth

needsneeds Quality

Quality--oriented

oriented

Government

Government

accountability

accountability

Socia

l justice

Socia

l justice

Sustainability

Sustainability

Partic

ipation

Partic

ipation

Intersectoriality

Intersectoriality

First Contact

First Contact Comprehensive,

Comprehensive,

integrated and

integrated and

continuing care

continuing care

Family a

nd

Family a

nd

community

community

based

based

Emphasis on

Emphasis on

promotion and

promotion and

prevention

prevention

Appropriate

Appropriate

care

care

ActiveActive

participat

ion

participat

ion

mecha

nisms

mecha

nisms

Sound policy,Sound policy,legal & institutionallegal & institutional

frameworkframework

ProPro--equity

equitypolicies

policies& programs

& programs

Optim

al

Optim

al

organiza

tion

organiza

tion

& management

& management

Appropriate

Appropriate

human

human

resources

resources

Adequate and

Adequate and

Sustainable

Sustainable

resources

resources

Intersectorial

Intersectorial

actions

actions

Universal Universal

coveragecoverage

and accessand access

Core Values, Principles and Elements in a PHC-Based Health System

PAHO understands PHC as an integral part and the axis for the development of

health systems and considers the building of health systems based on PHC as the most appropriate path to produce

equitable and sustainable improvement in the health of the people of the Americas

PAHO conceptual framework for

PHC

1.1. Responsiveness to peopleResponsiveness to people’’s health s health needsneeds

2.2. Accountable and transparent Accountable and transparent GovernanceGovernance

3.3. Results and Quality orientationResults and Quality orientation

4.4. Social justice and ethicsSocial justice and ethics

Main Principles of PHC-based Health Systems

5.5. Sustainability and continuitySustainability and continuity

6.6. Intersectoriality to work upstreamIntersectoriality to work upstream

7.7. Social and individual engagement Social and individual engagement

Main Principles of PHC-based Health Systems

In the past few years, the Region has faced considerable changes:

• Rapid and unplanned urbanization

• Structural changes in health systems

• Climate changes• Demographic transitions• Increased inequity and poverty

In the Americas, the principles of PHC have been adopted and adapted

by each country according to its own reality and needs.

Social and Environmental Aspects

of Primary Health Care

The emphasis on the environmental aspects of PHC has been highlighted with the definition of “primary environmental care” (Borrini, 1990) which includes a focus on community-based development to achieve sustainable livelihood with 3 elements:

• Fulfill basic human needs

• Empower peoples and communities

• Optimal and sustainable use and management of community resources

Social and Environmental Aspects

of Primary Health Care

One of the most effective approaches is to consider PHC in its wider concept,

embracing health promotion and prevention, care and rehabilitation,

active and conscious citizenship and community engagement to produce and sustain

better health for all ages

Social and Environmental Aspects

of Primary Health Care

The initiative analyzes local realities, develops critical

interventions, and provides targeted technical assistance with the

support of PAHO/WHO technical units and other UN system

agencies.

Communities are chosen by national Ministers of Health in

collaboration with PAHO/WHO Representatives (PWRs).

Selection is based on their extreme conditions of vulnerability

and poverty. To date there are in 26 communities in 13 countries

participating.

Is designed to foster a citizenry that exercises its capacity for

change through their collective and individual power.

It is a catalyst for change, that coordinates actions to allow

political leaders, the leaders and inhabitants of the communities,

NGOs, IOs, and the international cooperation community work

together at the local level.

Reviews the experiences of work done since Alma Ata and re-

energizes them through local work with a concrete objective;

advancing towards the MDGs.

This initiative’s contribution to the Region is to shift from the

analysis of MDG indicators to participatory, action-oriented

research that fosters local empowerment.

Puts the emphasis on improving conditions of peoples and their

territories through the community self-management model.

Empowers individuals and the community via a horizontal

exchange partnership between local communities and providers

of technical assistance.

Faces, Voices, and Places of the MDGs is a regional

initiative that targets the poorest and most

vulnerable communities in Latin America and the

Caribbean to help them achieve the MDGs from

the perspective of health.

Active

Selected

Movement

Community

"Our greatest concern must always rest with

disadvantaged and vulnerable groups. These

groups are often hidden, live in remote rural

areas or shantytowns and have little political

voice."

Dr Margaret Chan

WHO Director-General

WHO Commission on Social Determinants

of Health / Knowledge Networks and Faces,

Voices and Places

Social Exclusion

The initiative is aimed at addressing the most vulnerable, neglected and

economically deprived communities. In Ventanilla, Peru, through

participatory action research methodology exercises the community and

its citizens are being empowered to reduced social exclusion.

Measurement and Evidence

The initiative’s initial diagnosis includes a thorough study of available data

on the community, setting of baselines and targeting and monitoring of

advances. Through the PAHO - ECLAC-CELADE Agreement, census

data from 19 LAC countries was analyzed and sub-national poverty maps

were created to facilitate targeting of the most vulnerable communities.

Women and Gender Equity

In the Chiquimula and El Estor regions of Guatemala multi-cultural and

gender perspectives have driven the work. This will lead to the

development of healthy mechanisms, processes and actions to be taken at

the local level to reduce gender-based inequities in health.

Priority Public Health Conditions

In Santa Fe de Veraguas in Panama, malaria control has been

approached with a focus on socially and economically disadvantaged

groups. Interventions and actions to improve the situation will address the

social determinants causing inequities in health outcomes, barriers and will

facilitate access to health care.

Urban Settings

In four communities in the Greater San Salvador area in El Salvador work

is underway to address the most vulnerable and marginalized communities.

The strategy employs an intersectorial, multi-programmatic, approach to

influence health determinants through participatory activities centered on

situation analysis.

Early Child Development

In Yuty, Caazapa, Paraguay, efforts involving the community component of

the IMCI strategy are underway through participatory planning exercises with

local leaders. These have led to disease prevention and health promotion

activities under MDGs 1, 4 and 5. These provide opportunities to young

children and their mothers in shaping sound lifelong health and development

status.