AFR/RC57/13 25 June 2007
REGIONAL COMMITTEE FOR AFRICA Fifty-seventh session Brazzaville, Republic of Congo, 27–31 August 2007 Provisional agenda item 7.11
ORIGINAL: ENGLISH
KEY SOCIAL DETERMINANTS OF HEALTH: A CALL FOR INTERSECTORAL ACTION TO IMPROVE HEALTH STATUS IN THE WHO AFRICAN REGION Report of the Regional Director
CONTENTS Paragraphs BACKGROUND .........................................................................................................................1–4 ISSUES AND CHALLENGES .................................................................................................5–16 ACTIONS PROPOSED ..........................................................................................................17–25 CONCLUSION..............................................................................................................................26
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BACKGROUND 1. Health is profoundly affected by certain conditions commonly referred to as the “social determinants of health”.1, 2 These factors relate to the physical, social and economic environments in which people live, and they affect health by impacting on peoples’ living circumstances and quality of life. These conditions include income or wealth and its distribution, early childhood care, education, employment and working conditions, unemployment and employment security, food security, health-care services, housing, social exclusion, culture, religion, and social safety nets. 2. There is now ample evidence that policy, action and leadership to address the key social determinants can improve health.3 Investments in the basic social determinants of health will profoundly improve the health of populations most exposed to health-threatening conditions; these populations include the poor, the marginalized, and those people excluded from participation in certain aspects of society because of their living conditions. Some countries (such as Costa Rica, Cuba and Sri Lanka) have made concerted efforts to address the social determinants of health, and they have achieved high levels of health status despite their low income status.4 3. Though the World Health Organization (WHO) recognized the role of key social determinants of health many years ago when it launched the Primary Health Care (PHC) strategy, not much has happened in countries since. Consequently, in 2005 WHO set up the Commission on Social Determinants of Health to look into why the PHC strategy did not work and advise on how it could be revitalized. The Commission will support countries and global health partners to address the social factors leading to ill-health and inequities. It aims to evaluate, on a global scale, (i) the situation and evidence in relation to health inequities and social determinants, including interventions, and (ii) policies and programmes that tackle social determinants and have proven effective in helping to reduce health inequities. The Commission is expected to submit its report in May 2008. 4. This document responds to the request made by ministers of health during the fifty-sixth session of the WHO Regional Committee for Africa for an update regarding the Commission’s work. In anticipation of the Commission’s report, the document also briefly outlines issues, challenges and actions that countries should confront and address in order to improve the health status of populations in the WHO African Region. ISSUES AND CHALLENGES 5. Addressing the social determinants of health is essential if the health targets set in the Millennium Development Goals (MDGs) are to be met in the African Region. Without significant gains in poverty reduction, food security, education, women’s empowerment and living conditions, most countries will not attain the health-related goals. Without progress in health, other MDGs will also remain beyond reach. Promoting health policies that tackle the basic cause of unfair and avoidable human suffering provides an opportunity to achieve the MDGs. 1
2
3
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Fleming DW, More evidence, more action: Addressing the social determinants of health, American Journal of Preventive Medicine 24(3S):1, 2003. WHO, Action on the social determinants of health: Learning from previous experiences. A paper prepared for the Commission on Social Determinants of Health, Geneva, World Health Organization, 2005. Public Health Canada, The social determinants of health: An overview of the implications for policy and the role of the health sector. Proceedings of a conference on social determinants of health across the life-span held at York University, Canada, 2002. Cornia G, Economic decline and human welfare in the first half of the 1980s. In: Cornia GA, Jolly R and Stewart F (eds), Adjustment with a human face, Volume 1, Oxford, Clarendon Press, pp. 11–47, 1987.
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6. The WHO Commission on Social Determinants of Health is working with governments, civil society, international organizations and donors in pragmatic ways to create better social conditions for health, especially for the most vulnerable people. The Commission is supporting countries in health equity as well as helping build a sustainable global movement for action through the dissemination and use of existing knowledge; advocacy through regional forums; strengthening institutions and networks; and promoting participation. The fifth meeting of the Commission was held in Nairobi, Kenya, in June 2006. Four of the twenty commissioners are from the African Region. 7. A number of challenges should be met before any significant progress in addressing the social determinants of health can be realized in the Region. Foremost is poverty. Evidence shows that the poor are not only more prone to illnesses but are unable to cope with diseases; they are at increased risk for cancer, stroke, heart failure and drug abuse. In addition, poor children are unable to achieve their full potential. The WHO Commission on Macroeconomics and Health documented the relationship between health and development. Health is also central to the achievement of the Millennium Development Goals.5 8. Over the last twenty years the number of people living on less than US$ 1 a day in subSaharan Africa has increased.6 Economic stagnation or deterioration in some countries has resulted in fragile societies nurturing environments conducive to conflict, war and instability. 9. A second major challenge is inequity. There are significant inequities in the distribution of and access to the key social determinants of health globally and both within and across countries. Consequently, there are wide variations in life expectancy (or other health outcomes); the countries most affected by HIV/AIDS fare the worst.7 High maternal, infant and child mortality; low literacy; and wide gender disparities, all of which constrain social and economic development, are also prevalent. 10. Although education receives a large share of public funding in most countries, available evidence suggests that most education systems in the Region face a number of problems. Some communities are marginalized from the education system because of culture or geography. A major problem throughout the Region is the low attendance of girls. According to statistics, over half of school-age girls in sub-Saharan Africa are not in school. In some schools, girls who become pregnant are expelled.8 11. Regarding access to and use of health services, evidence shows that the richest 20% of the population receive over twice as much financial benefit from government health service expenditures as the poorest 20%. Wealthier population groups have a higher probability of obtaining health care when they need it. The wealthier quintiles are generally more likely to be seen by a doctor than are the poor groups; richer groups are more likely to receive medicines when they are ill. The wealthiest quintile consumes more than 42% of all national household expenditures. The richer population groups spend more on health care (measured in absolute terms) than do the poorer groups; the wealthier quintiles use less of their total expenditure on health care than do the poorer quintiles.9 5 6 7
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WHO, Macroeconomics and health: Investing in health for economic development, Geneva, World Health Organization, 2001. World Bank, World development indicators report, Washington DC, World Bank, 2005. UN, Report on the world social situation, 2005: The inequality predicament, New York, United Nations Economic and Social Council, 2005. ODI, Can Africa make it? Prospects for Africa's development, Overseas Development Institute, http://www.odi.org.uk/speeches/africa2002/meeting7.html (accessed 15-05-07). Makinen MH et al, Inequalities in health care use and expenditures: Empirical data from eight developing countries and countries in transition, Bulletin of the World Health Organization 78(1): 55–63, 2000.
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12. Environmental issues also present formidable challenges. Industrial waste as well as air, water, food and soil pollution can cause cancer, birth defects, respiratory illness and gastrointestinal ailments. Factors related to housing (population density, water, sanitation, indoor air quality) and the design of community and transportation systems influence physical as well as psychological well-being. 13. Globalization of trade, travel and migration, technology and communications has resulted in increasing cross-border flows of people, goods, services, information and ideas. A significant challenge concerns the globalization of the health sector. Trade in health services affects equity, access, costs and quality. The net impact ultimately depends on the specific country’s health care system, regulatory environment and government policies. Recently, however, globalization has contributed to health inequities which have negative implications for the poor.10 14. The African Region is experiencing rapid urbanization, resulting in huge demands for improved management and servicing of urban growth. Urbanization is strongly linked to economic growth, but this has not been the case in Africa. The main cause has been rural-urban migration due to unequal economic opportunities; differentials in social services provision, housing and sanitation facilities; and conflicts which displace many people. The phenomenal rate of urbanization has overwhelmed urban managers in nearly all Member States, resulting in enormous unserviced informal urban settlements where millions of poor live in dehumanizing conditions. 15. The key social determinants of health are not only the responsibility of ministries of health; many determinants are the responsibility of other ministries. For example, in some countries, water is a responsibility of the Ministry of Water or even local authorities; sanitation may be under the Ministry of Environment; housing may fall under the Ministry of Public Works or local government; education under the Ministry of Education. Nevertheless, there has been very little intersectoral or interministerial collaboration. Few countries have any established cross-sectoral mechanisms to coordinate intersectoral actions on health. Additionally, there is weak intersectoral cooperation, even where such mechanisms exist. The challenge for the Ministry of Health, therefore, is how to influence the actions of the other ministries that contribute to health. 16. In addition, few countries in the African Region have any concrete proposals to explicitly address the social determinants of health, although many national health policies recognize the determinants as a problem. ACTIONS PROPOSED Countries 17. In anticipation of the report of the WHO Commission on Social Determinants of Health, Member States are encouraged to establish a social determinants of health task force to consider the issues raised in this document as well as the anticipated recommendations of the Commission. The Task Force, ideally located in the prime minister’s or president’s office, should identify and advocate for policies by all levels of government and across all sectors to support public health. Alternatively, the ministries of health can accelerate cooperation with the various health-related sectors. Governments should respond in a formal manner through annual reports on the status of the social determinants of health.
10
WHO, Poverty, trade and health: An emerging health development issue (AFR/RC56/9), Brazzaville, World Health Organization, Regional Office for Africa, 2006.
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18. Countries are called upon to immediately start a review to ensure that their health policies and plans are oriented to addressing the key social determinants of health, and, where necessary, take appropriate corrective action. 19. Since the key social determinants of health are closely related and require comprehensive approaches that simultaneously target several determinants, countries are called upon to establish or strengthen intersectoral actions for health, including mechanisms to coordinate the planning and implementation of all activities that affect health—water, sanitation, education, infrastructure, among others. The application of initiatives such as healthy places (cities, schools, markets, prisons), Participatory Hygiene and Sanitation Transformation, and other interventions that equip populations with healthy behaviour and disease prevention should also be explored. 20. Special attention should be given to vulnerable populations, socially-disabled groups and those at increased risks of poor health. Issues of special importance are the provision of adequate income (through sustainable economic growth) and social assistance levels, promotion of affordable and decent housing, development of early childcare arrangements, and enforcement of anti-discrimination laws and human rights codes. It is also important to increase support for the social infrastructure, including public education, social and health services, and to improve job security and working conditions. 21. Mass media and civil society organizations should seriously consider dissemination of the rapidly-increasing findings concerning the importance of the social determinants of health and their impacts upon the health of populations in the Region. Mass media should inform the general population about the health impacts of diverse lifestyles, healthy diets and physical exercise, as well as health aspects of industrial processes. They should also help educate the public about the potential health impacts of various government decisions and thus improve public involvement in policy-making. Ways of involving the private sector should also be explored. 22. Governments are urged to immediately initiate situation analyses, if not already available, to document the relationship between the key social determinants of health and the health of the people and various population groups. Governments should ensure the inclusion of social determinants of health and health equity in national health targets. They should start monitoring the health impacts of policies and actions outside of the health sector, and, through research, start developing a database on social determinants of health.
23. In the medium term, governments are called upon to address the social determinants of health and the root causes of illness. They should increase resources and prioritize some key social determinants of health. 24. Countries are called upon to mobilize resources from external sources and allocate them to implement these actions. WHO and partners 25. WHO and partners should: (a) support countries to develop and implement regulatory frameworks and fiscal measures that protect individuals and communities from the harmful effects of environmental degradation; contribute to the creation of health-promoting environments through advocacy and appropriate frameworks that will enhance the contribution of the social determinants to decreasing poverty and ill-health;
(b)
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(c)
(d) (e)
develop a framework for use in countries to facilitate the monitoring and evaluation, on a sustained basis, of the progress made in addressing the social determinants of health; establish a regional forum or observatory for monitoring the progress that countries are making in addressing the social determinants of health; provide the necessary technical support and guidance as may be requested by countries, particularly for strategy development, implementation, monitoring and evaluation.
CONCLUSION 26. The Regional Committee is invited to review and adopt the actions suggested in this call.