Social Determinants of Health: Concepts & Regional Experience Abdi Momin Ahmed WHO Regional Advisor, Health Policy & Planning Capacity Development Workshop Tehran 11-15 July, 2010,
Objectives of the Presentation � Define Social Determinants of Health & Health Equity Concepts � Share the Regional Experience in Tackling Sh th R i l E i i T kli SDH through national health systems � Discuss health systems as determinants of Health
Why treat people… Why treat people… then send them back then send them back to the conditions that made them sick? to the conditions that made them sick? 3
Population health: Definition Is both a description & a concept that underlies the discussion of health disparities. It is concerned with the living and working g g environments that affects people's health, the conditions that enable and support people in making health choices, and the services that promote and maintain health. PHAC, 1997
Public health? � Is the combination of science, practical skills, and values directed to the maintenance and improvement of health of all people. It is a set of p p p efforts organized by society to protect, promote, and restore the people’s health through collective and social action…………..Public health activities change with changing technology and values but the goal remains the same.
The WHO Commission on Social Determinants of Health (CSDH � It completed its initial work in May 2008 with 20 commissioners to provide evidence on policies that improve health by addressing the social conditions which people live & work. G Goals: l � To support policy change in countries by promoting models & practices that effectively address the SDH � To support countries in placing health as a shared goal to which many institutions contribute � To help build a sustainable global movement for action on health equity & SDH
What are the social determinants of health? 7
Definitions and typology � “The social determinants of health refer to both specific features and pathways by which societal conditions affect health and that potentially can be altered by informed action.” potentially can be altered by informed action. Source: Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001; 55:693-700 � Two categories of social determinants: � structural – “fundamental structures of social hierarchy � intermediate - “socially determined conditions in which people are born, grow, live, work and age” 8
Themes underpinning SDH � Health equity � The absence of systematic disparities in health (or its social determinants) between more or less advantaged groups, or geographical areas. � The right to health � “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” (WHO Constitution 1946). 9
What is health inequality? � Is a generic term used to designate differences, variations, & disparities in health achievements & risk factors of individuals & groups - not imply a moral judgment - it may result from a personal choice � Some inequalities reflect random variations (unexplained causes � Others result from individual biology, personal choices, social organization, economic opportunity, or access to health care
What is health inequity? � Refers to those inequalities in health that deemed to be unfair or stemming from some form of injustice. � Equity in health implies that there are no differences in health services where health needs are equal (horizontal equity) or that enhanced health services are provided where greater health needs are present (vertical equity).
Equity definition cont’d Equity covers the absence of systematic and potentially remediable differences in one or more aspect of health subgroups of population defined socially, economically, demographically, or geographically.
The Final Report of CSDH – evidence is needed to act “ Our children have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil 72 years; India 63 Years.” h 80 i B il 72 I di 63 Y ” And in many countries, less than 35 years! “In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.” 13
Equitable access � Geographical access – overcoming barriers of distance � Economic access – overcoming barriers of cost � Cultural and social access Cultural and social access � Adequate, appropriate services � No barriers for women, or disadvantaged groups � Providers who deal with all patients/clients fairly, equally; according to their needs 14
Effective services for universal coverage (Source: Final CSDH report,, p 99) 15
Building a Knowledge Base on SDH in seven countries in the EMR: Regional Experience Reviews from: � Egypt � Islamic Republic of Iran � Jordan � Jordan � Morocco � Oman � Pakistan � Occupied Palestinian Territory
Egypt: Sensitization exercise on SDH � Objectives: To familiarize participants with report of CSDH and � recommendations for action; To present activities of Member States; � To identify policy implications of these activities; � � Participants: all govt. sectors, civil society, academia etc; � Outcome: Regional strategy and recommendations for Member States to: Advocate for the recognition of SDH and health equity at all � levels of government, both within and beyond the health sector; Collect and use examples of intersectoral action; � Continue to engage partners: civil society, research and training � institutions, UN organizations etc.
Iran: success stories Identified as a “champion country” by the Commission – Islamic � Republic of Iran Support at highest level: Health equity incorporated into the National � Constitution; On-going reforms in Primary Health Care strategy to respond to � changing health needs; Establishment of Secretariat for Social Determinants of Health in � MOH & ME; Intersectoral action in response to Burden of Disease Study – � addressing traffic fatalities.
Yemen: Success stories ISA initiative began in late 2007 with SDH situation analysis; � Health Policy Unit identified as the lead unit; � Sensitization workshop in April 2008 prioritized major social Sensitization workshop in April 2008 prioritized major social � � determinants of health; Incorporation of SDH into the health sector review activities; � Support for social research; � Increased awareness among all partners. �
Sudan: Country success stories Civil society workshop, March 2006 � Identified major SDH � recommended actions; � ISA initiative began in late 2007; � Task Force established by MoH conducted SDH situation analysis; � National Health Coordination Committee identified as appropriate � lead organization; Partnership for Development in Health intersectoral workshop, � Marawi, January 2009; Plans for sensitization meeting early in 2010. �
Jordan: Country success stories: Country SDH review; � Sensitization workshop in July, 2009; � National priorities for SDH identified; � National Lead organization identified (High Health Council); � Operational plan development: Prevention of obesity among � women as priority activity; Commitment to establish sustainable ISA structures at all � levels.
Morocco : Country success stories Review with focus on SDH associated with unusually high levels of � maternal & neonatal mortality; MOH plan for addressing maternal mortality through intersectoral � action; Stakeholder sensitization workshop Stakeholder sensitization workshop � � Commitment to ISA: � Human Development Initiative launched by King Mohamed VI in � May 2005; CBI; � Ministry of Social Development. �
Countries initiating ISA activities � Egypt: Sensitization meeting (early December); � Syria: Launching SDH review; � Pakistan: Contract for on-going health equity study; sensitization Pakistan: Contract for on going health equity study; sensitization workshop in planning stage; � Lebanon: intersectoral country launch of final commission report; situation analysis prepared and planning for sensitization exercise. � Bahrain: sensitization workshop in June 2010 � Somalia: SDH sensitization exercise in September, 2010
Under 5 mortality per Under mortality per 1000 1000 live births by live births by wealth quintile wealth quintile Poorest Less poor Middle Less rich Richest Average U5M for high income countries is 7/1000 200 150 100 50 0 Uganda India Turkmenistan Egypt 2000 Morocco 2000/01 1998/99 2000 2003/04 24 Gwatkin et al 2007, DHS data
Under 5 mortality per Under mortality per 1000 1000 live births by wealth live births by wealth quintile, Morocco quintile, Morocco 1992 1992 and and 2003 2003/04 04 Average U5M for high income countries is 7/1000 Poorest Less poor Middle Less rich Richest Pop average 120 100 80 60 40 20 0 25 Morocco 1992 Morocco 2003/04 Gwatkin et al 2007, DHS data
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